SECRETARY'S ADVISORY COMMITTEE ON REGULATORY REFORM REGIONAL HEARING #4
MEETING MINUTES/SUMMARY 

DAY TWO

May 16, 2002
Marriott City Center
Colorado Room
Denver, Colorado

Dr. Wood outlined the committee’s work plan for the day, to include EMTALA and HIPAA discussion. The committee continued discussion and voting on recommendations, the result of which is reflected in the agenda tables at http://www.regreform.hhs.gov/recommendations.htm. 

Mr. Prink, a patient advocate, said seniors are concerned that not enough providers are willing to participate in Medicare programs. A recent survey said only about one-third of primary care physicians are accepting new Medicare patients. The choice of Medicare HMOs is limited in most areas, and some have frozen their enrollments. Reasons for the low participation include inadequate reimbursement and onerous fraud and abuse regulations. Other beneficiary issues include confusion over Part B "buy-in" and overly strict rules and penalties for late buy-in; frequent benefit and co-pay changes from HMOs under the Medicare+Choice program; beneficiaries not realizing that they will have to change doctors when they sign up with an HMO; lack of coverage for annual physical exams; and the lack of a prescription drug benefit in Medicare.

Rosemary Pike, Centura Senior Health Centers

Ms. Pike, a manager of a physician group that caters to seniors, said the Medicare Secondary Payer questionnaire is required too often, takes up too much staff time, and leaves patients feeling abused. Billing forms (HCFA 1500 and the UB 92) are duplicative, too complex and consume too much staff time. Hospital outpatient clinics should be able to bill as simply as freestanding clinics. Ambulatory Patient Classifications are confusing and lack guidelines. Clear guidance should be issued, and Medicare should have a provider representative to go to for help. Getting credentials for a physician can take up to eight months, with inconsistent answers coming from different offices. A simple, clear process should be set up.

Dr. Lazaroff, director of geriatric medicine for St. Anthony Hospital, said Medicare is putting financial stress on office-based geriatricians. Freestanding practices are no longer an economically viable enterprise. Even hospital-based outpatient services are threatened. Geriatricians must take more time per patient than other doctors because the patients are often functionally impaired and require longer to treat and talk to. Consequently, geriatricians see fewer patients per day and get paid less. Medicare payments should include a frailty risk adjuster to pay doctors more when they treat sicker and more complex patients who require more care management. Administrative burdens and regulatory mandates (such as certificates of medical necessity and diabetic supplies order forms) fall heavily on these primary care physicians and are uncompensated.

Ms. Archuleta described the concerns that neighbors at her apartment building for seniors shared with her. These included difficulty finding doctors who accept Medicare patients; trouble paying for prescription drugs; doctors who act as gatekeepers and restrict patients from getting certain tests; doctors’ complaints about paperwork; and a lack of good information on the cost-effectiveness of various pharmaceuticals. She and her neighbors said they would be willing to pay a higher Medicare Part B premium in order to get a good drug benefit, but many people do not want to lose the drug benefit they currently have. Among their other recommendations: drug prices should be brought down; Medicare should cover more preventative services; more people should get coverage through Medicaid; Medicare should facilitate end-of-life care and provide more hospice care; and rigorous Medicare fraud and abuse enforcement should continue.

Ms. Fried, the project’s director, said people with Alzheimer’s run into particular barriers when exercising their Medicare coverage. Having thousands of different local medical review policies gives contractors wide latitude to deny services. CMS and Medicare contractors often require that a service should completely restore the patient’s functioning for it to be considered "reasonable and necessary," but the goal with Alzheimer’s patients is often short of full restoration, so the claim is denied. Contractors often require that the patient have the ability to learn and retain new information for some therapy services to be covered. Rules on life expectancy for hospice coverage are too rigid, since it is hard to predict how long an Alzheimer’s patient will live. Hospice care is often denied when it may be useful to the patient and family. People with dementia often have preventable medical conditions such as urinary tract infections and medicine-induced psychoses. Lack of prevention creates greater costs elsewhere.

Eileen Downs-Jacobs, Family Caregiver

Ms. Downs-Jacobs, who has a mother with Alzheimer’s and a father with congestive heart failure, said Medicare must do a better job with chronic care. This includes giving doctors adequate time to work with patients and their caregivers to set up good plans of care. Coding rules on the time spent are too restrictive. They should allow doctors to spend time with either the patient or the caregiver, and nurses could do some patient education tasks. Medicare focuses on specific wounds and ailments and fails to look at the whole person. Some personal care services such as home visits are not covered.

