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The Fickenscher Files, Vol. 18
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Quote Of The Week

"I and our members oppose the Senate bill. It's only for two months. I believe that
two months is just kicking the can down the road. The American people are tired
of that and, quite frankly, I'm tired of it."

Speaker of the House John Boehner (R-OH), in rejecting of the Senate Democrat [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108985572025&s=6409&e=001qzmMIgD048KVnoXYusUTPmiFnyzbBq4zCI1uXDXmme3lXq27FaTFBfp_wWL7XD_DADjWsksT1APcmlM2oEHgz5g2Bg4ULg6vQCfmkc0cQsL-VG7yO1oCnD2fy7-wgYra1E-HvXPv6bwh6sWsNzICog==]
proposal for a two month extension of the payroll tax legislation

"Trying to negotiate with Speaker Boehner is like trying to nail Jell-O to the wall.
He keeps moving the goal posts back because he can't control his caucus - they are
running off a cliff, and he is following."

Senator Chuck Schumer (D-NY) in comments [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108985572025&s=6409&e=001qzmMIgD048KXzagJlD4KtGqSkd1fBvZOGg2KixUER9M1BdJMMCEe5piPxlhzOMy0ZqPRem7dyI5Jw9K6KYBdqXozavvOGYCmA9jowosJ8ZTIZodYgKDyp3PDELc6NOjqXKpy4P6D3HcnzjWuwC5VbpKwjHhYm_GOdVM492TFnP85oUslIRwqKw==]
on Morning Joe on efforts by Democrats to negotiate with the Speaker of the House

Consolo Indicium

Information for your consideration...

Docs Embrace iStuff - When I first heard it, I couldn't believe it. But, the data
is clear. Over 70% of physicians [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108985572025&s=6409&e=001qzmMIgD048K3fKi20Bhe03x_oHvmhDuUBZFswGcMbrP7r-VTsYdTRHMcP9jZctqPFDvjfA_stKQZO6qxwO4JwnVbS2aBs2QCjTBB1uV-oz0fCUPrVr_D4YoKWW7uckJfal2HUS0W0FTuOuJ7n8ftUzxtZkWIrvzKNcrVflCM59joaKqS_gF3OGnbNmb4__3FXfWqfGxGBmkBgpaqyLiHQBo3CFGoUlAtFE3soUHmzj8=]
now use either the iPad or the iPhone. It seems that we have reached the critical
juncture where iStuff is now becoming a dominate feature of the clinicians life.
The survey was not clear on whether the devices are used in the office or at home.
Regardless, it's clear we're on to a new level of involvement by physicians in the
eWorld.

Reducing Readmission Rates An Increasing Hospital Focus- As the rollout of the Affordable
Care Act continues, one of the areas of focus for Medicare payments is to tie payment
to readmission statistics. Because of the focus - which is also penalizing hospitals
for avoidable readmissions - some hospitals have implemented a new program called
Project RED, for 'Re-Engineered Discharge. When it's fully implemented, the program
has been shown to result in a 30% reduction in readmission rates. Why? There are
several reasons why readmissions occur and the programs address them all. Specifically,
Project RED provides patients with better information about their diagnosis and
how to handle their condition once they are at home such as taking their medications,
arranging follow-up sessions with doctors and outpatient therapists, adjusting diet
and focusing on any lifestyle changes that may be required as a result of the illness.
The model even provides a specific telephone number to call if the patient has a
problem or a question. It's incredible that just doing the right things can result
in a 30% readmission reduction!! Imagine what would happen if we did the right thing
all of the time.

The New Accountable Care Organization Waivers

The first in a series of five on the new Medicare waivers....

Last month, the Centers for Medicare and Medicaid Services (CMS) and the Office
of Inspector General (OIG) published three new waivers in addition to two original
waivers which were included as part of the initial Accountable Care Organization
(ACO) final rule published on October 20, 2011. The three new waivers are: 1) the
Pre-participation Waiver, which applies to ACO-related start-up arrangements; 2)
the Participation Waiver, which applies to ACO-related arrangements in place during
the term of the ACO's participation agreement under the Medicare Shared Savings
Program (MSSP); and, 3) the Patient Incentive Waiver, which applies to medically
related incentives offered by ACOs to beneficiaries for preventive care and compliance
with treatment regimes.

