Does Patient Engagement lead to Higher Bills?

 

From Science Roll

“Patients who helped with medical choices had higher bills: Let’s Analyze This!

by Dr. Bertalan Meskó on June 1, 2013

As a huge fan and supporter of e-patients who want to use digital technologies and the information they find online in their health management, I don’t like news articles speaking against them without explanations and data.

The healthcare social media community has been discussing a study that concluded patients who wanted to participate in medical decision making had higher bills. It might predict that e-patients will have higher bills as well. Let’s take a look at it:

Analyzing the data, the researchers found that nearly all — 96.3% — wanted to receive information about their illnesses and treatment options, but that only 28.9% said they had a strong preference for making their own decisions about their care.

Those patients had longer hospital stays, by about a quarter of a day on average, than patients who preferred let their doctors take the lead. They also had greater hospital costs ($865 more, on average.)  By and large, people who were more likely to participate in medical decisions were better educated, and more likely to have private insurance coverage, than the rest of the patients who were surveyed.

You see? It says patients who had a strong preference for making their own decisions about their care. E-patients are partners with their doctors, not making medical decisions themselves alone. That’s the difference.”

This makes sense and should not be surprising. Discussion of the medical issues is patient engagement and leads to patients and physicians reinforcing decisions. Physicians are much less reticent to investigate further after discussing issues with the patient rather than just ordering tests without the patient’s understanding.

• 
  

Why Kids go to the E.R.

 

Huffington Post:

 

Sneezing, runny nose and other cold-like symptoms are the top reason kids are brought to the emergency room, according to a new government report on the state of Americans' health that includes a special section on emergency care.

The data show cold symptoms accounted for 27 percent of kids' ER visits in 2009 and 2010, and 14 percent of adults' ER visits.

The report also showed that Medicaid recipients were more likely to go to the ER at least once in a year, compared with people without health insurance or people with private insurance.

The use of advanced imaging (such as CT scans or MRIs) during ER visits has also increased, going from being used in 5 percent of visits in 2000 to 17 percent of visits in 2010.

More highlights from the report:

- About one in five people visited an emergency room in the last year, while 7 percent of people visited an emergency room two or more times in the last year.

- Falls were the No. 1 injury-related cause of an ER visit from 2008 to 2010.

- Life expectancy has increased slightly for men and women between 2000 and 2010, going up from 74.1 years for men in 2000 to 76.2 years in 2010, and 79.3 years for women in 2000 to 81 years in 2010.

- Deaths from heart disease decreased by 30 percent from 2000 to 2010.

- Deaths from cancer decreased by 13 percent from 2000 to 2010.

Nineteen percent of Americans smoked cigarettes in 2011.

- The number of U.S. adults ages 20 and older with a body mass index between 30 and 34.9 was 20 percent from 2007 to 2010, up from 14 percent during 1988 to 1994.

- Fewer U.S. adults had uncontrolled high blood pressure in 2007-2010: 49 percent, versus 74 percent in 1988-1994.

- Fewer U.S. adults had high cholesterol in 2007-2010: 14 percent, versus 20 percent in 1988-1994.

- A little less than half of U.S. adults didn't meet federal exercise guidelines (at least 150 minutes of moderate to intense exercise each week).

- Slightly fewer young Americans are uninsured now: 34 percent of people ages 19 to 25 in 2010, down to 28 percent in 2011.

SUMMARY:  FEWER HEART DISEASE RELATED DEATHS: ELEVATED CHOLESTEROL LEVEL DECREASED: CANCER DEATHS DECREASED BY 13%

LIFE EXPECTANCY INCREASED FOR BOTH MEN AND WOMEN

MAJOR PROBLEMS:   OBESITY, SMOKING

Healthcare approaching a nexus of Star Trek: The Tricorder, Incentivizing mHealth Innovation

 

 

Qualcomm (San Diego, Ca) a company well known for development of cellular phone technology is sponsoring an  XPRISE competition for an award worth $10 million global in a competition developed to incentivize healthcare technology

innovation.  The goal is to develop a hand-held device that would allow a consumer to access the state of their own health anytime, anywhere.

The goal is to develop a hand-held device that would allow a consumer to access the state of their own health anytime, anywhere.  The device will be able to capture key health metrics and diagnose a set of 15 diseases.  These metrics could include blood pressure, respiratory rate and temperature.  The device would ultimately collect large volumes of data from ongoing monitoring.

