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August 1999
Volume 63 |
Number 8
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WASHINGTON REPORT
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| President Offers
Medicare Reform Plan; Senate Votes Patient Protection Bill |
Michael Scott, Director
Governmental and Legal Affairs
To those of us forced to endure Washington weather in pursuit
of lofty goals, arrival of the dog days of summer this year has
seemed to touch off an ever-rising crescendo of events leading
up to the Fourth of July recess and beyond. The President finally
announced the outline of his Medicare reform plan, the Senate
debated and voted out a patient protection bill, hearings were
held in the House on a bill affording antitrust relief to physicians,
a new and radically improved bill on physician-assisted suicide
was introduced in both houses, the White House estimated that
the federal budget surplus over the next 15 years will be $15
trillion (that's 12 zeroes) larger than previously anticipated
and, not to be outdone, it was announced that Texas Governor George
W. Bush had already raised a staggering $36.3 million to "explore"
his presidential candidacy.
President's Medicare Plan
The centerpiece of the President's Medicare plan is a new voluntary
prescription drug benefit, with the government paying half the
cost of the first $2,000 per beneficiary in 2002, rising to half
the first $5,000 in 2008, at an initial premium cost of $24 per
month rising to $44 per month in 2008. Low-income individuals
and families would not be required to pay any premium for this
coverage. Estimated cost would be $118 billion over 10 years.
At a cost of an additional $3 billion, the President would also
eliminate co-payments and the deductible for certain preventive
services, including screening for prostate and colon cancer, bone
mass measurements, pelvic examinations and mammograms.
The plan would also include introduction of greater competition
among managed care organizations in the premiums they charge.
Health maintenance organizations (HMOs) would be required to offer
the same or greater services than covered by traditional Medicare,
and beneficiaries choosing low-cost plans would be permitted to
retain 75 percent of the savings.
In response to complaints by home health agencies and
skilled nursing facility administrators over the severity of cuts
imposed by the Balanced Budget Act of 1997, a $7.5 billion fund
would be established to provide additional funding where it could
be established that patient care had been impaired. No mention
in the plan was made of an adjustment to the current update formula
for the Medicare Fee Schedule.
Although the President's plan met with the predictable
mixed reviews, a general consensus appears to have emerged that
some form of voluntary prescription drug benefit should be developed.
Perhaps even more importantly, announcement of the plan essentially
starts the clock running on enactment of Medicare legislation
in some form this year, a fact important for possible inclusion
of a provision mandating the anesthesia outcomes study advocated
by ASA and called for in bills now pending in both houses.
Senate Passes Patient Protection Bill
By a vote of 53 to 47, with only two GOP Senators breaking ranks
to vote with the Democrats, the Senate, on July 16, adopted a
stripped-down bill containing modest new patient protections against
managed care excesses. Democratic Senate leaders characterized
the bill as a set of "empty promises," and shortly after the vote,
President Clinton promised to veto any legislation adopted by
Congress that resembled the Senate bill.
Perhaps most notably, the GOP majority as expected rejected
the concept of permitting patients to sue their insurer over coverage
decisions and instead adopted a combined internal-external grievance
procedure of questionable effectiveness. Many of the other patient
protections that were included, moreover, would be available only
to enrollees under employer self-funded plans that are beyond
the reach of state patient protection laws.
Although actual language of the GOP bill was not available
at press time, it appears that it includes a true "point of service"
option for most enrollees under employer self-funded plans. Such
a provision requires that an enrollee, at time of enrollment,
be offered at least one plan that would allow the enrollee to
select, without significant cost to the employer, a physician
outside the plan's provider network. ASA, as a member of the Patient
Access Coalition, has been working with other medical groups to
gain this kind of patient protection; many state laws already
require such an option under managed care plans other than those
self-funded by the employer.
Also of specific interest to ASA members, the bill apparently
contains a provision applicable to self-funded plans prohibiting
discrimination in the selection of panel providers solely on the
basis of licensure or certification. The provision is said to
be identical to that already applicable under the Medicare program,
and if so, then the plan would still be permitted to select among
providers on the basis of cost or quality considerations. ASA,
which did not actively lobby on this issue, has for some time
maintained that plans should be permitted to select among providers
on the basis of education, experience or outcomes - all of which
of course potentially fall under the rubric of permitted quality
considerations.