There are four federal laws which CMS and the OIG wanted to address as part of the
Final ACO Waivers Rule. They include the federal physician self-referral or Stark
law (the Stark Law), the federal anti-kickback statute (the Kickback Law), the law
which prohibits hospital payments to a physician to induce the physician to reduce
or limit care to a Medicare or Medicaid beneficiary under the physician's direct
care (the Gainsharing provision); and, the law which prohibits inducements to Medicare
or Medicaid beneficiaries that are likely to influence their choice of a provider,
practitioner or supplier (the Beneficiary Inducements provision). We thought it
would be useful to have a more detailed discussion on each of these new waivers
because of their potential impact on the ACO movement throughout the healthcare
system. This article is the first in a five part series and, begins with an overview
of the Pre-participation waiver.

In essence, the Pre-Participation Waiver [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108985572025&s=6409&e=001qzmMIgD048Iow774BesZIiGhH1DKw6rwkxMVjwm_JsjQmOcgnOydXQwISloOA9qEkdiTWz7EWQHGMPIffAvJDbD8qWY8NhBTedTQ7TJXa6_bxtPLF80BQKK3O2XdOIX7-XR_CtQMTQ0XCmT0FuHrfOCJCJNyV8MfI367-wjXGH0=]
provides protection to qualified ACO participants and providers or suppliers (e.g.
a hospital) for investments that they make to create or develop an ACO and which
provide economic benefit of all of the ACO participants. The provision specifically
addresses one of the concerns of many healthcare systems that referring physicians
could potentially be penalized. Under the pre-participation waiver, the risks are
mitigated.

The pre-participation waiver goes on to describe in some detail the specific nature
of the investments that are protected, including:


* Infrastructure creation and provision,
* Network development and management,
* Care coordination and care utilization management,
* Clinical management and quality improvement programs,
* Creation of governance and management structure
* Creation of performance-based payment systems and transitions from fee-for-service,
* Hiring of new staff, including care coordinators, quality leadership, organization
management, analytical team, liaison team, IT support, and risk management,
* Information technology, including EHR systems, electronic health information exchanges,
data reporting systems, and data analytics,
* Consultant and other professional support, including market analysis, legal services,
and financial and accounting services,
* Organization and staff training,
* Incentives to attract primary care physicians; and,
* Capital investments, including loans, capital contributions, grants, and withholds.

The pre-participation waiver also outlines six conditions for meeting the waiver
requirements, including:


1. The arrangement must be undertaken by parties intending - in good faith - to
develop an ACO that will participate in the CMS program and must include one participant
eligible to form an ACO. The condition explicitly excludes drug and device manufacturers,
distributors, DME suppliers, or home health suppliers from serving as the organizers
of the initiative,
2. The ACO developers must be take steps to satisfy the CMS governance, leadership,
and management requirements,
3. The ACO governing body must make a bona fide determination that the arrangement
they develop is reasonably related to the purposes of the CMS program,
4. The start-up arrangement, the authorization of the development of the ACO by
the governing body, and documentation of the steps made in developing the ACO must
be documented at the time of the activity and retained for at least 10 years following
completion of the arrangement,
5. The description of the ACO arrangement must be publicly disclosed in accordance
with guidelines issued by the Secretary of HHS; and,
6. If the organization does not submit an ACO application, it is required to submit
a statement of reasons as to why it was unable to submit the application on time.

A waiver is available to any organization meeting the six conditions starting on
October 20, 2011, which is one year preceding the 2012 application date for organizations
seeking CMS designation. The rule also sets forth an extension of the waiver period
for any ACO which fails to meet the application submission deadline. However, in
that case, the extension must be approved at the sole discretion of the Secretary
of HHS and is not reviewable. The waiver (including any extensions which are granted
as part of the process) may only be used one time. Finally, the waiver expires when
either the ACO submits an application, enters into a participation agreement with
CMS or has its application denied.