So far, more than 250 teams from around the world have already filed Intent to Compete forms. Look at this map (from the website) to see where the teams come from:

 

HealthWorks Collective’s Joan Justice interviews Mark Winter, Senior Director, Qualcomm Tricorder XPrize, to get an update.

 

BOOTILICOUS----The formula for Beyonce’s Butt

 

Alternative title:   The Algo Conspiracy, or how a graph deceives us . What Beyonce can tell us about health statistics, or what are we measuring?

Huxters play on this….”The Million Man Match” “Hummers are more Green than Prius’  These are distortions to prove a pre-conceived goal.

Charles Seiffe explains:

Healthcare decisions, like those in other fields are based upon statistics, which measure disease, treatment, alternative treatments, outcomes, reimbursements, market share,,morbidity, mortality. Well to sum it up, watch the video. It tells it much more eloquently than I am able to.

 

del.icio.us Tags: algorithm,statistics,graphs

What I’ve learned from saving physicians from suicide

 

At one time or another we all face this demon, and develop the defensive adaptation to deal with it successfully.  However there are very many highly intelligent and responsible physicians who fall into the black hole of desperation. How do we help them?

I ask the group, “How many physicians have lost a colleague to suicide?” All hands are raised. “How many have considered suicide?” Except for one woman, all hands remain up—including mine.

 

From KevinMD by Pamela Wible MD

A psychiatrist in Seattle had picked out the bridge. At 3am he would swerve across his lane and plunge into the water. Everyone would assume he fell asleep.

A surgeon in Oregon was lying on the floor of her office with a scalpel. Nobody would find her until it was too late.

An internal medicine resident in Atlanta heard an anesthesiologist joking about the lethal dose of sodium thiopental. Alone in the call room, she would overdose that night.

Three planned suicides. All three physicians survived. Why?

Physicians have the highest suicide rate of any profession,” I explain. “In the United States we lose over 400 physicians per year to suicide. That’s the equivalent of an entire medical school. Even that’s an underestimate because many physician suicides are incorrectly identified as accidents.”

While preparing to overdose, the internist was interrupted by an endocrinologist calling to check on her. Before grabbing her scalpel, the surgeon called several physicians pleading for help—I responded immediately. Two days before he was to drive off the bridge, the psychiatrist spotted my ad for a physician retreat. He called me begging to attend.

It’s easier to say accident than suicide. Doctors can say gonorrhea and carcinoma. Why not suicide? Maybe we can’t face our own wounds.

Too many patients and not enough time sets us up for failure. Rather than kill myself, I invited my patients to help me design an ‘ideal clinic.’ It is possible to love medicine again.”

Here, physicians, nurses, and medical students share their wounds and their wisdom—in community. We share new practice models, communication techniques, and strategies to care for ourselves—so we can care for our patients.

Tonight we begin a retreat for doctors who yearn to love medicine again. Studies confirm most doctors are overworked, exhausted, or depressed. The tragedy: few seek help.

In four days, I witness more healing than in four years of med school. Once strangers, we’ve become family. Parting ways, the psychiatrist from Seattle thanks me again……..excerpts from the story

 

del.icio.us Tags: suicide,physician suicide,overdose,accidental overdose,scalpel,physician retreat,psychiatrist,anesthesiologist

Would Toys decrease the Cost of Health Care Devices?

 

What may be a new and disruptive technology in healthcare is being studied and developed at the MIT Little Devices Laboratory,, part of the International Innovations and Health Group.

Currently medical devices are very expensive for a variety of reasons, research and development, patent licenses, marketing cost, government regulations and more.  Our current development cycle does little to reduce the cost of such devices.

 

MIT sells a Medikit (MEDIKits (Medical Education Design Invention Kits) are Do-It-Yourself medical device kits designed to foster innovation and creativity with all the pieces to assemble a medical  device

The devices are assembled from a variety of Lego parts, the internal workings of other toys with electronic parts, LEDs,

By demystifying medical technology and providing appropriate tools and materials, MEDIKit enables healthcare professionals to develop their own solutions.

As an innovation in international health it affords affordable medical devices for patients who would otherwise have nothing.

