July 1997
Volume 61 |
Number 7
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WASHINGTON REPORT
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| Congress Adopts
Budget Resolution; Committees Draft Medicare Changes |
Michael Scott,
Director
Governmental and Legal Affairs
Shortly after returning from the Memorial Day recess, the Senate
and House ironed out their minor differences concerning provisions
of the five-year budget resolution, and the various congressional
committees began work to implement its terms.
For physicians, the key committees were Ways and Means and Commerce
in the House and Finance in the Senate. Almost immediately after
the end of the recess, the Ways and Means Health Subcommittee,
chaired by Representative William M. Thomas (R-CA), began its
markup of the Medicare portion of the budget reconciliation bill.
That markup lasted for about five hours, after which the Chairman's
bill was reported out to the full committee without amendment.
Of importance to anesthesiologists, the bill contained a provision
setting the 1998 anesthesiology Medicare conversion factor (CF)
at 46 percent of the new single conversion factor for all other
specialties, as recommended by the Physician Payment Review Commission
(PPRC). ASA had lobbied heavily in favor of the PPRC recommendation
and against the President's proposal to cut the anesthesiology
CF by 10 percent. Under the subcommittee's approach, the 1998
anesthesiology CF would be $17.08, which is a 2.4-percent increase
over 1997.
On June 9, the full Ways and Means Committee took up the subcommittee
bill and approved it with a minimum of debate. During this markup,
ASA was able to persuade committee staff to make technical amendments
to the anesthesiology provision, making clear that the 46:100
ratio could be adjusted in future years as a result of changes
in relative values related to physician work, practice expenses
or malpractice costs.
Prior to the full committee markup, ASA representatives began
to hear rumors that an amendment sponsored by the American Association
of Nurse Anesthetists (AANA) would be offered to do away with
the current requirement of physician supervision of nurse anesthetists
in the Medicare Conditions of Participation for Hospitals. ASA
President Phillip O. Bridenbaugh, M.D., sent letters opposing
any such amendment to all Ways and Means Committee members, and
ASA key contacts followed up with individual calls. Gratifyingly,
the potential sponsor of the amendment decided at the "11th
hour" not to put it forward. As a consequence, because the
House Commerce Committee does not have jurisdiction over such
matters, it does not appear that any such amendment will be included
in the House version of the reconciliation bill.
As of this writing, it appears that both the House Commerce and
Senate Finance versions of the reconciliation legislation will
substantively track with the Ways and Means bill on the anesthesiology
CF issue. Whether or not the AANA will attempt to advance its
amendment in the Senate is not clear at this point, but key contacts
have been alerted in any event.
The GOP leadership in the House is predicting that the House
will complete its work on a budget reconciliation bill by the
Fourth of July recess. This target seems quite optimistic, but
ASA is pursuing its lobbying efforts as if the prediction were
correct. Although final Senate Finance Committee action is likely
by that date, the rules of the Senate are such that Senate action
on budget reconciliation will almost certainly carry over to the
summer.
Pressure Mounts on Congress to Revise Practice Expense Date
Several physician organizations are currently bombarding the
Congress with pleas to extend the effective date, now fixed by
statute as January 1, 1998, for implementation of resource-based
practice expenses under the Medicare Fee Schedule. As noted in
previous columns, the principal basis for these requests is that
the Health Care Financing Administration (HCFA) is developing
its proposed revisions to the practice expense component of reimbursement
for the various medical and surgical procedures on the basis of
inadequate, flawed data. If more time and analysis are not devoted
to this project, severe dislocations in the delivery of medical
care will occur.
At this point, there is no clear indication of what action Congress
will take on this issue. Some GOP leaders have suggested that
the new practice expense values should be phased in over three
to five years, rather than delaying implementation of the new
values. Both the Practice Expense Coalition and the AMA oppose
this approach, arguing that phasing in flawed data is simply no
solution at all.
In all likelihood, HCFA's proposed rule setting forth the new
values will have been published by the time this column appears.
As a practical matter, the content and methodology represented
by that rule will have much to do with whether Congress acts to
delay the effective date. Current information suggests that HCFA
intends to publish three "options" for determining the
practice expense component and, if this turns out to be true,
that fact will lend credibility to the argument that more time
is required to develop and verify new values.
ASA's stake in this issue is uncertain, even at this late date.
When HCFA published tentative values for the various specialties
last January, it did not include anesthesiology, essentially because
anesthesiology is reimbursed somewhat differently from other specialties
under the Medicare Fee Schedule and HCFA did not have the time
to translate its research into anesthesiology values. ASA has
since learned informally from HCFA personnel that HCFA does not
expect any significant change in anesthesiology practice expense
values, but we cannot be sure of this until the HCFA proposed
rule appears.
As a check against HCFA's proposed values, ASA commissioned Abt
Associates Inc. to conduct a survey of anesthesiology practices
in order to determine national average practice expense values
for the specialty. Abt reports that the data received from surveyed
practices is of high quality, and it is anticipated that survey
results will be available to the ASA leadership well before the
Society's comments on the proposed HCFA rule must be filed.
Co-sponsorships Grow on Bills Regulating Managed Care Excesses
In mid-May, Senator Charles E. Grassley (R-IA) introduced the
Medicare Patient Choice and Access Act of 1997 (S.701) as a Senate
companion measure to H.R. 66, introduced in the House earlier
this year by Representatives Tom Coburn (R-OK) and Sherrod Brown
(D-OH). Original co-sponsors of the Senate bill were Senators
Kent Conrad (D-ND), Jesse Helms (R-NC), Alfonse M. D'Amato (R-NY)
and Richard J. Durbin (D-IL). H.R. 66 enjoys 100 co-sponsors in
the House.
The companion bills would impose a series of restrictions and
requirements on Medicare managed care organizations, including
the requirements that such plans: 1) offer a point-of-service
option at the time of enrollment, 2) offer a meaningful grievance
procedure to enrollees and 3) make a checklist available to prospective
enrollees with essential plan information. Plans are prohibited
from maintaining a "gatekeeper" incentive program that
would limit medically necessary care or, through so-called "gag
clauses," would restrict most communications between provider
and patient concerning care and treatment options.
More than half of the members of the House have co-sponsored
a bill (H.R. 586) introduced by Representatives Greg Ganske (R-IA)
and Edward J. Markey (D-MA), dealing with the prohibition on managed
care gag clauses. Both independently and through the Patient Access
to Specialty Care Coalition, ASA is supporting both these measures
in the face of vigorous and well-financed opposition by the managed
care industry.
An additional bill enjoying significant co-sponsorship is H.R.
1415 introduced by Representative Charles Norwood (R-GA), as well
as its companion measure in the Senate, S.644, introduced by Senator
D'Amato. Although ASA supports many provisions of these bills,
it has not endorsed them because of a provision prohibiting managed
care organizations from excluding providers from their plans solely
on the basis of type of licensure. This provision is strongly
supported by the American Association of Nurse Anesthetists and
many other nonphysician provider organizations. ASA believes a
managed care organization should be free to decide which types
of providers it wishes to include on its panel; the AMA also has
advised Representative Norwood of its reservations on essentially
the same ground.
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