By Drew Armstrong, CQ Staff

House Speaker Nancy Pelosi is pressing her caucus to agree to clear the Senate health care overhaul plan along with a package of compromises passed through expedited reconciliation rules, according to a well-placed lobbyist—in spite of her recent declarations that the Senate plan cannot pass the House and decision to float a series of more limit alternative bills.

"I spent time last night talking with the speaker and her chief of staff and to lots of members of the House, and the notion of the leadership wants to play small ball is absolutely wrong," Families USA Executive Director Ron Pollack said late Thursday.

Pollack and his consumer advocacy group have been deeply involved in the health care overhaul process, with a seat at the table during crafting the Senate legislation in committee, and close contacts at the White House and elsewhere Congress.

Pollack said Pelosi, D-Calif., discussed with him a procedural tactic he has advocated—to have the House clear the Senate bill (HR 3590), and concurrently have the Senate and House pass a set of compromise measures through the Senate using reconciliation, a package that would incorporate key agreements with the House on items like a tax on high-cost plans.

"I think they are very intent to get legislation . . . and it's this two-step process," he said.

Pelosi has continued to meet regularly with committee heads and other party leadership in her chamber and also with Democratic leaders in the Senate. But all involved have been tight-lipped about their discussions.

"I had a conversation with the speaker today. We're moving forward," Senate Majority Leader Harry Reid, D-Nev., said Friday. Asked what process they would use to do so, he said, "We haven't determined that. That's why we're still communicating."

A spokeswoman for House Majority Leader Steny H. Hoyer, D-Md., would not comment on whether House Democratic leadership has decided to go forward with what Pollack said the speaker will push.

"We are not confirming a decision on the process moving forward," said spokeswoman Stephanie Lundberg. "We continue to look at options."

Pollack said Pelosi had not spoken to him about defaulting to a far-less-ambitious package of small health care proposals, as has been suggested recently by some lawmakers.

"I spoke to a lot of members last night, including folks we had concern about, and I think there is movement toward accepting this strategy," he said of plan to pass the Senate bill and a reconciliation package.

"At the early stages, after a week ago Tuesday, I think people were acting out of the first stage of grief," he said, referring to the surprise loss of Democrats' Massachusetts Senate seat to GOP candidate Scott P. Brown. "As people have taken some time and taken a deep breath, they know they've got to get this done and know they can't play small ball."

Using reconciliation to pass a package of changes to the bill would ensure that House members get important concessions from the Senate that they feel they need in order to clear the Senate bill, and would also let the Senate bypass the 60-vote threshold that has stymied health care efforts.

"It would enable House members who want to get this done but have significant concerns about the Senate bill to ultimately pass the Senate bill knowing that these modifications will be part of final law," Pollack said of his conversation with Pelosi.

Top Democrats in the House and Senate still have to agree about exactly what the reconciliation package will include.

"Once this agreement is reached, she will be able to get the Democratic caucus behind this legislation and follow the process she will outline," Pollack said.

Democrats have insisted that they remain committed to a comprehensive overhaul, but many have questioned whether they are only trying to create some political cover as they shift their focus to jobs legislation.

"Members in both bodies need to know what that final outcome is intended to be," Pollack went on. "Then the effort will be made to round up the votes. You can't round up votes until you have a product which people will ultimately be voting for."

So far, the idea appears to be Democrats' best and only remaining chance to get a comprehensive health care bill to President Obama.

But it hinges on rallying a majority in both chambers to pass the Senate bill and the reconciliation package.

"It's legislatively possible," said one lobbyist with a group working for the overhaul effort. The lobbyist said that it would be impossible to do a comprehensive overhaul through a series of smaller bills, because each incremental change would create a ripple effect through the health insurance marketplace.

The time-line for going ahead with any new strategy is uncertain, however.

Hoyer said recently that Democrats would need to find a way forward next week. Reid, meanwhile said this week that Democrats were focusing on jobs now, not health care.

"It seems like you have different things coming out of different leaders' mouths," said the lobbyist.

Kathleen Hunter contributed to this report.

By Paul Jenks

Democrats, encouraged by President Obama's State of the Union address, consider options to pass a health care overhaul measure. A freeze looms on discretionary health spending.

