TO: Board of Directors
FR: Kevin J. Burke
Director, Division of Government Relations
CC: Doug Henley
Todd Dicus
Rosi Sweeney
RE: State and Federal Legislative Update (Week of March 14)
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March 18, 2005
MEMORANDUM
Federal Budget
On Thursday, March 17, by a vote of 52-48, the Senate approved an amendment to the FY 2006 federal budget resolution (S. Con. Res. 18) that would restore $14 billion in Medicaid reductions that the Budget Committee had proposed. The amendment called on Congress to approve a commission to study the program for a year and to recommend changes designed to improve its effectiveness and efficiency.
Subsequently, the Senate approved the amended budget resolution by a vote of 51-49.
The House approved its version (H. Con. Res. 95) by a vote of 218-214. The House calls for $69 billion in reductions split between Medicare and Medicaid funds. The differences will be addressed in a conference committee.
Subsequently, the Senate approved the amended budget resolution by a vote of 51-49.
The House approved its version (H. Con. Res. 95) by a vote of 218-214. The House calls for $69 billion in reductions split between Medicare and Medicaid funds. The differences will be addressed in a conference committee.
Medical Imaging
On Thursday, March 17, the House Ways and Means Health Subcommittee held a hearing on the growth in Medicare spending on medical imaging. Witnesses included Mark E. Miller, Executive Commissioner of the Medicare Payment Advisory Commission (MedPAC); James P. Borgstede, MD, Chair of the Board of Chancellors for the American College of Radiology; and Kim Allan Williams, MD, Professor of Medicine and radiology and Director of Nuclear Cardiology at the University of Chicago’s School of Medicine.
In its March Commission Report, MedPAC recommended that to control the rapidly expanding use of imaging technology, HHS should set standards for all providers who bill Medicare for performing and interpreting diagnostic imaging studies. The goal would be to improve the accuracy of diagnostic tests and reduce the need to repeat studies, thus enhancing the quality of care and helping to control federal spending.
Dr. Borgstede, on behalf of the American College of Radiology, called for tighter accreditation standards for those who interpret imaging studies. He said that these standards would, in turn, lead physicians to invest in better education, training, personnel and equipment. However, Dr. Williams noted that several non-radiologist specialties are currently trained to provide imaging interpretations. He said that standards should not serve simply to limit imaging services to ACR-accredited radiologists. Proximity of imaging technology and rapid interpretation of test results are valuable to patients and should be supported by Medicare.
Committee members, including Rep. Johnson, Pete Starke (D-CA), John Lewis (D-GA), Jim Ramstad (R-MN), Mike Thompson (D-CA) and Rahm Emmanuel (D-IL), suggested that the most effective way to produce standards that were acceptable to the physician community would be for the various specialties that have an interest to confer and produce an commonly agreed to set of standards that will allow CMS to monitor quality and usage.
In its March Commission Report, MedPAC recommended that to control the rapidly expanding use of imaging technology, HHS should set standards for all providers who bill Medicare for performing and interpreting diagnostic imaging studies. The goal would be to improve the accuracy of diagnostic tests and reduce the need to repeat studies, thus enhancing the quality of care and helping to control federal spending.
Dr. Borgstede, on behalf of the American College of Radiology, called for tighter accreditation standards for those who interpret imaging studies. He said that these standards would, in turn, lead physicians to invest in better education, training, personnel and equipment. However, Dr. Williams noted that several non-radiologist specialties are currently trained to provide imaging interpretations. He said that standards should not serve simply to limit imaging services to ACR-accredited radiologists. Proximity of imaging technology and rapid interpretation of test results are valuable to patients and should be supported by Medicare.
Committee members, including Rep. Johnson, Pete Starke (D-CA), John Lewis (D-GA), Jim Ramstad (R-MN), Mike Thompson (D-CA) and Rahm Emmanuel (D-IL), suggested that the most effective way to produce standards that were acceptable to the physician community would be for the various specialties that have an interest to confer and produce an commonly agreed to set of standards that will allow CMS to monitor quality and usage.
Pay-for-Performance
On Tuesday, March 15, the House Ways and Means Health Subcommittee held a hearing entitled, "Measuring Physician Quality and Efficiency of Care for Medicare Beneficiaries." Testifying before the subcommittee were Herb Kuhn, Director for Medicare Management, Centers for Medicare and Medicaid Services (CMS); Ken Kizer, M.D., National Quality Forum (NQF); Peter Lee, President and CEO, Pacific Business Group on Health; and Jeffrey Rich, M.D., Society of Thoracic Surgeons.
Rep. Nancy Johnson (R-CT), who chairs the subcommittee, observed a growing interest among healthcare payors in linking quality to payments. In response to comments made by Rep. Pete Stark (D-CA), Chairman Johnson said there is no desire to use pay-for-performance to privatize Medicare. However, she said that there is a compelling need to recognize the unintended consequences that fragmented Medicare reimbursement has on the health care system. Since, in her view, health care is delivered in a system, it is time to transform payments to link quality throughout the system.