Beyond the organizational aspects, the Pre-Participation and Participation Waivers
also affect the deployment of electronic health records by the ACO organization.
Based on everyone's reading of the conditions and requirements, the ACO and its
participants (e.g., hospitals) can provide EHRs to physicians who participate in
the ACO organization. The waiver adds a protection from the Stark Rules which have
been an impediment to organizational deployment of EHRs in the last year. However,
while these waivers are helpful towards fostering ACO development, they "do not
provide a final solution for funding the acquisition, implementation and integration
of EHR systems," according to the Health Information Management Systems Society
(HIMSS) since the waivers are limited to Medicare ACOs and expire once the ACO is
no longer involved in the CMS program. As such, they provide incomplete coverage;
however, it is anticipated that this issue will most likely be resolved through
further DHHS clarifications.

We are keeping our eyes on the development and implications of the CMS proposed
waivers. Next week, we will provide a closer look at the proposed Participation
waiver.

A 2012 Healthcare Wish List for Santa

In the spirit of the holidays, there seem to be some things we all want...

Every year as the holidays approach, many of us pull out our scratch pads to start
making our lists and checking them twice as Santa considers who's naughty and nice.
I've actually been through the SkyMall magazine on United Airlines about 20 times
over the last several weeks. So, it seems that many of us are getting into the season.
But aside from "things" there are lots of other results we might wish for in the
coming year. So, here is my 2012 Healthcare Wish List for Santa Claus:

1. Enough already - let's demand that the politicians start solving problems!! You're
no doubt a bit tired of me talking about this issue. But, the disharmony in Washington,
DC is getting in the way of solving real problems. I really am almost ready to start
the Throw The Rascals Out (TTRO) Foundation if progress is not made.

2. Fix the "doc fix". For the last several years, Congress has been kicking the
can down the road on the "doc fix" question. This is the issue of how much physicians
will be paid under the Medicare program. Because the fee adjustment methodology
has not been "fixed", it seems that about once a year, we get into this last minute
debate on what to do? The "doc fix" question lends itself to resolution by considering
major modifications to the entire fee-for-service mechanism which drives the delivery
of healthcare services today. If we are going to move from a volume-based to a value-based
healthcare system, it needs to start with physician and hospital reimbursement.

3. In fact, let's go beyond the "doc fix" question and start a national discussion
on changing the reimbursement incentives of healthcare. It's very clear that in
order to create sustainability in healthcare, we need to change the incentives from
a procedure oriented, volume-based payment model to a value-based approach. While
there have been efforts to develop accountable care organizations, primary care
medical homes and other such initiatives, there has been far too little discussion
on how we can alter the incentives of healthcare. I believe the healthcare system
is doing exactly what it is incentivized to do!! If we want to increase quality,
reduce costs and enhance service then we need to change the incentives and, I believe
healthcare will change rather quickly. For those of us who were around when the
diagnosis related groups (DRGs) were implemented, there was a radical shift in hospitalizations
over the course of about 18 months. The same thing will happen - I'm convinced -
if we changed the incentives to a value-based reimbursement model.

4. Let's get more aggressive on changing consumer incentives. The pareto principle
applies to the cost of healthcare. About 80% or so of health outcomes can be attributed
to lifestyle and behavioral choices. When people have to reach into their own pockets,
they actually pay more attention to what they are buying. So, we should consider
more taxes (yes, that nasty word of the day) like the tax on tanning beds. What
about a tax on bad-for-your-health fast foods? And, we should increase the tax
on cigarettes, which has been shown to have a major impact on the smoking habits
of young adults who are disproportionately the fastest increasing group of smokers
in America. Perhaps we should decrease the premiums or create other incentives for
those people who actively manage their illness. For example, what are the best incentives
we can create for diabetes? How can we best incentivize people to keep their weight
at a reasonable level? Incentives, again, should apply to consumers as much as they
apply to healthcare professionals. In fact, we should work out a mechanism to hold
physicians harmless if their patients do not engage in healthy behaviors. How can
we create "accountable" care on the healthcare delivery side if we don't also simultaneously
create "accountable" responsibility on the consumer side? But, these are simply
ideas. We need a focused discussion on what the details for implementing these ideas
should be and how they should be implemented. Rather than a willy nilly approach,
let's start a national discussion...

