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Medicare officials may this year propose creating a new payment for time that doctors spend helping their patients plan for how they would confront terminal illness and rapid declines in health.
Patrick H. Conway, the chief medical officer for the Centers for Medicare and Medicaid Services, gave an update on this work Friday at an Institute of Medicine conference on end-of-life planning. CMS last year rejected a request from the American Medical Association to create a new billing code, but clearly signaled an interest in looking further at this proposal as part of a future rule on payments for doctors.
“In this year’s rulemaking, we will be considering whether to propose that code and whether there will be a payment for that code,” Conway said, adding that he couldn’t comment further.
Many doctors and lawmakers are pressing to incorporate end-of-life counseling into routine medical practice in the United States, moving beyond the limited discussion now covered as part of the wide-ranging “Welcome to Medicare” visit. The approach came under fire during the debate leading to enactment of the 2010 health law, with critics portraying it as a government effort to establish “death panels.”
Advocates for end-of-life planning say a lack of planning can lead people to suffer through needless treatments and long hospital stays when they might prefer to spend more time at home. Noted surgeon and author Atul Gawande pointed out at Friday’s meeting that the week in which people in the United States are most likely to undergo surgery is the last week of their life. Without advanced consideration, the wishes of the dying person can be overlooked in a hurried chain of discussions about their care, with family members often flying in from all over the country to attend a loved one, he said.
“There’s been no plan and no discussion,” he said.
While CMS’ rulemaking may provide the most direct path for expanding end-of-life planning among elderly Americans, lawmakers also are weighing action. Sen. Susan Collins, R-Maine, and Mark Warner, D-Va., addressed the IOM meeting early in the day. Collins had helped get the advanced directive discussion included in the Welcome to Medicare visit.
“Many people nearing the end of life may not be physically or cognitively capable of making their own decisions about care,” Collins said in remarks prepared for the IOM meeting. “Moreover, some of these patients will, at some point, receive acute hospital care from physicians who do not know them or their families.”
Warner is likely to reintroduce a measure that he offered in the last session of Congress, a bill developed with Sen. Isakson, R-Ga., that would create a Medicare and Medicaid benefit for end-of-life planning. Speaking at the Institute of Medicine meeting Friday, Warner recalled how that even families with access to good medical information now struggle when confronting with terminal illnesses, as happened in his own mother’s fight with Alzheimer’s disease. After her initial diagnosis, his family didn’t discuss living wills and advanced care directives or what his mother wanted in her final years.
“I was an informed citizen at the time – the governor of Virginia – and yet my family and I didn’t have a full understanding of everything that was before us,” Warner said. “With more information and support, we could have been able to hold important family discussions with my mother, worked with her doctors and pastor to craft a care plan that truly reflected her wishes.”
Thursday’s snowstorm delayed a House hearing on the government’s 340B discount drug program, but Congress’ advisers on Medicare soldiered on with a separate discussion about the issue.
The Medicare Payment Advisory Commission plans to include a discussion of the 340B program in its regular June report to Congress, although the drug discount offerings fall somewhat outside of its jurisdiction.
“We are not yet close to the point of making recommendations,” said Glenn M. Hackbarth, MedPAC’s chairman, beginning a discussion about the program and Medicare’s drug purchase through its Part B benefit. “If we as a group elect to pursue recommendations, that would happen next cycle,” meaning that publication would not happen before 2016.
There has been great interest from lawmakers in the 340B program, which allows some hospitals and clinics to obtain pharmaceuticals at a steep discount. These discounts don’t have to be shared with patients. Eligible hospitals and other entities saved about $3.8 billion in fiscal 2013, according to the Health Resources and Services Administration, which administers the 340B program.
HRSA has been struggling in recent year to come up a comprehensive framework for the 340B program, which was created by Congress in the 1990s.
There have been complaints from hospitals about having to pay more than they should for medicines, and about a lack of accountability on the part of hospitals on how they have used the money saved.
“It’s a program that has been run rather loosely,” Hackbarth said.
The House Energy and Commerce Committee’s health panel had to reschedule a planned Thursday hearing on the program due to weather.
In a memo prepared for the postponed hearing, the Health subcommittee staff said that the Government Accountability Office and the Inspector General of the Department of Health and Human Services are both looking at the 340B program.