Weekly Review
Prospects for legislative action on a health care overhaul measure remained in limbo this week but Obama pressed Congress to act in his State of the Union address Wednesday evening. Virginia's Gov. Bob McDonnell, in the customary GOP response address, called for a scaled-down health measure. CQ reported on initial lawmaker responses to the address and Roll Call reported Thursday on distinctly negative reactions from Democratic Sens. Mary L. Landrieu of Louisiana and Mark Pryor of Arkansas. Roll Call also reported Thursday that House Speaker Nancy Pelosi, D-Calif., vowed to press ahead with a two-pronged legislative approach that will broach the differences between the House (HR 3962) and Senate (HR 3590) measures.

Congressional anxiety about the path forward for a health care overhaul measure was evident all week in both the Senate and House. Roll Call reported Thursday that Senate Majority Leader Harry Reid, D-Nev., is actively considering a health reconciliation measure. But CQ reported Thursday that Senate Majority Whip Richard J. Durbin, D-Ill., suggested that budget reconciliation rules could delay action on a new measure until April. Also, several moderate senators hedged their opinions on moving new legislation through the Senate using budgetary reconciliation rules, which allow a simple majority vote for passage. CQ reported on wavering positions of several key moderate Democrats and HealthBeat reported that Sen. Joseph I. Lieberman, I-Conn., is also uncertain about voting for a health reconciliation measure. Conversely, HealthBeat reported that Sen. Ben Nelson, D-Neb., who cast the deciding vote for the Senate health bill last month, wants the Senate to vote again on the bill.

House Democrats, who likely hold the cards for any initial action, have not decided on whether to adopt the Senate approved bill (HR 3590) and offer new legislation with adjustments or proceed with smaller measures. CQ reported Thursday that the House might begin considering smaller options before the Presidents Day recess, which starts Feb. 11. Earlier in the week, House Democratic Leader Steny H. Hoyer of Maryland blasted (view Roll Call report) the Senate's past actions on the health care bill. Roll Call also reported Wednesday that House Democratic Whip James E. Clyburn of South Carolina pressed to move a bill through the reconciliation process.

Congressional Republicans, almost content in letting debate on health care options play out between Democrats, echoed all week a go-slow approach to a health measure. The House Budget Committee's top Republican, Paul D. Ryan of Wisconsin, on Wednesday reintroduced an alternative tax and health care overhaul measure as an alternative option).

Obama also raised congressional anxiety about fiscal 2010 health discretionary spending when he announced a freeze on non-defense and national security spending. The White House will unveil its new budget proposal Feb 1. The Senate this week debated a longer-term spending overhaul plan but rejected an amendment Tuesday to create a congressionally authorized panel to suggest changes to federal spending including Medicare. Obama vowed on Wednesday to create a similar panel to advise lawmakers on budget reform options.

On Tuesday, the Congressional Budget Office released its key annual Budget and Economic Outlook report that links a leveling of future Medicare spending to lower Medicare physician payments, an action Congress is likely to block. The Senate prepared the ground for action to block the scheduled decrease in physician Medicare rates on Thursday by adopting a pay-as-you-go (PAYGO) budgeting amendment to a measure to increase the federal debt level (H J Res 45). The amendment applies statutory pay-as-you-go budgeting rules for new spending measures and includes special provisions for adjusting the Medicare physician rates.

In committee action this week, CQ reported that House Energy and Commerce Chairman Henry A. Waxman, D-Calif., is amenable to calling for White House documents on closed-door negotiations on a health care overhaul bill with various health groups. Here is a list of upcoming committee meetings and news events scheduled for next week.

Finally, CQ HealthBeat reported Thursday on a new report from the Surgeon General on curbing obesity and the Department of Health and Human Services published a final ruling on changes to reporting requirements for medical errors.

By Jane Norman, CQ HealthBeat Associate Editor

Physician Elliott Fisher gained fame—and some critics—when he and his colleagues at the Dartmouth Atlas of Health Care shined a spotlight on the high-spending outliers in the health care world.

More health care does not necessarily mean better health care, the researchers at the Institute for Health Policy and Clinical Practice at Dartmouth College have argued repeatedly as they compare communities and find vast geographic differences in Medicare spending. What's more, they contend, spending continues to spiral upward with no connection to better outcomes for patients.

On Friday, as the future of the health care overhaul and attempts to rein in spending teetered, Fisher told a Washington conference of health care advocates that he still holds out hope that higher quality and lower costs in health care can be achieved over time. At least the problem has begun to be identified and a groundwork laid, he said.