5. Move toward national licensure of healthcare professionals. Increasingly, healthcare
has no borders. Cross-state as well as cross-national work by healthcare professionals
is the norm. Radiologists and pathologists who provide tele-diagnostic services
are forced to get multiple, redundant licenses. With the advent of telemedicine,
we should move toward national standards and licensure - like most other nations
of the world. It's time for US medicine to catch up.

6. Support the individual mandate. The healthcare community has been remarkably
silent on the need for the individual mandate. It's somewhat ironic since it was
the healthcare community that lobbied Congress to include the mandate as part of
the healthcare reform initiative of the Obama Administration.

7. Initiate a national discussion on our approach toward the healthcare workforce.
It's increasingly clear to everyone that we have a looming physician and clinician
shortage in the USA. Current estimates by the American Association of Medical Colleges
are that we are facing a shortage of about 150,000 by 2020. Furthermore, the nursing,
pharmacy, and other clinical worker shortages are just as acute.If we think we can
take the workforce delivery model which we've developed in healthcare over the last
half century and simply ratchet forward - I believe we are sadly mistaken. We can't
train enough doctors and clinicians fast enough to deal with the changing demographics
(i.e. our nation is getting older, quicker) and the increased demand (i.e. the uninsured
will suddenly have access to services in the very near future). So, we should engage
in a national healthcare professional dialogue about how to change the workforce
delivery model. For example, under the current model, institutions are accredited.
How about accrediting or even licensing "teams" of healthcare professionals to deliver
accountable care? If we believe that fostering team care delivery gets better results,
let's organize ourselves to deliver in that manner.But, to accomplish that objective,
there are a plethora of obstacles that exist in licensure, accreditation, certification
and a host of other rules we've created in the healthcare delivery system of the
last half century that need to be debated and revised in order to move forward.

8. Demand interoperability standards for health information exchange. While the
healthcare industry has developed a number of excellent standards (e. LOINC for
laboratory nomenclature), interoperability standards are still lacking across the
industry. While a lab result may be the same inside of a system, when we move the
lab result from say a Cerner database to an Epic database (...just an example),
it does not happen. And, without government and industry demands for interoperability,
it will not happen. Imagine what interstate commerce would be like in the railroad
industry if we did not have standards for track sizes. A train from the Union Pacific
would not be able to travel on CSX Transportation tracks when the train reached
the East Coast nor could the goods be moved across the border from the USA to Mexico
on Ferromex in the south or, move north to Canada on the Canadian National Railway.
Standards make moving the goods and services on trains possible and that keeps the
North American economy humming!! The same applies to health information.

9. Stay calm when the Packers go to the Super Bowl. I don't want to jinx things
but, it's getting awfully exciting to think about the Packers going to the Super
Bowl. For the first time in many years last week, the Packers offer a sale of
their stock to the public for $250 per share. While it only entitles the holder
to attend the annual meeting, meet players and talk with the coaches; it's quite
a deal in my book. As the last remaining community-owned, American football team
- it's exciting to think about the first part of next year. While this is my wish
list for 2012, my prediction list for 2012 will be coming out shortly...and, expect
a thought on the Packers.

10. Let's support peace in the world!! We've had enough war, trauma and turmoil
in 2011 to last a long while. In whatever fashion befits your particular perspective,
I ask that we all pray for stability in Afghanistan and Iraq. Let's also pray for
the people who are leading the Arab Spring. And, let's extend our prayers to the
people of Syria and other oppressed nations. For those who suffer - like the people
of Somalia - let's offer a helping hand. And, for the man we walk by on the way
to the Metro Station, let's extend a helping hand. It's the season for thoughtfulness.
Let's try to make it a year-round effort...

Kicking The Can Down The Road: Another "Fix" of the Medicare "Doc Fix"

While the House moves ahead, the Senate balks and the can is kicked further down
the road...