GAO’s work includes a look at how hospitals that qualify for the 340B discount program compare with those that don’t, according to memo. The inspector general of HHS is examing how much Medicare might save if it were able to share in the discounts offered through the 340B program, according to the memo.
When Congress returns for a new legislative work period next week, lawmakers will be forced to make a decision on extending, adjusting or overhauling the Medicare physician payment system. Doctors treating Medicare beneficiaries would see their fees reduced by about 21 percent if Congress doesn’t act before a current payment adjustment expires on March 31. The payment formula has been adjusted to avoid a payment cut 17 times since 2003.
Action on the payment change will not be easy. The Congressional Budget Office earlier this month increased by $30.5 billion the price tag of a repeal and replacement of the current payment formula. According to the updated CBO estimates, a nine-month patch that freezes current payment rates would cost $12 billion over the fiscal 2015 to 2025 time span, while a freeze through the end of 2016 would cost $30.4 billion over the same period.
The price tag calculations are important because Republican lawmakers have generally insisted that any payment adjustment or overall fix must be paid for with other spending cuts or new taxes. Previous physician payment measures have usually tagged other Medicare provider payments to offset the cost of fixing physician payments.
The complexities and cumbersome operations of federal programs were highlighted on Wednesday, as the Government Accountability Office updated its ongoing list of high-risk programs. The special tally identifies the most troublesome government programs due to vulnerabilities that can lead to waste, fraud, abuse, or mismanagement. The programs are deemed a high risk not only for the vulnerabilities but also an apparent lack of an effective policy for improvement. This year, after a year-long scandal over veterans’ treatment wait times, the Veterans Administration’s medical system has been added to high-risk list. The GAO notes that while Congress has passed legislation that addresses VA system problems and adds funding, the audit agency still needs to monitor how the VA implements the changes.
Adding the VA health system to the list adds another vulnerable health care concern to the 31 other worrisome programs. The Medicare program is a charter member and has been on the high risk list since the GAO began monitoring risky programs in 1990 – and it has not been removed from the list. Other programs currently programs on the tally are the Medicaid program, federal food safety monitoring and FDA oversight of medical products.
Four different congressional panels today focus on Government Accountability Office (GAO) efforts to monitor program implementation within the Department of Health and Human Services. The GAO is the main outside agency that examines HHS operations and its audit reports are frequently critical of the agency.
Two House Energy and Commerce subcommittees today cast a spotlight on recent audit reports. An oversight panel reviews a report on HHS leadership on mental health programs (view GAO report released on Feb. 5) which pegged HHS inter-agency coordination of programs supporting individuals with serious mental illness as “lacking.” The health subcommittee examines a report on HHS implementation of new health care disease codes (ICD-10, view GAO report released on Feb. 6). Additionally, a Senate panel this morning and a House subcommittee this afternoon mull the GAO’s efforts to monitor high-risk programs. The Medicare and Medicaid programs are charter topics for the auditor’s annual compilation of federal programs that are prone to fraud and waste risks.
The GAO on Tuesday provided lawmakers with additional fodder for more committee hearings, with two new audits calling for better planning and coordination of programs that address prenatal prescription drug abuse and action to improve the collection of money from third-parties covering health expenses of Medicaid recipients.
Congress has one time-sensitive health care agenda item prior to April 1, the adjustment of Medicare physician payment rate. A long-dismissed payment formula has been continuously calculating cuts in physician payments and Congress has been halting the payment cuts every year for over a decade. This year’s payment relief is due by April 1.
The Congressional Budget Office this week assembled some budgetary estimates to guide lawmakers on either another short-term payment relief patch or a long-term payment formula adjustment. The long-term cost estimates range from $12 billion for a 9-month freeze of current payment rates to $191 billion for a one-percent annual payment increase for the next 10 years.
A major Medicare element of the Affordable Care Act was a requirement to fully cover annual preventive care visits. Before 2005, Medicare did not cover any preventive care visits, except for mammography and Pap smears. In 2011, the health law added annual wellness visit coverage offering a range of preventive care services at no cost to the beneficiary.
A research study released this week in HealthAffairs (view abstract) indicates that the requirement appears to be enticing wellness consultations. Preventive care visits in the test group increased from 1.4 percent before the health law wellness visit addition to 27.5 percent afterwards. Patients on Medicare’s standard fee-for-service plans have flocked toward preventive care services. However, the study notes that fee-for-service preventive care visits are still lower than private and Medicare HMO plans.
