Legislative "Cliff Notes": The Difference Between House and Senate Health Reform Bills

Tomorrow 60 senators expect to vote out their version of the health care reform bill. Then comes the Conference Committee to resolve the many differences, while preserving the narrower Senate margin needed for final passage.

The Division of Legislative Counsel for the AMA has assembled a Health System Reform Legislative Summary Chart of Major Provisions of the House, Senate and the recent "Manager's Amendment" to the Senate bill.

Expect the combined legislation to look much like the Senate columns.

Back of the Napkin on Health Care Reform

Dan Roam presents an insightul back of the napkin look at health care reform.

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Health Wonk Review

Health Wonk Review is up at Workers Comp Insider featuring a very funny Santa Sessions video and some terrific posts on "Sausage Making" and more traditional wonkish categories including Quality/Safety and Technology/Innovation.

Consistent Time

Guest author and Vice Chair of the HIT Standards Committee John Halamka reports on HITSP's Consistent Time Transaction and its implications for clinical decision making and health information exchange.

Consistent Time
by John Halamka

I was recently asked by my staff how we should coordinate the time of day across organizations which exchange healthcare information. In a future which treats data from outside data sources as appropriate for clinical decisionmaking, you can imagine the following data exchange:

Hospital 1 posts lab result 12:01pm

Hospital 1 sends result to Hospital 2 12:02pm

Hospital 1 revises lab result 12:15pm

Hospital 1 sends revision to Hospital 2 12:16pm

Order is entered at hospital 2 12:17pm

Time synchronization among participants in a healthcare information exchange is important. If Hospital 2's clocks were 3 minutes slow, it would be challenging to know if the order was entered based on the original or revised lab result.

HITSP has published T16, the Consistent Time Transaction to help address this problem. It's based on an IHE profile created to support the synchronization of security audit logs.

It uses the Network Time Protocol (NTP) or Simple Network Time Protocol (SNTP).

Here is the relevant section IHE ITI TF Vol 2: 3.1.4.1 from IHE-CT profile

"The NTP transactions are described in detail in RFC1305. There is also extensive documentation on the transactions and recommendations on configurations and setup provided at http://www.ntp.org. Rather than reproduce all of that material as part of this Framework, readers are strongly encouraged to explore that site. The most common mode is the query-response mode that is described below. For other forms, see RFC1305 and the material on http://www.ntp.org.

The Time Server shall support NTP (which implicitly means that SNTP clients are also supported). Secure NTP may also be supported. The Time Client shall utilize NTP when it is grouped with a Time Server, or when high accuracy is required. For ungrouped Time Clients with 1 second accuracy requirements, SNTP may be useable. Time Clients may also support Secure NTP."

Although original designed for audit trails, the transaction has been expanded to other transactions, since organizations have realized that having synchronized clocks really helps documentation integrity and workflows. As the use of the consistent time is extended beyond audit trails, there are interesting issues about just how precisely synchronized devices in a network should be - a few seconds, one second, a subsecond?

At BIDMC, we point to stratum 1 servers that are directly connected to computers attached to atomic clocks.

The interesting question for HIEs is what should be synchronized.

My hospital servers are all synchronized against one set of time sources.

Our HIE, NEHEN, has suggested that all the gateways used to exchange data among multiple hospitals should be synchronized with one time source to ensure that all send and receive timestamps for clinical data exchange are consistent. Otherwise, data might arrive at one hospital before it leaves another!

However, since HIE gateways will be synchronized with one time source and hospital internal servers may be synchronized with others, the HIE time may vary from the hospital time.

Maybe the right answer is that as part of our national healthcare IT effort, we should mandate that all hospitals and HIEs should use a single set of known-adequate time servers to ensure all healthcare time is consistent.

For the moment, the following strategy seems reasonable

1. Require hospitals use NTP to ensure their internal time stamps are consistent. This will ensure audit trails within an organization, whether merged in an audit repository or just reported from disparate systems upon request, are consistent.

2. Synchronize health information exchange gateways within an HIE to a single time source so that transactions have consistent send and receive times.

If we know the hospital audit trail time stamp is consistent and we know the HIE send/receive times are consistent, we can recreate any event that is disputed.

Expecting every hospital to change its time synchronization servers to those used by the HIE is unrealistic - what if the hospital participates in multiple HIEs?