"These are dark times for those of us who expected health care reform to have been passed months ago, let alone two weeks ago," he said at the Families USA meeting. "I will leave you with what I think is a very hopeful message—I think we really have the opportunity, especially working in communities in partnership with health systems and supported by the kinds of national reforms I am confident are going to pass, to really fix our health care system."

Clearly there's too much money in the system, added Fisher, professor of medicine and community and family medicine at Dartmouth Medical School. "I'm increasingly worried about the integrity of the healing professions, the integrity of the leaders of our health care systems, that are threatened under our increasingly entrepreneurial health care system," he said.

The Dartmouth Atlas divides up 306 regional markets in the nation and data for Medicare claims so that variations in spending can be compared. "This map has now made everybody in the country angry," joked Fisher as he displayed it on a screen.

The Dartmouth work was cited at length in a June 1 article in New Yorker magazine by surgeon Atul Gawande that was published just as congressional work on the overhaul was launched. Its emphasis on McAllen, Texas, as a medical profit center provoked an uproar over health care spending. Even President Obama referred to the article and Dartmouth, in remarks to the American Medical Association as he campaigned last summer for his overhaul plan and innovations such as bundled payments.

Fisher said Dartmouth studied about a million Medicare beneficiaries and details about their particular diagnoses, and compared quality of care and outcomes in low-spending regions with those with high spending.

"Where does the money go?" he asked. "We consistently found that higher spending regions are less able to provide high quality care." Physicians in high-spending areas said they had more problems coordinating care, it was harder to get patients admitted even though more beds were available, and it was more difficult to obtain a specialist, said Fisher.

Patients are not driving the variations—it's volume at least in part, he said. "Supply and payment are a very powerful influence on the way health care payment happens in the United States but they don't explain all the variation," he said. Some is due to differences in judgment, but case studies are under way to pinpoint other pressures at work.

There needs to be clarity that the aim of health care is better health, better care and lower costs; better data that's available to the community, consumers and providers; a model of health care that moves more toward a team approach among physicians; and a payment system other than fee-for-service, said Fisher.

He said the patient-centered medical home is a good idea though many consumers think it means a nursing home. "It's fundamentally about practice redesign to support the core functions of primary care," he said. Fisher also praised the concept of accountable care organizations, included as pilot programs in the health care overhaul bills. ACOs are groups of providers responsible for Medicare patients.

"I think some form of legislation will pass," he said. "The federal support for this kind of reform is likely to be there." But local leadership is also key, he said, and a sense of shared goals among physicians in a community. For example, getting rid of excess and unneeded hospital capacity—agreeing on just one cancer center instead of two—would slow rising costs. But that will take pressure from the community, Fisher said.

"Local solutions, with national support," he said.

By John Reichard, CQ HealthBeat Editor

Interest in testing new ways to pay for and deliver health care is on the rise in health policy circles as the need becomes increasingly urgent for more efficient health care spending. Pending health care overhaul legislation would fund a variety of experimental approaches; noted health policy writer Atul Gawande passionately made the case in a New Yorker article earlier this year for essentially making robust experimentation a permanent feature of the health care system.

Gawande argued that such an approach could benefit health care in the same way that the rural extension service of the Agriculture Department transformed U.S. agriculture in the 20th century.

With health overhaul legislative prospects in doubt, it was perhaps no accident that Jonathan Blum, a top official of the Centers for Medicare and Medicaid Services (CMS), played up the need for a strong research agenda in a speech Monday to the National Rural Health Association. "We are very much committed to returning CMS back into the research world," Blum told rural health care administrators and policy specialists.

Blum is the director of the Center for Medicare Management and the acting director of the Center for Drug and Health Plan Choices at CMS. Essentially, he's in charge of both the traditional Medicare program and the private health plans side of Medicare.

Medically underserved areas would be among the beneficiaries of some of the changes policy makers have in mind. That includes fostering "medical homes" that would improve primary care services to those with chronic illnesses by improving their preventive care and giving them easier access to doctors and nurses to stick with their treatment regimens. But health care generally is seen as benefiting from more research on how to streamline care.

Medicare historically has been a trendsetter for payment changes. Its adoption in the 1980s of prospective payments—a fixed sum of payment for a specific clinical condition—is credited with big savings to the Medicare program without harming quality of care.

"I think it's fair to say that CMS once did very exciting cutting-edge research," Blum noted. "That was a huge priority. That is still a priority today. But I think that the CMS budget has not kept pace with the need for future research and I think sometimes that the CMS research budget gets filled with projects that possibly don't have the most merit."

