SUSAN M. PETTEY has directed health policy and advocacy programs for long-term care physicians, administrators, and other professionals, including AMDA and the American Association of Homes and Services for the Aging. Her experience also includes work with the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) and the National Association for Home Care. She currently is a health policy consultant.
As the hot rhetoric of summer turned to a cool reception for health reform in Washington, President Obama was hoping that his September speech to Congress would make the porridge just right. Democrats were reevaluating what legislation could realistically pass, and Republicans were overtly or indirectly saying that the president and his party weren't exactly telling the truth about their plans.
As of late September, Sen. Max Baucus (D-Mont.) was pushing his reform plan through his Finance Committee with little bipartisan support. Notable for physicians was that the Baucus proposal would provide only a temporary positive update of 0.5% in Medicare physician payment to offset the proposed 21% cut due in 2010. The outline included an additional 10% bonus for primary care practitioners for 5 years, which would be offset by 0.5% reduction in other services.
Nursing home groups such as the American Association of Homes and Services for the Aging and the American Health Care Association were pleased that the Baucus plan would not lower facilities' yearly Medicare cost-of-living increases, or “market-basket updates,” as legislation in the House would.
Given what seemed to be slipping support for health care reform, some Washington insiders were recommending that medical liability relief should be part of a compromise bill as a means of gaining Republican support. In his recent speech, Mr. Obama said he would explore state experiments in malpractice reform. While the president didn't endorse caps on damages or include other specifics, White House spokesmen subsequently clarified that options could include programs that require screening and approval by medical experts before a suit can be filed, grants for programs that encourage early disclosure of medical errors and prompt settlements, and some form of liability protection for physicians who follow evidence-based practice guidelines.
Fever Pitch
Washington has immediate problems to attend to besides the colossal issue of reform. Among them is pandemic influenza A(H1N1). As the country and the federal government braced for the worst, several pieces of good news came along for policy makers and the long-term care community. First, new clinical trials indicated that one shot would provide sufficient H1N1 immunity for most adults. The trials showed 96% of adults under age 65 years achieving immunity 8–10 days after the injection.
Response among persons over 65 years was about 50%, but that result is about the same as with the seasonal flu vaccine, according to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases in Bethesda, Md. At this time, the recommended vaccine dose for people over 65 years is still one shot only, said Dr. Fauci.
The results were welcome in light of a projected H1N1 vaccine shortage. Government health officials had been concerned that immunization would require two shots. Then on Sept. 15, Health and Human Services Secretary Kathleen Sebelius announced that the Food and Drug Administration had approved four vaccines for H1N1. Ms. Sebelius also said that the first batches of vaccine would be available in early October, which was earlier than predicted during the summer. She testified to the U.S. House Energy and Commerce Committee that eventually, there will be enough vaccine available for everyone who seeks it.
While elderly patients per se are not a top priority for the H1N1 vaccination campaign, health care workers are. The Centers for Disease Control and Prevention recommended that health care workers be vaccinated as soon as possible. Mr. Obama highlighted this in a September statement, “We need hospitals and health care providers to continue preparing for an increased patient load and to take steps to protect health care workers.”
There's Work to Do
Despite the benefits of immunization, the CDC estimates that only 40% of the nation's health care personnel with potential exposure to infectious patients and materials are vaccinated each year.
An informal AMDA survey of the association's Public Policy and Clinical Practice Committee members this summer showed that annual employee influenza vaccinations programs in nursing facilities can be challenging under the best of circumstances. Now facilities will need to persuade employees to sign up for shots for both seasonal influenza and H1N1 influenza.
Many survey respondents indicated that it was much easier to convince residents to get flu shots than it was to coax staff to do so. The AMDA survey showed ranges of 30%–60% vaccination rates for employees. As one member explained, “The challenges faced in getting health care personnel to accept immunizations (primarily an influenza vaccine issue) are present in both office and nursing facility [because of] misguided fear of acquiring illness from the vaccine and cost. Also, I find that many do not understand just how important … it is that the staff achieves a high percentage of immunization.”
One survey respondent noted, “The issue of education falls to the medical director in the facility and the providers in the office to champion the issue, and it makes a huge difference.”
H1N1 vaccination priority also goes to some nonelderly long-term care residents, such as individuals 25 to 64 years old who have chronic health disorders or compromised immune systems. Once the top priority groups are vaccinated, CDC recommends vaccinations for the remainder of Americans.
Once individuals exhibit symptoms of influenza and even before lab tests confirm whether the infection is seasonal flu or H1N1, Ann Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Disease recommends that individuals in high-risk groups (including the frail elderly) be treated promptly with antiviral medications. Dr. Schuchat said that the CDC hopes to prevent overuse, hoarding, and shortages of antiviral drugs, as well as prevent drug resistance. “So the majority of adolescents and adults and most children won't need antiviral drugs and can be cared for with Mom's chicken soup at home, rest, and lots of fluids,” she said.
As HHS Secretary Sibelius stressed in a weekly H1N1 update, elderly patients are still a top priority for annual influenza vaccine and should receive it as soon as possible.
AMDA has an Immunization Tool Kit available to assist in immunization campaigns in long-term care settings (see page 1). HHS also has developed the Health Care Personnel Initiative to Improve Influenza Vaccination Toolkit, which is available at www.hhs.gov/ophs/programs/initiatives/vacctoolkit/index.html.
CMS has notified Medicare claims processing contractors to anticipate claims for administration of earlier than usual seasonal flu shots as well as an additional H1N1 vaccination. The CMS guidance is available at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0920.pdf.
Health IT, Part D
The administration has announced the availability of $1.2 billion in federal grants for transitioning to electronic health records (EHRs). The grants will establish 70 regional information technology centers to help physicians and hospitals select, acquire, and implement certified EHR systems and then use the information in a meaningful way.
Additional grants will go to states to establish and support health information exchanges. These will “enable information to follow patients within and across communities, wherever the information is needed to help doctors and patients make the best decisions about medical care,” according to Dr. David Blumenthal, national coordinator for health information technology.
Meanwhile, the Agency for Healthcare Research and Quality intends to identify what accelerates and what hinders doctors' and pharmacists' adoption of electronically transmitted prescriptions. The agency plans to interview physicians, medical directors, information technology administrators, pharmacists, and others at 110 organizations over 2 years.
On the topic of prescriptions, most Medicare beneficiaries enrolled in Part D drug plans should see only small changes in their premiums or benefits in the coming year. The average monthly premium is expected to rise from the current $28 to $30, according to Jonathan Blum, acting director of HHS's Center for Health Plan Choices. Nevertheless, beneficiaries or their surrogates need to pay attention to 2010 premium announcements coming out this month, he said.
Some beneficiaries must change plans to continue receiving the full low-income subsidy for Part D coverage because their premiums have risen above the government threshold. Others will need to change because their drug plans haven't renewed their contracts with CMS or become ineligible for parts of the program. Mr. Blum predicted that about 800,000 beneficiaries will need to move to a new plan or be automatically reassigned.
The agency noted that it is working with its partners and will notify all individuals in this situation to make sure they are aware of their options. By the way, the strongest opinion that emerged from that informal AMDA survey was to support efforts to cover new vaccines, such as herpes zoster vaccine, under Medicare Part B instead of Part D.
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