At some future time, we all may change to a national healthcare time server that is part of the NHIN, but for now the hospital use of NTP will be decoupled from the HIE use of NTP.

The Facts on Health Care Reform

Will the reform bills passed in the House and Senate raise or lower premiums?

The health insurance industry has recently funded two studies that purported to show that health care reform legislation would cause premiums to rise substantially. An AHIP commissioned study by PriceWaterhouseCoopers predicted a 111% increase over 10 years and a Blue Cross Blue Shield funded report by accounting firm Oliver Wyman estimated a 50% or greater increase. When a firestorm erupted, PWC issued a clarification which in a nutshell said "that AHIP paid it to focus on four parts that AHIP didn't like and ignore everything else in the bill." The New Republic's Senior Editor Jonathan Cohn reports that "the big problem with the PriceWaterhouseCoopers study ... was that it treated certain elements of reform in isolation, leaving out key parts that would have changed the outcome. Unbelievably--or, perhaps, all too believably--Oliver Wyman does the exact same thing."

So when more objective analysis was finally presented, it was not surprising to find very different conclusions. In his November 27 report, MIT Professor Jonathan Gruber analyzed data from the non-partisan Congressional Budget Office and found that individuals' premiums in the new exchanges will be "considerably lower than what they would face in the non-group insurance market, due to the market reforms put in place by the Senate Bill, the mandate on individuals to participate regardless of health, and the market economies of new exchanges."

In his December 2nd article (Getting the Facts Straight on Health Care Reform, New England Journal of Medicine), Gruber systematically rejects many of the criticisms of the legislation:

• Government takeover? No. "The primary role of the government in this reform is as a financier of the tax credits that individuals will use to purchase health insurance from private companies through state-organized exchanges. The public insurance alternative that is included in the Senate bill simply adds another competitor — on a level playing field —to the insurance market, and the Congressional Budget Office(CBO) projects that it will enroll only a tiny minority of Americans."

• Budget busters? No. "This is simply incorrect. Both bills are completely paid for — indeed, both would reduce the deficit by more than $100 billion over the coming decade. And the CBO estimates that both would reduce the deficit even more in the long run, particularly the Senate bill with its strong cost-containment measures."

• Attack on Medicare? No. "There is substantial evidence that reducing these overpayments will not harm the health of Medicare patients — just the pocketbooks of those who profit from them. This reform would simply use market bidding to set the reimbursement rate for Medicare Advantage plans, rather than setting administrative prices, which have traditionally been much too high; and it would reduce payments to hospitals by a small percentage, while tying them to outcome measures. Moreover, the dollars that are raised will save thousands of lives each year by increasing insurance coverage among the non-elderly."

• Unafordable mandates? No. "Both bills contain billions of dollars in subsidies to help families pay for health insurance — and an exclusion from the mandate for families that still find coverage unaffordable. Rather than imposing an unaffordable mandate, these bills would finally guarantee that almost all Americans could find affordable insurance."

• Harming the privately insured? No. "CBO data show that the average enrollee in the new exchanges will either pay substantially less or obtain more generous coverage than the average person in today’s nongroup insurance market. Employees of small businesses that enroll in the exchange will also benefit from the lower prices and wide variety of health plan choices available to larger groups, and their employers will benefit from a small-business tax credit. Employees in large businesses will benefit from a shifting of their employers’ money from excessively expensive insurance to increased wages."

• Insufficient cost control? No. "...The Senate bill in particular ... includes a four-pronged attack on health care costs. First, it imposes a tax on high-cost insurance plans that will put pressure on insurers and employers to keep the cost of insurance down, while delivering $234 billion in wage income to workers over the next decade. Second, it includes funds and a structure for comparative-effectiveness research that will provide the information necessary to guide our health care system toward care that works and away from care that doesn’t. Third, it establishes a Medicare advisory board with the power to set rates (subject to an up-or-down vote by Congress) if costs grow too rapidly. Finally, it sets up an innovation center within the Centers for Medicare and Medicaid Services and launches pilot projects to explore alternative reimbursement and organizational structures that could transform the delivery of care.

Grand Rounds

Welcome to Grand Rounds! A special post-Thanksgiving edition serving up Seinfeld as the lighter fare after the big holiday meal.



In "The Burning" Kramer and Mickey act out sick conditions for medical students.