Medical Devices are not Toying Around 

The term DIY Medical Device might conjure images of a FDA nightmare in the minds of most. But in a time when healthcare costs are increasing globally, Jose Gomez-Marquez, director of the Director of the IIH (Innovations in International Health) Lab at MIT, has embraced the idea by heading up MIT’s Little Devices group, dedicated to design, invention, and policy toward DIY health technologies.

 

Created with the healthcare needs of the developing world in mind, the MEDIKit (Medical Education Design and Invention Kit) allows medical professionals to design their own medical devices using easy-to-assemble modular components. The MEDIKit allows users to customize and quickly assemble medical devices that address the challenges of work environments in many developing nations.

Right now the MEDIKits span six areas: drug delivery, diagnostics, microfluidics, prosthetics, vital signs, and surgical devices. Each kit contains a platform with a combination of medical device parts that can be adapted and assembled into various functions like LEGOs. In fact, many of the Little Devices group’s many still developing projects revolve around reconfiguring and finding new uses for cheap, readily available products (like toys).

Watch the Video about fluidics, diagnostics and more using inexpensive materials such as paper to test for Anemia, Dengue, Protein Content, and routine laboratory testing.

 

del.icio.us Tags: medikits,leggo,diy,medical devices,medical technology,toys,mit little device lab

PRACTICE PROFITABILITY

 

QuantiaMD, an online medical education site recently did a survey on medical practice economics, as reported from HIT Consult  (Fred Pennic).

Many medical practices operate on the edge of insolvency on a month to month basis. Predicting monthly income is a challenge dependent on timeliness of reimbursements, practice volume, cyclic demands of overhead and accounts payable in addition to the increasing demand of health information technology capital investment as well as maintenance costs.

Although purchase of EMR has been subsidized by the federal and state governments, it comes with a price of increase reporting requirements (meaningful use) as well as the conversion from ICD-9 to ICD-10 coding.

The initial funding by HHS for EMR purchases does not include the considerable hardware/software maintenance.  This cost is considerable and often amounts to as much as the original capital investment.

Although the Affordable Care Act is intended to improve outcomes, and  increase accessibility to care for patients sadly lacking is cost containment for operating medical practices and hospital operations.

 

INFOGRAPHIC

“The Physicians’ journey for profitability can be measured with the PPI (Physicians Profitability Index)  The study was done in April 2013 with the survey of 5,012 physicians.

The opinions reveal a dichotomy of approval/dissatisfaction with the status quo.

The overriding concern is indicated by the fact that only 9% believe their staff and technology are adequate to “getting paid”.

36% felt that profitability was trending down while 22% of those surveyed saw profitability as trending up.

When asked what were the concerns about profitability there was a large regional difference.

Declining reimbursements: 65%,   Rising costs 57%   Affordable Care Act  48%  Coding and billing changes 44%

Accessibility for patients was a large regional difference, with California Physicians (48% ) expressing doubts about absorbing the increased patient load from the ACA.

Maintaining independence was highest in California, Massachusetts, and Texas.

A surprising finding was that over 60% of independent physicians were not interested in selling their medical practice.

How are physicians looking to  increase profitability?  Streamlining billing process 50%   Improving technology 31%  Optimizing staff 31%”

48% seek guidance from peers for improving their practice profitability.

 

del.icio.us Tags: physicians,physician profitability,rembursement,affordable care act,billing,staff,technology HHS,EMR,ICD-10,Fred Pennic,HIT Consult,PPI,Physician Profitabilty Index

Not quite a “Blue Screen” perhaps HIE needs just a Reboot

 

After five or more years of terrifyingly slow progress in developing a nationwide health information network, several large enterprise vendors have agreed to bypass the nationwide effort in favor of their own agreement. While not stating the impetus to form their own alliance the vendors have entered into an agreement, named “CommonWell Alliance”

Frustrated with the snail-like pace for development of health information exchange, several U.S. Senators have suggested a ‘REBOOT”. This is detailed in a white paper entitled, “Re-examining the Strategies Needed to Successfully Adopt Health IT. They took issue with what they said is paltry progress on system interoperability so far, raised alarms about unnecessary billing enabled by EHRs, sought better oversight of the MU program, called for more stringent patient privacy protections and wondered about the chances for long-term health IT sustainability.

And at the same time there has been a critique of the new plan from the EHRA (EHR Association) Their concerns include launching  a new Collaborative .