Blum noted that President Obama proposed in early 2009 "to dramatically increase CMS' research and development budget." He called for a $30 million increase in research on the Medicare and Medicare program; Congress did not fund the request.

But given Blum's remarks, it won't be a surprise if Obama similarly calls for a robust research budget in his upcoming budget proposal. "We think it's important to help Congress lay the foundation for future payment reforms and I expect and the goal really is to make sure that CMS has as strong" an agenda as possible, Blum said.

Blum said that CMS has heard from state officials in Maine and Vermont that the medical home model could best be implemented if all payers—Medicare, Medicaid and private insurers—coordinated in the adoption effort. Blum said that CMS later this year will invite states to apply for a CMS demo to implement an all-payer medical home model. CMS also will solicit proposals later this year for community health centers to serve as medical homes as part of a demonstration project.

CMS also aims to make its huge database of health care claims more readily available to researchers trying to figure out how to improve the efficiency and quality of the current system. "We understand that CMS sits on probably the most valuable health care database in the country," Blum said. "Folks that want to do health policy research do have access to the data, but it's not as transparent and it's not as easy to access as I think some would hope," he observed.

CMS is working with the White House Office of Management and Budget on the issue.

"We are working very closely with our colleagues at OMB to . . . put much more data on line on the cost and the utilization of fee-for-service Medicare services," he said.

By John Reichard, CQ HealthBeat Editor

Who knew? It may be that President Obama's big win on health care already happened—just weeks after he took office.

On Feb. 17 last year, Obama signed into law an economic stimulus provision jump-starting health information technology—puny stuff compared to the overhaul proposals now stalled on Capitol Hill. It is likely nonetheless to leave a lasting mark on the nation's health care system.

"Health IT" may be something Washington is getting right on health care, thanks to an estimated $36 billion that will flow over the next decade through Medicare and Medicaid to doctors, hospitals and clinics that make "meaningful use" of technology. That is the proposed new regulatory test announced Dec. 30 to ensure that new systems don't remain crated in boxes and are actually used to improve care and cut costs.

New standards are coming to certify that systems work together. Seventy new "Regional Extension Centers" are springing up to teach caregivers how to use IT the way that agricultural extension agents teach farmers new techniques. Fifteen "Beacon Communities" are planned to serve as models of how lab results, medical images, prescriptions, and other medical data can zip instantly and securely around communities to streamline care.

The whole federal effort is under the leadership of David Blumenthal, the former Harvard Medical School professor Obama named last March as his National Coordinator for Health Information Technology.

But like everything involved in the quaint notion of "fixing" health care, getting IT right is enormously complex, a process that will take years, if not decades, and require doctors, nurses, and administrators to abandon familiar ways and learn to do their jobs all over again using technology that may make them feel inept.

The difficulty involved, and the carrot-and-stick approach designed to lower payments to caregivers who don't use IT meaningfully, may make the proposed rules among the most heavily commented upon in the history of federal health regulations. The volume may dwarf even the 100,000 comments filed in the years-long rulemaking on privacy and streamlining health care data, predicts Neal Neuberger, head of the Institute for e-Health Policy, an IT think tank.

The complaints are as varied as the stakeholders in health care. The American Hospital Association says fewer than five percent of hospitals overall now could qualify for higher payments because the proposed "meaningful use" standard is too tough. Rural hospitals say they lack IT expertise, capital, and broadband to transmit data.

Meanwhile, it's unclear what systems will qualify for reimbursement, yet providers face pressure to buy systems now. Lawmakers like Sen. Charles E. Grassley, R-Iowa are promising tough scrutiny of stimulus dollars spent on IT, expressing concern about faulty software that produces incorrect drug doses, for example.

Help from Computers
How Congress and the administration respond to the many questions that arise over the implementation of the regulations will help determine whether the ingredients of success now on the table can be assembled into effective policy.

To that end, it helps to have someone in charge who can relate to techies and non-techies alike, as well as to older doctors who tend to have a distaste for new information technology. Blumenthal's Harvard chops and 30 years as a primary care doctor get respect in the worlds of policy and medicine, but he also relates easily to those who aren't turned on by IT.

"My wife thinks it's a huge failure of vetting when I got this job because she takes care of the computers at home," Blumenthal joked in a speech to rural hospital administrators recently. "But what I do have is experience using an electronic health record. One arrived on my desk about a decade ago and I gradually came to terms with it."