Alison looks at her promiscuous history with insulin companies, questions whether she's become too comfortable in her current insulin relationship and whether she should get back on the insulin dating scene. "I think I might be an insulin tart" in Shoot Up or Put Up: Comatose and rotting toes – the lighter side of insulin dependency.

Diabetes Mine honors Dr. Frederick Banting for his work on the ultimate diabetes invention which was of course insulin, which keeps diabetics. Diabetes Mine also reports on the hope for a new non-invasive glucose measurement device.

In "The Boyfriend", Elaine breaks up with Hernandez because he smokes. Jerry tells her, "You're like going out with C. Everett Koop!" referring to the U.S. Surgeon General who crusaded against smoking in the 1980s.

The Happy Hospitalist advises to Quit smoking now or experience the rare but unsightly side effects of continued tobacco abuse.

In "The Fusilli Jerry", Kramer tells a story of how the surgeon once performed a procedure on a teenage boy from Guatemala with no nose and "turned him into Ricardo Montalbán!"

The Examining Room brings us an advanced look at a book about a compassionate pediatric surgeon's experiences taking care of gruesome injuries and heartbreaking problems in Iraq.

Bringing together the worst in popular culture with a serious look at facial lacerations, Inside Surgery frames it up around Tiger Woods' car crash.

Other Things Amanzi posts Decisions for surgery: "when in doubt, cut it out".

In "The Seven", Elaine strains her neck trying to get a bike down from the wall. In pain she promises the bike to whoever fixes her neck. Kramer saves the day and wants the bike.

How to Cope with Pain published this post as part of a series on medications used for chronic pain. Ketamine, an anesthetic, holds great potential to help patients with chronic pain. However, currently it is controversial and still considered experimental.

Timed perfectly to coincide with the Twilight: New Moon vampire file fervour sinking its teeth deep into the world's neck, Canada's National Advisory Committee on Immunizations has updated its recommendations for rabies shots after bat run-ins. The requirement: "They must suck your blood."

In "The Parking Space", after borrowing Jerry's car, Elaine comes up with a wild story involving a pack of teenagers with a gun, because the car is now making a strange clanking noise.

Primary care physicians can assess readiness for treatment in depressed teens and should be prepared to follow teens not ready for treatment more frequently.

In "The Cheever Letters", George is to meet Susan's parents and is not looking forward to telling her father that his cabin had been burned down (by Kramer with the Cuban cigars Susan's father had given to George as a gift). Jerry suggests that the Rosses are likely to see the irony of the situation.

Medicine for the Outdoors provides this comprehensive background report on Wilderness Emergency Medical Services

In "The Diplomat's Club", Pitt goes to the pharmacy and mistakes Jerry for a pharmacist, as he is re-stocking a display that Kramer had knocked over. Jerry then proceeds to give Mr. Pitt some medications.

Florence Dot Com in "Thanks for Speaking Up" thanks two patient safety leaders for speaking out about the case of an Ohio pharmacist who has been jailed for an on-the-job medication error. As the blogosphere lights up this week to commemorate the 10th anniversary of To Err is Human, it's worth pointing out or (as Wachter and Cohen have done) calling out stakeholder groups that are not yet on board.

Laika's MedLibLog challenges the legitimacy of homeopathic medicines and their place on pharmacy shelves.

In "The Note", Jerry, George, and Elaine get free physical therapy massage by getting a note from Jerry's dentist (Roy) to present to the insurance company.

Colorado Health Insurance Insider focuses on Addressing the Problem of Cost. " Obviously no single health insurance company can set out on its own to reduce reimbursement rates, since the result would likely be that doctors and hospitals would leave that network in favor of other carriers with higher reimbursement rates. A government-set fee schedule makes sense (and would go a long way towards standardizing our health care costs), but it would likely face tremendous opposition from medical lobbying groups."

InsureBlog takes on the former Chief of Staff of a large Michigan hospital regarding health care "reform."

In "The Jimmy", George says he shouldn't have exercised because, even though he took a shower, "it wouldn't take" — he's a "human heat pump" and will be sweating later at an important meeting.


Dr. Jolie Bookspan provided this humorous post on the Forward Air Head Syndrome - Doing Sets and Reps and Missing The Point of the Exercise. "The Department for Silly Syndromes has determined that Forward Air Head Syndrome is closely related to Cerebral Detachment Syndrome..."

Thanks to Wikipedia for the Seinfeld descriptions.