One of the main criteria for incentive funding for providers is meaningful use and attestation requiring interoperability and the ability to communicate with differing vendor EMRs.  What happens after the fact when many providers find their EMR, although certified as interoperable by CCHIT, Drummond, or ANSI do not function correctly, and has not been used. Will HHS demand refunds from providers who have already received their incentive payments?.

I would enjoy hearing comments and feedback about the Reboot

 

Technorati Tags: ehra,commonwell alliance,health IT,drummond,cchit,ansi,hhs,incentive payments,interoperability

Health Insurance Card does not mean You have Healthcare

 

 

I was a big fan of Andy Rooney, that curmudgeon that reported television news in a manner that caught our attention using a combination of disbelief and an air of incompetence and confusion.

It went a bit like this, “I can't complain about my life….neither should we.

I’ve been reading about the new health care law, and I am somewhat confused. Perhaps one of my listeners could explain this to me better."?!

I am getting close to the age where I should be a bit confused, but my younger colleagues also seem confused about the Affordable Care Act. There are those who think the ACA is the best thing since Medicare went into effect in 1964. At the time it may have been true, but the Congress did not listen to the medical establishment who said it would bankrupt the country in short time. In less than 50 years, this has become largely true.

Then there remain significant numbers of providers who say  “Hell no, I will go!” Go where? Anywhere, but certainly not stay in medicine.  I was brought up in an era where ethics and patient welfare were the first, last and always guiding light for practitioners.  My decisions now can be overrriden by a clerk with a pencil checking or unchecking boxes

Some advocates like to level the playing field by calling themselves consumers, instead of patients, and physicians are providers, not doctors.

I preface my remarks by stating that I unequivocally believe that health insurance should be a right, however not at the expense of providing an inadequate program that tramples upon human rights, individual liberties, nor economic common sense.

The Affordable Care Act was born in the midst of confusion and not read by our illiterate congress and senators.  Imagine our leaders, the head of the Democratic part in the Senate stating that we would not know what was in the Affordable Care Act would do until it was passed.

From what I read the Affordable Care Act is not affordable, nor is it patient oriented. Patients really had little to do with its formation. (but more about that later)

My mind works more slowly now, so perhaps I will rest a bit and wait for my next curmudgeonly ideas to form .

The Trials of Progress in the Affordable Care Act

 

Five months after primary care doctors who treat Medicaid patients were supposed get a big pay raise, most physicians have yet to see it.

While Medicaid fees vary by state, they are generally far below those paid by Medicare and private plans. The change means an average 73 percent average pay increase nationally, according to a 2012 study by the Kaiser Family Foundation (Kaiser Health News is an editorially independent program of the foundation.)

One of the main tenet of the ACA is the assimilation by Medi-caid of the eligible uninsured.  In order to attract more physicians who will accept medicaid CMS and the states have promised to increase reimbursements for physicians who accept Medicaid.

Stephen Zuckerman, senior fellow at the Urban Institute, said doctors were hesitant to sign on as a result of the pay raise given that it expires at the end of 2014, and the implementation problems won't help. "Because of the temporary nature of the pay raise, it was always questionable how many doctors would jump at treating Medicaid patients if they had not done in the past," he said. "If doctors were tentative before, they still have a reason to be."

The federal government’s offer to fund the increase for the first several years leave a very real open question as to how state’s will fund it when the federal subsidy ends.

It does not look promising as even before the ACA’s January 2104 timetable kicks in with this delay.  The ACA requires the reimbursement increase for medicaid in 2014.

Is this a portender to the financial squeezes of the ACA?  The Affordable Care Act only mandates the reimbursement rate if the physician attests to being a primary care provider. Earlier this year, CMS said doctors will be able to get the higher fees retroactively to Jan. 1, when states do implement the provision. But many states have set deadlines for April and May for doctors to self-attest that they are primary care physicians in order to get the retroactive pay. Those that miss the deadline will only receive the pay raise once they fill out a form showing they are licensed as a family doctor, pediatrician or internist.  (Many OB/GYN MD’s offer primary care as well.)

 

Technorati Tags: medicaid,aca,affordable care act,kaiser foundation,medi-caid,cms demonstration program,attestation,family physicians,internist,pediatrician,january 2014

Uncertainty Still Clouds Health Care Law

 

The New York Times summarizes quite accurately the current status of the Affordable Care Act.