With the Senate having enacted its patient protection
bill, the scene now shifts to the House where the Republican majority
is considerably more shaky than in the Senate. At press time,
it was expected that the House Commerce Committee would promptly
begin to mark up the ASA-supported bill drafted by Congressmen
Charlie Norwood (R-GA), Tom Coburn (R-OK) and John Shadegg (R-AZ),
a bill that is considerably more favorable to patient interests
than that adopted by the Senate. This bill contains strong provisions
on point of service and right to sue over coverage decisions,
and does not contain a provider anti-discrimination clause such
as that apparently now in the Senate bill. A House floor debate
and vote is expected prior to the August recess.
ASA Responds to Testimony on Campbell Bill
On June 22, the House Judiciary Committee held a hearing on the
Quality Health Care Coalition Act of 1999 (H.R. 1304), introduced
by Representative Tom Campbell (R-CA) and co-sponsored by 131
Representatives from both parties. Under the bill, providers would
be permitted collectively to negotiate with health plans such
as HMOs, without concern that their action would violate the antitrust
laws.
Substantial testimony was heard both for and against the
legislation. The principal proponent was the American Medical
Association, supported by numerous specialty organizations, including
ASA. Representatives of both the Justice Department and the Federal
Trade Commission expressed their opposition. Also testifying against
the bill was Jan Stewart, President-Elect of the American Association
of Nurse Anesthetists (AANA), who expressed concern that physicians
would use the collective negotiation opportunity as a vehicle
to foster discrimination against competition by nonphysician providers.
ASA's response to this testimony,
submitted for inclusion in the record of the hearing, appears
on page 6 of this issue of the NEWSLETTER.
Noteworthy in connection with the hearing is the fact
that on the next day, the AMA House of Delegates voted to form
an entity to engage in the collective representation of physicians
who, because of employment status, may not currently join in negotiations
under the terms of the National Labor Relations Act. Further discussion
on the AMA action will be included in future issues of the NEWSLETTER.
Current Co-Sponsors of Anesthesia Bills in Congress
First announced in December 1997, the proposed rule to eliminate
the long-standing physician supervision requirement remains under
consideration by the Health Care Financing Administration (HCFA).
Three ASA-supported bills have been introduced in Congress calling
for an anesthesia outcome study, S. 818, H.R. 632 and H.R. 2002.
Two AANA-supported bills, S. 866 and H.R. 804, have been introduced,
requiring the proposed HCFA rule be placed into effect by January
1, 2000.
Sponsors of all the bills are listed on page 5. ASA
members are strongly urged to write listed Senators and Representatives,
expressing their appreciation for or disappointment with the legislator's
action on this important patient health and safety issue.
Where your Representative is not listed, please write asking for
support of H.R. 632 and/or H.R. 2002 (a slight variant of H.R.
632 introduced by some key House Democrats); Senators not listed
should be asked to support S. 818. Addresses should include the
member's name, U.S. Senate or U.S. House of Representatives, Washington,
D.C.; ZIP codes for Senators and Representatives are 20510 and
20515, respectively.
Nickles Offers Revised Pain Relief Bill
On June 23, Senator Don Nickles (R-OK), the Senate Majority Whip,
introduced a significantly improved version of his 1998 bill broadly
banning the use of controlled substances for assisted suicide.
The original bill, which attracted opposition from a wide coalition
of organizations, including ASA, was concerned with the promotion
of aggressive treatment of intractable pain in terminally ill
patients.
Senator Nickles' new bill, the Pain Relief Promotion Act
of 1999 (S. 1272), while denying support in federal law for the
intentional use of a controlled substance for the purpose of causing
death, sets forth in federal law the recognition that alleviating
pain is a legitimate medical purpose for dispensing a controlled
substance, even when increasing the risk of death, and is consistent
with public health and safety.
ASA's House of Delegates last year adopted a resolution
expressing the Society's opposition to assisted suicide as incompatible
with the role of the physician. ASA became the first medical association
formally to endorse the new Nickles bill, basing its endorsement
in major part on the recognition contained in the bill of the
legitimacy of aggressive treatment of pain through the use of
controlled substances. ASA also offered to work with the Senator's
staff to improve provisions of the bill calling for development
of educational programs for law enforcement personnel, to assure
that those individuals truly understand the nature of a pain management
practice.
On June 17, Congressman Henry J. Hyde (R-IL) introduced
a companion measure (H.R. 2260) in the House, with numerous co-sponsors.