The proverbial "doc fix" continues to languish on Capitol Hill as the albatross
of the 112th Congress. Last week, the House voted 234 to 193 to pass a GOP-led payroll
tax cut extension (HR 3630), which would extend a $1,000 payroll tax break set to
expire next week. It included a provision for a temporary "doc fix" that would stave
off a nearly 27.4% Medicare physician payment reduction which goes into effect on
January 1, 2012 if nothing is done. The legislation - as passed by the House - would
increase Medicare reimbursement rates by 1% over the next two years. The proposal
garners most of the $38 billion fix by increasing Medicare premiums for high-income
beneficiaries and moving funding from prevention and public health services where
funding was increased under the federal healthcare reform law.
However, the bill's chances for passage in the Senate remained slim as we went to
press. The Senate Democrats worry that the cost of the tax break extension will
fall disproportionately on the middle-income citizens. As an alternative, Senate
Democrats were considering a surtax on high-income individuals as a method for
coming up with sufficient dollars to pay for the "doc fix". The Republicans are
opposed to such a move so the impasse continues. It seems like a lot of issues are
being kicked down the road by members of Congress and, the leading can that has
been kicked for any number of years now is the "doc fix".
In essence, the House bill essentially postpones a pay cut for physicians for 2
years and requires Congress to work with the Medicare Payment Advisory Commission,
the Governmental Accountability Office, and the Department of Health and Human Services
to replace Medicare's current method for setting physician reimbursement or, what
is called the sustainable growth rate (SGR) formula. The formula, which was approved
by Congress in 1997, is responsible for triggering the massive pay cut because the
methodology of the formula has never been reset. Instead, we get the periodic "doc
fix" legislation which amounts to no real decision but rather an extension and bypassing
of the formula.

Legislators on both sides of the aisle are feeling mounting pressure to replace
the SGR formula prior to 2014 when an estimated 37% cut in physician pay is legislated
to occur as a result of the healthcare reform initiative. The physician groups were
hoping for a permanent doc fix to percolate through the bipartisan Select Committee
on Deficit Reduction, which was charged with finding at least $1.2 trillion in deficit
reduction moves. However, the so-called Super Committee - which had the power to
come up with the projected $300 billion required for permanently fixing the problem
because its recommendations could not be amended or filibustered in the Senate -
failed to reach a bi-partisan agreement on the overall deficit reduction package.
So, we await the results of the gridlock debate which seems to have brought Washington,
DC to a standstill. As always, more later...

A Personal Perspective...

Considerations for your consideration...

In this season of reflection and consideration, I hope that all of us - regardless
of faith or belief - will in our own way reach out to our higher power and ask that
the people of this planet seek peace and support for one another. I remember when
the Vietnam War came to a close with the evacuation of people from then Saigon and,
thinking that finally we would be moving toward peace in the world. However, my
desire was an illusion. It seems that over the last 30 some years there has been
a war or semblance of war someplace in the world virtually the entire time. As
we move toward disengagement from Iraq, my thoughts again move toward - ah yes,
now we can enjoy peace in the world. Unfortunately, I've aged since the Vietnam
War days and I'm now a bit more cynical. I can only hope at this point that the
peace will be longer than usual, which often is not very long.

I think that many of us look upon the Arab Spring as a new beginning for that region
of the world. It has sparked not only change throughout the Middle East but is having
ramifications throughout Africa, in Latin America, in India and in China - just
to name a few places. Even Myranmar has opened the doors a bit and been rewarded
with some recognition by Washington in the form of a visit by Secretary of State
Hillary Clinton.

But, it's not just peace. We also need to feed the hungry throughout the world.
For those of us who will enjoy the feast of Christmas, Hannukah or whatever holiday
you celebrate at this time of year, there will be much to offer across America.
Turkey, ham and an abundance of other foods will be laid out on tables all over
the nation. As we enjoy the plenty, let us also remember those who do not benefit
from the same level of stability as a nation that we do in the USA - despite our
ongoing difficulties. The USA remains one of the greatest nation's on earth. We
are a nation of plenty and we should share what we can. I encourage all of you
to consider a donation to the World Food Program USA, a group I've mentioned before
that does great work in helping peoples throughout the world. If not them, donate
to the charity of your choice.