Three years after President Obama signed the health care reform law, there are concerns that the process of implementing it will be rocky. Even some of the law’s supporters are worried.

Perhaps more troubling for the White House, the Affordable Care Act is still not well liked or well understood. The Obama administration had hoped that over time, the legislation would gain enough support to help smooth over the rough patches of putting it into practice. Instead, public opinion has remained mostly static: a plurality of Americans still disapprove of the law, and a substantial portion of the public remains uncertain about what it says, according to recent polls.

Now the National Physician’s Alliance has published and emailed a position paper endorsing the ACA as the greatest good for the public health, without addressing basic concerns expressed by those who oppose the ACA as it is now mandated.

Their own analysis reveals the dichotomy of approval and disapproval of specific portions of the ACA, and disregards the critical financial aspects of implementing the far reaching mandate that will reach into every sector  of our lives and the economy.

There is even confusion about whether the health care law is still, in fact, law. A Kaiser Family Foundation survey [PDF] conducted in April found that 41 percent of American adults did not know that the Affordable Care Act remains the law of the land. A separate tracking survey conducted by Kaiser, which has done far more surveys on health care than any other polling organization, found that roughly half of American adults said they did not have enough information about the law to understand how it will affect them.

 

The National Physicians Alliance disregards several key and critical elements:

1. The use of the IRS to monitor businesses who provide, and individuals who have health insurance.

2.The misguided intent to expand Medi-caid to accept the uninsured.  It is a means tested subsidy

3.The effects upon business growth and increasing business operating expenses.

4.The largely untested rate of implementation and the integrated use of health information technology and federal incentives and subsidies for HIT

5.The effects of meaningful use, forcing MDs to accept inadequate electronic medical records systems which reduce clinical efficiency.

6.The lack of accessibility to primary care physicians in many regions of the country. This will take at least five to eight years to address unless unqualified

Even the National Physician’s Alliance whose work is guided by the principles for health care reform advanced by the Institute of Medicine: proposes that:

1. Health care coverage should be universal.
2. Health care coverage should be continuous.
3. Health care coverage should be affordable to individuals and families.
4. The health insurance strategy should be affordable and sustainable for society.
5. Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.

The ACA as written cannot meet the requirements of #4.

Conclusions:

One reason the Obama administration might still be optimistic is that while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law.

For example, Kaiser has found that about 70 percent of adults support providing financial assistance to low- and moderate-income Americans who do not have employer-provided health insurance, and also that about 70 percent support health insurance exchanges and the elimination of out-of-pocket costs for many preventive services — both elements of the health care law.

Physicians by a vast majority want a Health Law that will insure all Americans, they are a keystone for healthcare, they know what has worked and what does not, and we insist on a stable workable model financially for all components of the health system…..not a pipe dream.

 

Technorati Tags: aca,affordable care act,kaiser foundation,institute of medicine,health care reform,national physicians alliance,obamacare

How to Start A Movement

 

We are seeing the second phase of HIT adoption….the leaders have come and gone, and how the second and third tier of users are multiplying.

It is easy to explain and visualize from a TED talk by Derek Silver

The same mechanism will apply to the Accountable Care Act and perhaps Accountable Care Organizations.  The challenge with ACA is to make it a financially sustainable business model.

The same applies to Integrated Health Systems. 

However in the case of IHS the first indications are a decrease in individual practitioners with some collaboration and business solutions to reduce overhead and hopefully improve efficiency. This phase is largely driven by economic concerns and market dominance in a region. 

The current planned changes in reimbursement will be a driver for the next phase of integration.  This phase will require a sophisticated data analytical approach to determine changes in outcomes based upon  treatment models.  It is expected  that outcome improvements will lower costs.

The further growth of HIS will be at the expense of the present individual, and small medical groups.   Eventually the Integrated Health System will provide the most efficient administrative and clinical organization.

The team approach will become mandatory for clinical  excellence.

Integrated health systems such as Mayo Clinic, Kaiser Permanente, Cleveland Clinic, Henry Ford Hospital Systems and many others are at a distinct advantage to develop the accountable care organizations described by CMS. University Systems also provide an integrated system with their own faculty medical groups or those physicians already employed by the University.

The investment necessary to develop these organizations will be felt the most by the smaller entities that will require information technology infrastructure outlay, as well as C-suite reorganization. 