Chances of passage of these bills are believed to be very good.
| (AL) |
Rep. Bachus, Spencer |
| (AL) |
Rep. Everett, Terry |
| (AZ) |
Rep. Salmon, Matt |
| (AZ) |
Rep. Shadegg, John |
| (CA) |
Rep. Becerra, Xavier* |
| (CA) |
Rep. Doolittle, John |
| (CA) |
Rep. Matsui, Robert T.* |
| (CA) |
Rep. McKeon, Howard (Buck) |
| (CA) |
Rep. Miller, Gary G. |
| (CA) |
Rep. Sherman, Brad |
| (CO) |
Rep. McInnis, Scott |
| (FL) |
Rep. Deutsch, Peter |
| (FL) |
Rep. Diaz-Balart, Lincoln |
| (FL) |
Rep. Goss, Porter J. |
| (FL) |
Rep. McCollum, Bill |
| (FL) |
Rep. Miller, Dan |
| (FL) |
Rep. Scarborough, Joe |
| (FL) |
Rep. Shaw, E. Clay, Jr. |
| (FL) |
Rep. Stearns, Cliff |
| (FL) |
Rep. Thurman, Karen* |
| (GA) |
Rep. Barr, Bob |
| (GA) |
Rep. Deal, Nathan |
| (GA) |
Rep. Isakson, Johnny |
| (GA) |
Rep. Lewis, John* |
| (GA) |
Rep. Linder, John |
| (IL) |
Rep. LaHood, Ray |
| (IL) |
Rep. Manzullo, Donald |
| (IN) |
Rep. McIntosh, David |
| (IN) |
Rep. Souder, Mark |
| (KY) |
Rep. Fletcher, M.D., Ernest L. |
| (MD) |
Rep. Ehrlich, Robert, Jr. |
| (ME) |
Rep. Baldacci, John E. |
| (MI) |
Rep. Dingell, John D.* |
| (MI) |
Rep. Ehlers, Vernon |
| (MN) |
Rep. Gutknecht, Gil |
| (MN) |
Rep. Ramstad, Jim |
| (MO) |
Rep. Talent, James |
| (MS) |
Rep. Shows, Ronnie |
| (MS) |
Rep. Thompson, Bennie G. |
| (MT) |
Rep. Hill, Rick |
| (NC) |
Rep. Burr, Richard |
| (NC) |
Rep. Hayes, Robin |
| (NC) |
Sen. Helms, Jesse |
| (NC) |
Rep. Jones, Walter, Jr. |
| (NC) |
Rep. Myrick, Sue |
| (NJ) |
Rep. Holt, Rush |
| (NJ) |
Rep. LoBiondo, Frank A. |
| (NJ) |
Rep. Pallone, Frank, Jr. |
| (NJ) |
Rep. Pascrell, William J., Jr. |
| (NJ) |
Rep. Payne, Donald M. |
| (NJ) |
Rep. Rothman, Steven R. |
| (NJ) |
Rep. Smith, Christopher H. |
| (NV) |
Rep. Berkley, Shelley |
| (NV) |
Rep. Gibbons, Jim |
| (NV) |
Sen. Reid, Harry |
| (NY) |
Rep. Forbes, Michael P. |
| (NY) |
Rep. Maloney, Carolyn |
| (NY) |
Rep. Walsh, James T. |
| (OH) |
Rep. Pryce, Deborah |
| (OK) |
Rep. Largent, Steve |
| (OR) |
Rep. DeFazio, Peter A. |
| (OR) |
Rep. Hooley, Darlene |
| (OR) |
Sen. Smith, Gordon |
| (PA) |
Rep. Brady, Robert A. |
| (TX) |
Rep. Bentsen, Ken |
| (TX) |
Rep. Brady, Kevin P. |
| (TX) |
Rep. Gonzalez, Charles A. |
| (TX) |
Rep. Green, Gene |
| (TX) |
Rep. Hall, Ralph M. |
| (TX) |
Sen. Hutchison, Kay Bailey |
| (TX) |
Rep. Sandlin, Max A. |
| (TX) |
Rep. Sessions, Pete |
| (UT) |
Rep. Cook, Merrill |
| (VI) |
Rep. Christian-Chris- |
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tensen, M.D., Donna |
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(Delegate from the Virgin |
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Islands) |
| (WA) |
Rep. Smith, Adam |
| (WY) |
Rep. Cubin, Barbara |
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