The 114th Congress convenes this week and congressional Republicans will assemble majorities in both the House and Senate. A top early priority is action on extending relief from a planned Medicare physician payment cut, which is set to begin on April 1. Action on a payment adjustment could be tied to an increase in the federal debt limit, which will begin to press upon lawmakers starting on March 15.
Also, several new committee chiefs will get the first crack at determining the fate of major health care legislation and changes to the 2010 Affordable Care Act. Rep. Tom Price. a Georgia physician and health law foe, is likely to become the next chairman of the House Budget Committee, which holds the keys to initial planning on any changes in the health care overhaul law. Wyoming Sen. Michael B. Enzi, another health law opponent, is poised to take the helm of the Senate budget panel. Separately, the House Ways and Means Committee will be led by Wisconsin Republican Rep. Paul D. Ryan, who take the lead in any possible health care entitlement program changes.
Ryan, the previous chief of the House Budget Committee, has led a long-running campaign to overhaul the Medicare program. His annual budget proposals (view the 2015 budget plan) have suggested ideas on overhauling the Medicare program allowing Medicare beneficiaries to choose between competing private coverage programs with the federal government offering premium support payments. In 2011, a liberal advocacy group attacked an earlier Ryan Medicare proposal with a video featuring a Ryan look-alike actor pushing an elderly woman in a wheelchair off a cliff.
Congress will return in January with some new faces and a newly-minted Republican Senate majority (check out Roll Call’s guide to the 114th Congress) but lawmakers will face decisions on a an old topic. The first major item on the health care legislative agenda is action on adjusting Medicare and Medicaid payments to physicians, which expire on Dec. 31 for special Medicaid reimbursement and March 31 for Medicare payments.
The primary roadblock for any physician payment adjustment is finding sufficient offsetting spending reductions in other programs (or tax increases) to pay for halting the payment cuts. The search for fiscal offsets has bedeviled action on physician payment measures for years and is shadowed by more troublesome decisions on federal deficit spending reduction. Health care and entitlement program spending, which accounts for the bulk of all federal spending, lies at the center of any effort to reduce annual spending deficits.
Medicare health service providers have to navigate a complex payment system, which is frequently adjusted to meet federal fiscal needs. On Wednesday, the Centers for Medicare and Medicaid Services added additional requirements on provider enrollment. New regulations were unveiled Wednesday culling health care providers that have unpaid debts, employee felonies and abusive billing practices. The new rules, which are set for official publication on Friday, seek to save more than $327 million each year.
The rules prevent organizations from enrolling as a Medicare provider if they already have unpaid Medicare debts, thus preventing a group from withdrawing from the program then re-entering the program as a new business.
Congress also has mulled the dunning of Medicare providers for delinquent income taxes. On several occasions this year and in 2012, lawmakers tried to increase the tax levy authority to seize Medicare payments of tax delinquent providers and suppliers. However, the tax seizure idea offered by lawmakers was not a part of an effort to cull bad Medicare providers but rather a means to fix highway trust funding.
Adjustments to health care spending, particularly regarding Medicare benefits and payments, is often central to soothing any fiscal concerns about almost any new program or renewal bill in Congress. Today, the House plans to vote on a bill that creates new tax-exempt accounts for individuals with disabilities.
Of course, there is a fiscal cost to offering the new accounts and the last-minute substitute version of the measure adds several of Medicare adjustments to pay for bulk of the cost of the tax exemption. The most visible offset item is a ban on Medicare payments for vacuum systems for the treatment of erectile dysfunction (penis pumps). Ending the pump payments is coordinated with any changes to existing restrictions on Medicare Part D payments for erectile dysfunction drugs.
The measure also extends for an additional year, through 2024, the current Medicare policy on separate payments for oral drugs used to treat end-stage renal disease. The provision is a perennial offset element and 2023 payments were extended in an earlier Medicare physician payment bill. Additionally, the bill seeks to expedite plans to begin adjusting Medicare payment rates for misvalued physicians’ services. The total savings over 10 years for just these three Medicare provisions exceeds $1.2 billion, which illustrates why Medicare is a popular place to look for fiscal savings.