Herb Kuhn described the projects underway at CMS to choose and implement clear, valid and widely accepted quality measures. These include the Hospital Quality Initiative which rewards hospitals for reporting on ten quality measures; the Doctors' Office Quality - Information Technology (DOQ-IT) designed to test the adoption and effective use of EHRs in ambulatory settings, which in turn are used to report performance measures; and the Chronic Care Improvement Program (CCIP) to test the a population-based model of disease management. Mr. Kuhn testified that CMS is examining performance-based payments to improve both the quality of care delivered to beneficiaries and the efficiency of its delivery.
Chairman Johnson asked Mr. Kuhn whether claims data was an appropriate place to start with pay-for-performance programs. He replied that, while not perfect, claims data would capture some basic elements and combined with chart abstraction could offer a good view of the quality of care delivered in the office.
Dr. Kizer testified that NQF is currently in reviewing and approving performance measures for the ambulatory office that have been developed by the AMA Physician Consortium for Performance Improvement, DOQ-IT or the National Committee on Quality Assurance. These measures should be ready between June and October of this year.
In response to a question from Chairman Johnson about how to start encouraging the use of technology in the physician office, Dr. Kizer said the need was for interoperable standards and that Congress should simply assign this task to some entity.
Rep. Stark asked about the public reporting, which he believes is a more appropriate lever of change for physician behavior than money. Dr. Kizer agreed with Rep. Stark that public reporting is an important tool for change.
Peter Lee testified about three different value based purchasing programs in use around the nation. The first example is the UNITE-HERE Labor Management Trust Fund which funds health care services on behalf of 120,000 hotel workers in Las Vegas, Nevada. The Trust examined variation in physician quality by analyzing the cost-efficiency of longitudinal care delivered to beneficiaries and then decided to exclude 50 of the 1,800 physicians that had been in the network.
Mr. Lee also described the Bridges to Excellence program and California's Integrated Healthcare Association's medical group pay-for-performance program. Mr. Lee referred to NQF's project to develop a "starter set" of measures as a way of ensuring there was a transparent and unified set of performance measures. To further aid in promoting value-based purchasing, Mr. Lee suggested that a significant portion of physician reimbursement, up to 20 percent, be contingent upon performance. In addition, CMS should make patient identity-encrypted claims data available to private payors for purposes of building physician profiles.
Jeffrey Rich, M.D., testified about the Society for Thoracic Surgery's experience in collecting clinical data on open-heart surgery over the past 16 years. Dr. Rich stressed the importance of clinical measures over administrative data, which he reported varied widely, was unreliable and gave little sense of what specific actions were taken by a surgeon in an inpatient setting. On the other hand, Dr. Rich claimed process measures alone could encourage physicians to simply order more medications or tests without clinical relevance. Based on STS's experience, Dr. Rich testified that quality improvement could only be achieved by focusing on risk-adjusted outcomes measures. Dr. Rich also testified that mandatory withholds which forced physicians to compete against one another for limited monies would discourage the quick dissemination of best practices that STS found to be a requirement for quick implementation of high quality, low cost protocols.
Rep. Nancy Johnson (R-CT), who chairs the subcommittee, observed a growing interest among healthcare payors in linking quality to payments. In response to comments made by Rep. Pete Stark (D-CA), Chairman Johnson said there is no desire to use pay-for-performance to privatize Medicare. However, she said that there is a compelling need to recognize the unintended consequences that fragmented Medicare reimbursement has on the health care system. Since, in her view, health care is delivered in a system, it is time to transform payments to link quality throughout the system.
Herb Kuhn described the projects underway at CMS to choose and implement clear, valid and widely accepted quality measures. These include the Hospital Quality Initiative which rewards hospitals for reporting on ten quality measures; the Doctors' Office Quality - Information Technology (DOQ-IT) designed to test the adoption and effective use of EHRs in ambulatory settings, which in turn are used to report performance measures; and the Chronic Care Improvement Program (CCIP) to test the a population-based model of disease management. Mr. Kuhn testified that CMS is examining performance-based payments to improve both the quality of care delivered to beneficiaries and the efficiency of its delivery.
Chairman Johnson asked Mr. Kuhn whether claims data was an appropriate place to start with pay-for-performance programs. He replied that, while not perfect, claims data would capture some basic elements and combined with chart abstraction could offer a good view of the quality of care delivered in the office.
Dr. Kizer testified that NQF is currently in reviewing and approving performance measures for the ambulatory office that have been developed by the AMA Physician Consortium for Performance Improvement, DOQ-IT or the National Committee on Quality Assurance. These measures should be ready between June and October of this year.
In response to a question from Chairman Johnson about how to start encouraging the use of technology in the physician office, Dr. Kizer said the need was for interoperable standards and that Congress should simply assign this task to some entity.
Rep. Stark asked about the public reporting, which he believes is a more appropriate lever of change for physician behavior than money. Dr. Kizer agreed with Rep. Stark that public reporting is an important tool for change.