Two vivid experiences made him a champion of the technology, Blumenthal said. In one case he tried to order a sulfa drug for a patient being discharged from the hospital. "The computer said to me, in big, red, bold letters across the screen, 'this patient is allergic to sulfa.' I was very grateful."

Another time, he tried to order a CT scan of a patient's kidney. The computer asked "are you sure you want to do that?" It told him the patient had received a similar scan weeks before, allowing Blumenthal to cancel a costly test and spare the patient exposure to radiation.

But few doctors practice in organized systems like Blumenthal's, where electronic medical records capture and transmit data throughout a network of providers. So many Americans will not see such a system for years.

In the meantime, there's likely to be intense pressure from lawmakers to surmount obstacles to health IT because of hopes it can cut rising health costs without harming care. Said Sheldon Whitehouse, D-R.I., to a group of IT professionals at a Capitol Hill seminar last month: "You are doing God's work."

By Paul Jenks

President Obama urges lawmakers to pass a health overhaul measure and vows to restrain discretionary spending increases. A committee votes on a request for documents on private White House agreements with health care organizations.

President Obama pressed the case Wednesday for a health overhaul measure in the State of the Union address to Congress.

CQ Today reported that the president declined to elaborate a specific approach to passing legislation but pressed for action. Roll Call reported on different interpretations of the speech from lawmakers.

CQ reported before the speech that some interest groups were waiting for the president to give the green light to the House to act on the Senate bill (HR 3590). On the House floor Wednesday, Majority Leader Steny H. Hoyer, D-Md., held out the option (view video that the House could consider a health measure before the Presidents Day recess (Feb. 15). Roll Call reported that House Democratic Whip James E. Clyburn of South Carolina pressed to move a bill through the reconciliation process. In the Senate, CQ HealthBeat reported Wednesday that Sen. Joseph I. Lieberman, I-Conn., is uncertain about voting for a health reconciliation measure.

Lawmakers now grapple with forging alternatives and options for the two main proposals approved by the Senate or House (HR 3962). One example of a smaller measure, which includes some Republican support, is a small-business insurance pool proposal (S 979) offered by Sen. Richard J. Durbin, D-Ill,. Additionally, Democratic Sen. Ron Wyden of Oregon and Republican Sen. Robert F. Bennett of Utah have also proposed a more substantial health overhaul bill (S 391) for the past several years. House Republicans, led by Budget Committee ranking member Paul D. Ryan, R-Wis., on Wednesday introduced alternative tax and health overhaul legislation. Ryan previously offered a similar bill (view text) in 2008.

Budgetary reform pressures continue to tangentially press on discussions on the future of a health measure. The Morning Take on Tuesday reported on Senate efforts to craft a budgetary task force to overhaul the federal fiscal situation. President Obama weighed in on Wednesday with a commitment to create an alternative budget task force created by the White House. Slowing the growth of federal health spending is one of the original goals of health care overhaul proposals. Obama also reiterated a pledge to freeze non-defense and national security discretionary spending in his fiscal 2011 budget proposal.

Additionally, the administration also issued a statement Wednesday supporting statutory "pay as you go" (PAYGO) legislation in the Senate. The House passed a new PAYGO measure last year (HR 2920), which excludes several major spending items including an adjustment of pending Medicare physician rate cuts. The Medicare physician rate issue, combined with offsetting spending to fund the rate cut, has been a constant thorn in bicameral deliberations on health reform. The Senate last year failed to consider a separate measure (S 1776) to permanently block the physician rate increase and did not include it in its final health overhaul bill. The Morning Take on Wednesday reported that a new Congressional Budget Office budget outlook report specifically noted the physician payment issue impacting the growth of Medicare spending.

The House Energy and Commerce Committee on Wednesday tackled a controversy over White House closed-door negotiations with health associations and unions that crafted agreements to advance health overhaul legislation. The committee agreed to a motion to report a resolution of inquiry (H Res 983) without recommendation that requests documents on White House negotiations with various groups and specifically cites the Advanced Medical Technology Association, the American Medical Association, America's Health Insurance Plans, the Pharmaceutical Research and Manufacturers of America, the American Hospital Association, and the Service Employees International Union. CQ reported that while the committee's "no recommendation" effectively shelves the measure, committee Chairman Henry A. Waxman, D-Calif., supports the call for documents.

Today, the Senate Judiciary Committee might consider a medical expense bankruptcy protection bill (S 1624) in its regular Thursday morning markup.