A seemingly permanent fixture on the congressional agenda is ongoing action to thwart cuts to Medicare payments to physicians and other health care providers. Congress is always focused on the annual effort to halt substantial Medicare payment cuts to doctors. However, there is another looming deadline on enhanced Medicaid payments to primary care physicians.
The Affordable Care Act included a provision that allowed for increased Medicaid payments to primary care physicians at 100 percent parity with Medicare payment rates. The revised payment program began in 2013 but the enhanced payment term was limited to two years and is now set to expire. Unlike the Medicare physician payment deadline, which expires on March 31, 2015, the Medicaid parity payment adjustment expires on Dec. 31, 2014.
A prepared Senate bill (S 2694) offers a parity payment extension for two more years and adds payments to other physician groups. The White House’s initial request for a stopgap-spending bill in September also included a suggestion for an extension of Medicaid payments. Congress now is scrambling to craft the elements of a final year-end omnibus spending bill or another stopgap funding resolution. If the Medicaid payment parity adjustment expires, physician groups likely will to press for retroactive adjustments in next year’s spending bills.
Every year for nearly two decades Congress has adjusted the Medicare physician payment formula to avoid payment cuts. The annual – and sometimes monthly – ‘doc fix’ adjustment is the result of a set payment formula that has regularly forced reductions in physician payments.
Ideally, lawmakers and physician groups have long sought to eliminate the formula, instead of haggling over annual adjustments. However the cost of a complete repeal of the formula is an expensive proposition. The current stopgap fix for physician payments ends on March 31 and CQ Roll Call’s Melissa Attias on Monday reported (subscription) on some Republican interest to eliminate the vexing payment formula as early as this year. However, any repeal effort must overcome demands for fiscal offsets to pay for either a complete repeal or another annual extension of relief from a payment cut. The Congressional Budget Office on Friday conveniently reminded lawmakers of the cost options in an update of its analysis of the budgetary impact of various physician payment adjustment alternatives.
The Centers for Medicare and Medicaid Services today announced a trial program requiring Medicare prior-authorization approval for persons seeking repetitive, non-emergency ambulance transportation. The prior authorization trial, which begins on Dec. 1, is limited to New Jersey, Pennsylvania and South Carolina.
CMS records the three states as having the highest rates improper payments fraud. The issue has been a festering for many years as all ambulance transport requests have been increasing. A 2012 GAO report noted an increasing demand for basic life support non-emergency transportation but also cited the possibility that local governments are more inclined to bill Medicare for services that used to be provided free of charge. Additionally, Department of Health and Human Services auditors estimated as long ago as 2006 a 25 percent improper billing rate for non-emergency transportation.
The focus on upcoming November congressional elections understandably centers on possible election results and which party will control the Senate. However, the election of a new Congress, which convenes in January, also starts the process for reconfiguring the leadership of pivotal House committees. Roll Call’s Emma Dumain and Matt Fuller today examine possible GOP leadership changes in 11 different committees.
Health care program funding authority, particularly for the Medicare program, falls under the jurisdiction of the House Ways and Means Committee. The committee’s current chairman, Michigan Republican Rep. Dave Camp is retiring and Wisconsin Republican Rep. Paul D. Ryan has the inside track — but has some competition — to take over the gavel of the powerful tax committee.
Ryan has led a long-running campaign to overhaul the Medicare program as the chief of the House Budget Committee. His annual budget proposals (view the 2015 budget plan) have suggested ideas on overhauling the Medicare program allowing Medicare beneficiaries to choose between competing private coverage programs with the federal government offering premium support payments. In 2011, a liberal advocacy group attacked an earlier Ryan Medicare proposal with a video featuring a Ryan look-alike actor pushing an elderly woman in a wheelchair off a cliff. At the helm of the Ways and Means Committee, Ryan would have the opportunity to craft a Medicare overhaul measure instead of offering budgetary suggestions.
If Ryan departs from the budget panel, the heir apparent is the committee’s current Vice Chairman, Rep. Tom Price, a conservative physician from Georgia. Price is a staunch opponent of the 2010 health care overhaul law and has authored his own proposal on overhauling health insurance coverage options. Price’s plan relies on offering tax breaks to give people the means to buy health insurance instead of the current health insurance exchange plan subsidies.