Peter Lee testified about three different value based purchasing programs in use around the nation. The first example is the UNITE-HERE Labor Management Trust Fund which funds health care services on behalf of 120,000 hotel workers in Las Vegas, Nevada. The Trust examined variation in physician quality by analyzing the cost-efficiency of longitudinal care delivered to beneficiaries and then decided to exclude 50 of the 1,800 physicians that had been in the network.
Mr. Lee also described the Bridges to Excellence program and California's Integrated Healthcare Association's medical group pay-for-performance program. Mr. Lee referred to NQF's project to develop a "starter set" of measures as a way of ensuring there was a transparent and unified set of performance measures. To further aid in promoting value-based purchasing, Mr. Lee suggested that a significant portion of physician reimbursement, up to 20 percent, be contingent upon performance. In addition, CMS should make patient identity-encrypted claims data available to private payors for purposes of building physician profiles.
Jeffrey Rich, M.D., testified about the Society for Thoracic Surgery's experience in collecting clinical data on open-heart surgery over the past 16 years. Dr. Rich stressed the importance of clinical measures over administrative data, which he reported varied widely, was unreliable and gave little sense of what specific actions were taken by a surgeon in an inpatient setting. On the other hand, Dr. Rich claimed process measures alone could encourage physicians to simply order more medications or tests without clinical relevance. Based on STS's experience, Dr. Rich testified that quality improvement could only be achieved by focusing on risk-adjusted outcomes measures. Dr. Rich also testified that mandatory withholds which forced physicians to compete against one another for limited monies would discourage the quick dissemination of best practices that STS found to be a requirement for quick implementation of high quality, low cost protocols.
Physical Therapists
Rep. Melissa Hart (R-PA) introduced H.R.1333, a bill to allow Medicare beneficiaries direct access to physical therapists without benefit of physician referral. The bill was introduced on March 16 and referred to the Energy and Commerce Committee.
FDA Authority to Regulate Tobacco Products
On Thursday, March 17, Senators Mike DeWine (R-OH) and Ted Kennedy (D-MA) introduced a bill (S. 666) to grant the Food and Drug Administration (FDA) authority to regulate tobacco products. Reps. Tom Davis (R-VA) and Henry Waxman (D-CA) introduced the House version (H.R. 1376). FDA would be able to regulate both current and new tobacco products and restrict tobacco marketing. Among other provisions, the legislation would reinstate the 1996 FDA Rule on youth access and marketing; require detailed disclosure to the FDA of what is in each tobacco product; and expand state authority over tobacco marketing.
The Week Ahead in Congress
Congress is in recess until Monday, April 4.
STATE ACTIVITY
Georgia
The Georgia Board of Pharmacy proposed regulations that would allow pharmacists to make therapeutic substitutions of prescribed medications when working under a protocol of a physician. GAFP President, Dr. Robert B. Hash provided testimony in opposition to these regulations.
In addition, the chapter wrote a letter to Sen. Unterman opposing SB 184, which would allow chiropractors to order and interpret lab tests, urinalysis, diagnostic imaging and neurodiagnostic studies. Georgia used the Graham Center paper, Chiropractors are not a Usual Source of Primary Heath Care, as evidence in support of their position.
In addition, the chapter wrote a letter to Sen. Unterman opposing SB 184, which would allow chiropractors to order and interpret lab tests, urinalysis, diagnostic imaging and neurodiagnostic studies. Georgia used the Graham Center paper, Chiropractors are not a Usual Source of Primary Heath Care, as evidence in support of their position.
Missouri
Medical liability insurance reform moved one step closer when HB 394 was approved in committee by a unanimous vote. Among other provisions, the bill:
- Requires the director of the department of insurance to report to the General Assembly the actual rates charged for malpractice insurance and include a comparison to the rates of the previous year.
- Prohibits insurance companies and other entities providing malpractice insurance to health care providers in Missouri from:
- Increasing premium charges by more than 10 percent without 60 days' prior notice to the insured;
- Refusing to renew policies without 60 days' prior notice, unless the refusal to renew is based upon nonpayment of insurance premiums, license termination or suspension, termination of the insurer's reinsurance program, or a material change in the nature of the insured's health care practice;
- Ceasing to issue insurance policies without 180 days' prior notice to the department; and
- Requiring any insurer that fails to provide the required notice, at the option of the insured, to continue the coverage.
- Provides insurance premium rates charged by insurance companies and other entities providing malpractice insurance in Missouri which are no greater than 20 percent higher or lower than the published market rate will be presumed reasonable, and rates greater than 20 percent higher or lower will be presumed unreasonable.
- Requires the department to establish reporting standards for insurers to report base rates for health care provider classifications in categories determined to be actuarially appropriate. The department will create a database, available to the public, comparing base rates charged by insurers.
- Requires the department to study and report to the General Assembly on the feasibility and economic impact of offering medical malpractice policies written to apply to injuries which result from acts or omissions occurring during the policy period. Insurers are not mandated to write medical malpractice insurance on an occurrence basis.
2005 Archives
Year End Summary (Members Only)
November 2005 Report (Members Only)
September 2005 Report (Members Only)
July 2005 Reports (Members Only)
April Federal Legislative Report (Members Only)
March 18, 2005
March Federal Legislative Report (Members Only)