In many cases this will also require physical relocation and not be isolated to just IT and/or administrative functions.

The pushback against the ACA has become considerable, however organization and communicating with all of Congress is essential, both Democrats and Republicans.

 

Technorati Tags: integrated health system,aca,obamacare

OBAMACARE 411

 

About three months ago I posted an edition title “Obamacare 911”   For some reason this excited the search engines and I continue to receive a majority of hits when people search. Not certain if it’s the Obamacare or the 911, or perhaps both.

Today I realized Obamacare 411 is a much better title. It hints that this is the place for Information, or today I guess it is called ‘Directory Assistance.”

Health Train is here ready to serve your 411 and even 911 requests.  I recommend you dial 911 if it’s a life threatening emergency or what you perceive to be life threatening. (for instance, I am out of vanilla ice cream)

411 or Directory assistance for the Accountable care Act is becoming overloaded. The numbers and information changes rapidly

Sen. Max Baucus    HHS Kathleen Sebelius

Senator Max Baucus (Democrat) who previously supported the Affordable Care Act strongly admonished the Head of HHS (Kathleen Sibelius) before a congressional  hearing stating the law was badly flawed and miscalculated in terms of start up expenses.

WASHINGTON – A senior Democratic senator who helped write President Barack Obama’s health care law stunned administration officials Wednesday, saying openly he thinks it’s headed for a “train wreck” because of bumbling implementation.

“I just see a huge train wreck coming down,” Senate Finance Committee Chairman Max Baucus, D-Mont., told Obama’s health care chief during a routine budget hearing that suddenly turned tense.

Baucus is the first top Democrat to publicly voice fears about the rollout of the new health care law, designed to bring coverage to some 30 million uninsured people through a mix of government programs and tax credits for private insurance.

A six-term veteran, Baucus expects a tough re-election in 2014. He’s still trying to recover from approval ratings that nosedived amid displeasure with the health care law in his home state.

Normally low-key and supportive, Baucus challenged Health and Human Services Secretary Kathleen Sebelius at Wednesday’s hearing.

He said he’s “very concerned” that new health insurance marketplaces for consumers and small businesses will not open on time in every state, and that if they do, they might just flop because residents don’t have the information they need to make choices.

Responding to Baucus, Sebelius pointedly noted that Republicans in Congress last year blocked funding for carrying out the health care law, and she had to resort to raiding other legally available departmental funds.

The administration is asking for $1.5 billion in next year’s budget, and Republicans don’t seem willing to grant that, either.

At one point, as Sebelius tried to answer Baucus’ demand for facts and figures, the senator admonished: “You haven’t given me any data; you just give me concepts, frankly.”

“I don’t know what he’s looking at,” Sebelius told reporters following her out of the room after Baucus adjourned the hearing. “But we are on track to fully implement marketplaces in Jan. 2014, and to be open for open enrollment.”

That open-enrollment launch is only months away, Oct. 1. It’s when millions of middle-class consumers who don’t get coverage through their jobs can start shopping for a private plan in the new marketplaces.

But half the states, most of them Republican-led, have refused to cooperate in setting up the infrastructure of Obama’s law. Others, like Montana, are politically divided. The overhaul law provided that the federal government would step in and run the new markets if a state failed to do so.

After the hearing, Baucus’ office clarified that he still thinks the Affordable Care Act is a good law, but he questions how it is being carried out.

And the Washington Times Reports;

“rom the outset, the senator’s terse and pointed questions made it clear that he did not think her agency had done enough to implement key pillars of the law by 2014.

He also said he is “very concerned” by the lack of information among small business and accountants who are “throwing their hands” up over the law.

“I just see a huge train wreck coming down,” Mr. Baucus said Wednesday. “You and I have discussed this many times, and I don’t see any results yet.”

His comments turned heads because Republicans are typically the ones who openly criticize Mr. Obama’s signature domestic achievement.

Mr. Baucus has served in the Senate since 1978 but faces a tenuous battle for re-election in 2014.

Last month, he was among four Democrats from traditionally red states who voted against the Senate Democrats’ budget plan for the coming year. And Wednesday, he was among a handful of Democrats who did not support a bill that would expand background checks before certain gun sales signs of just how fragile his political terrain has become.”

 

Technorati Tags: max baucus,kathleen sebilius,acccountable care act,budget,obamacare911,obamacare411