While I've had a great year, I've also had a tough year. I've learned much about
myself, about the people around me, about my family and - through my various journeys
around the globe - an increasing understanding about the truths of the world. I've
learned that I can take nothing for granted. I've learned that while professional
growth is important, family sustenance is the most important part of life. I've
experienced change I wanted and change I didn't want. Both parts have been great
learnings. I've learned that learning is continuous...

I'm sure that all of us have similar thoughts and perspectives. So, I hope and pray
for peace in the world. I hope and pray that we will move beyond acrimony that stifles
discussion in our great nation. I hope and pray that all of you enjoy the abundance
and plenty that has been bestowed upon your lives. Have a great holiday and enjoy
your time with family. More later...as always...

The Weekly Whisk

Musings from a foodie...

There's a new little bistro in New York City that you need to check out. It opened
on September 1, 2011 and in its short life has already started to develop some acclaim
and a loyal clientele. Zoe

[****] not to be confused with Restaurant Zoe, which closed back in 2009, is definitely
a place to consider. Zoe Feigenbaum is the Chef and Inna Shats serves as the General
Manager. Prior to starting Zoe's, she was at PerSe under the tutelage of Chef Thomas
Keller. Both Zoe and Inna, along with a host of other committed workers, are very
involved in all aspects of the restaurant from greeting, to cooking, to serving,
to clean up. It's one of those intimate places and runs more like an entrepreneurial
start-up or, sort of a Silicon Valley venture of restaurants!

For starters, the octopus with green olives marinated in red wine with harissa and
labne sprigs was truly excellent. I also tried the lamb ribs with roasted and pickled
cherry tomato and it fell off the bone. Then for a main course, the whole grilled
dorade was accompanied by some awesome spiced grapes although the fish was slightly
overcooked. And, the pappardelle with a chicken thigh, oxtail and guanciale ragout
was great. I thought the top item of the evening; however, was the crispy brussels
spouts with cranberry and sour cream. It was truly outstanding. In this Thanksgiving
season, I've been trying to replicate the dish but can't quite get there. I must
be missing some spice. Finally, I ended the evening with the Lemon posset with
a parsley and tarragon graham crust. It was like lemon cream layered over graham
crackers - to die for.

So, Zoe's is yet another find for The Weekly Whisk! I recommend it. In fact, as
is usually my case, I asked to meet the Chef and obtain a signed copy of the menu.
Zoe was very cordial and admitted that I was the first person who had ever asked
her for a signed menu. I noted it for December 9, 2011 and told her that when she
got to be the James Beard Chef of the Year, I intended to come back wherever she
was at the time and ask her to sign it again. Call ahead. Zoe's is small and
intimate and needs a reservation. Zoe [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108985572025&s=6409&e=001qzmMIgD048IgKxAm19e6vU4GN5z7zraj_DhrrbFXXGt91XG2HWRGqOs-TKz5B4NAwPPN-YRZ4t42HBerLXzyuW0veUAMHSNZWryWCRPlOs4_GeeC97kjkQ==]
- 245 Eldridge Street - New York, New York 10002 - (646) 559-5962.

The Good, The Bad, And The Ugly

The ongoing saga...

The Good - The US Department of Labor announced that the Consumer Price Index was
expected to show only a 0.1% increase in November from the prior month which leaves
the price level up only 3.5% from the prior year. The end result is that inflation
seems to be held at bay, which is some encouraging news as the economy continues
to recover.

The Bad - The military reaction to the occupiers of Tahir Square in Cairo has created
a groundswell of angst from all quarters. The beating of the women in the square
was abominable.

The Ugly - For those who don't use discretion, the new Timeline feature on Facebook
could make it harder to undo the uploading of one's history, photos, links and other
connections in the future. So, without discretion on what you post - your life could
come back to haunt you in the future.
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Sponsors
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