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March 1998
Volume 62 |
Number 3
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WASHINGTON REPORT
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| Congress to Consider
Medicare Expansion, Possible Limits on Managed Care Abuses |
Michael Scott, Director
Governmental and Legal Affairs
Shortly before delivering his State of the Union address on January
27, 1998, President Clinton proposed to open up the Medicare program
for two relatively small groups of older Americans who increasingly
have difficulty in buying affordable health insurance. If enacted,
the proposal would represent the first time that people, otherwise
ineligible for Medicare, would be permitted to "buy in" to the
program.
The first group covered by the President's proposal would
include individuals aged 62 to 64, who could sign up for Medicare
by paying a fee of about $300 a month. After turning age 65, they
would then pay a monthly surcharge over the normal premium of
between $10 and $30, depending on how soon before age 65 they
had signed up. The second category, so-called displaced workers
beginning at age 55, would be allowed under certain circumstances
to buy in at a premium of $400 a month.
Further details of the President's proposal have not yet
been defined, but the essential purpose would be to assist a relatively
small group, estimated to number about 300,000, to bridge the
health insurance gap between employer-provided insurance and Medicare
in an era when many Americans are retiring or being retired before
age 65.
Most congressional observers believe that the Administration's
suggested premiums will not be adequate to cover the cost of these
new beneficiaries, especially if one assumes the proposal would
principally be attractive to sicker retirees. It is generally
expected, however, that the proposal will receive serious consideration
during the current session. The greatest likelihood is that ultimately
it will be referred to the newly constituted presidential advisory
commission on Medicare, now that Senator John B. Breaux (D-LA)
has been named chair.
What has not been unnoticed, however, is the Administration's
possible hidden agenda: as a practical political matter, the only
way the new commission could consider raising the eligible Medicare
age from 65 to, say, 67, is to make sure that a safety net is
in place for those forced into early retirement. Conceptually,
the commission, in trying to rein in the Medicare program, has
before it the Homeric choice between the Scylla guards to port
and the Charbydis to starboard: raise taxes or cut benefits. But
raising the eligibility age and perhaps adding means-testing premiums
steer a shaky course in between.
Besides the President's proposal on retirees, the only
health care issue expected to receive serious congressional attention
in 1998 will involve the various proposals to deal with managed
care abuses, or stated more euphemistically, to establish greater
patient protections. The President weighed in on the issue during
his State of the Union address, declaring that "medical decisions
ought to be made by medical doctors," not insurance clerks.
Representative Charles Norwood (D-GA) used the long congressional
recess as an opportunity to lobby his "Patient Access to Responsible
Care Act" (H.R. 1415) to various medical groups, including the
Patient Access to Specialty Care Coalition (of which ASA is an
active member) and the Board of the American Medical Association
during its December meeting. Both groups have given only qualified
endorsements, principally because of a provision in the bill that
would require managed care organizations not to discriminate among
providers on the basis of licensure. The AMA has told Representative
Norwood that it is prepared to endorse his bill if the antidiscrimination
provision is amended to make clear that managed care organizations
can discriminate on the basis of training and experience, and
ASA is supporting the AMA's efforts.
In late January, a coalition of business groups and health
care maintenance organizations announced the kick-off of a major
campaign to kill patient protection legislation in this Congress,
saying that the various proposals would unacceptably raise premium
costs. The GOP congressional leadership is not unsympathetic to
this view, essentially believing that the question of patient
protections should be left to the marketplace to solve. In the
last analysis, the issue ultimately will be whether the Republicans
eventually decide that they must enact at least some protections,
as they head into the November elections.
HCFA Extends Comment Period For Conditions of Participation
With less than a week to go before the February 17 deadline,
HCFA announced that it was extending, for 60 days, the period
for public comments on its proposal to eliminate the long-standing
federal requirement that nurse anesthetists be supervised by a
physician. The new deadline is April 20.
It is not precisely clear why HCFA took the action that
it did. We are aware that some influential health policy advocates
believe that, in general, the proposed rule - of which the proposal
on nurse anesthesia is only a small part - is not well-drafted
and requires extended analysis.
Based on copies of letters received in the Washington
Office, I estimate that by the time of extension, about 3,500
ASA members had filed comments with HCFA. Commitments of support
had also been received from the American Medical Association,
the American College of Surgeons and other surgical groups, and
numerous community groups. The extension obviously permits us
time to gain even greater support. At the same time, I want to
acknowledge our appreciation to ASA members who have already written,
and to apologize for the fact that it has not been possible for
us to individually acknowledge receipt of the letters.
At this writing, it is reasonable to anticipate that the
American Association of Nurse Anesthetists will use the additional
time to step up its campaign, evident from the beginning of the
original comment period, to attempt to gain congressional support
for the proposed HCFA rule. Needless to say, ASA representatives
will respond to this effort, focusing particularly on the fact
that Medicare beneficiaries have made absolutely clear their desire
to have a physician involved in their anesthesia care.
ASA, AANA Meet With HCFA On Medicare Payment Rules
Acting pursuant to authority given by the 1997 House of Delegates,
ASA President William D. Owens, M.D., and President-Elect John
B. Neeld, Jr., M.D., met in Baltimore, Maryland, on February 10
with representatives of the AANA and HCFA to discuss possible
changes in reimbursement rules for Medicare medical direction
cases. ASA's principal objectives in participating in the meeting
were to gain for its members somewhat greater flexibility - consistent
with modern anesthesia practices - in the conditions for medical
direction reimbursement and to persuade HCFA to establish workable
documentation requirements for reporting compliance.
There appeared to be a significant level of agreement
between ASA and AANA representatives as to appropriate changes,
and HCFA has agreed to take the matter under advisement. It appears
possible that, based upon the discussion at the meeting, HCFA
may propose changes in its reimbursement rules in the 1999 Medicare
Fee Schedule proposed rule, due to be published May 1.
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The comment period on the HCFA proposed rule change
has been extended to April 20.
Address your comments to:
Nancy-Ann Min DeParle, Administrator
Health Care Financing Administration
Attention: HCFA-3745-P
P.O. Box 7517
Baltimore, MD 21207-0517
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