Q&A

The committee and the panel discussed local medical review policies, the appeal process, hospice coverage rules, the homebound status rule, and increasing co-pays in Medicare + Choice.

10:25 a.m. Evaluation & management Guidelines Workgroup Update, Dr. Wood

The chairman briefed the committee on the progress of the E&M Workgroup, which has been looking at E&M documentation guidelines that doctors use. He traced the development of the guidelines from 1994 to the present. Many doctors feel that the system is too complicated, has adversely affected medical practice, creates an adversarial billing environment, and suffers from a high error rate. The workgroup is aiming to produce its report by August 2002, with a 2004 implementation date.

Q&A

The committee discussed the uses of the E&M guidelines, the value or lack thereof they bring to billing documentation, and how the Advisory Committee’s work on this topic could assist the workgroup’s efforts.

The committee, on a motion by Judith Ryan, voted to recommend that the E&M guidelines be eliminated. Dr. Olsen voted no.

10:55 a.m. break

11:05 a.m. Resume, Public comments

Alan Canner, executive director of the Colorado Hospice Association, said Medicare fiscal intermediaries were driving down patients’ length of stay at hospices, denying the benefit of hospice care until the very last few days of some patients’ lives. Claims reviews cause short-term cash crunches for hospices, since all of that beneficiary’s payments are held up until the review is satisfied. Many of the denials are later overturned by administrative law judges. He recommended that fiscal intermediaries not be allowed to review the prognosis that placed a patient in hospice.

Helen Thompson, a geriatric specialist with the American Dietetic Association, said many older patients are not eligible to receive dietetic services. These services often provide cost-effective care, since they can prevent complications and hospital re-admissions. Other health care workers, such as home care nurses, lack the specific diet training to deliver this care.

Ellen Caruso, executive director of the Home Care Association of Colorado, said regulatory burden and paperwork are killing off agencies and causing nurses to leave the field. The OASIS assessment form is wasteful, since the data from many of the required questions are never used. The new prospective payment system for home care may impact small rural facilities hard. Nurses do not have the time to comply with every rule. She recommended that OASIS be required only for Medicare patients, the elimination of the cost report, and the repeal of the new home health conditions of participation.

Beverly Hirsekorn, a policy analyst with the Colorado Developmental Disabilities Planning Council, said Medicare and Medicaid should provide incentives for greater community-based services. Regulations should be streamlined, and paperwork should be expedited. Government agencies should have to explain why care in community settings is being denied.

Jane Orient, Association of American Physicians and Surgeons, said letters from Medicare carriers are hard to read and convey the impression to patients that their doctor is "a crook." Medicare rules currently prevent willing patients from paying for additional tests themselves.

James Dean, with Colorado Legal Services, said Medicaid eligibility rules prevent people from saving much money. The resource limit should be waived, and the process for determining eligibility should be automated. Coverage rules for home- and community-based services are also lengthy and cumbersome.

Virginia Fraser, a former long-term-care ombudsman for the state of Colorado, said the regulatory environment surrounding nursing homes is in a bad state and requires a radical solution. She endorsed the "Pioneer" movement, which aims to put the resident at the center of care. Elements of this approach include making nursing assistants part of the care-planning process and setting up community meetings to discuss issues with nursing home residents. Nursing home inspection and enforcement are overly negative. Oversight agencies should give facilities public praise for good performance.

Jeff Jerebker, with Piñon Management, a nursing home, said nursing care should embrace innovation and change and should switch to a "psychosocial model." Oversight and enforcement of regulations is currently overzealous and inhibits this innovation. Enforcement should focus mostly on the serious violators – those delivering substandard care – and tread more lightly on agencies that provide good care.

Linda Gorman, with the Independence Institute, said government is rule-bound and inflexible, imposing health care regulations on even the smallest of agencies. Government should let standards emerge from the bottom up. Efforts to address care for schizophrenics in Colorado Medicaid have only worsened the situation. She endorsed the idea of eliminating the E&M guidelines. People should be required to pay for their own care if they have the assets.

11:50 a.m. committee discussion

The committee discussed possible agenda items for the final public hearing in Minneapolis and/or further subcommittee work. These included local medical review policies, dual eligibles, the homebound status restriction, HIPAA and capital investment, the process of regulatory implementation, and Medicare Part B registration.

The committee continued discussing its work plan and schedule for Minneapolis, to possibly include issues surrounding dual eligibles, adverse event reporting at the Food and Drug Administration (FDA), and coordination between the FDA and CMS on new technology approval.

12:25 p.m. Adjourn

Meeting summary prepared by John McCoy, Health Policy Analyst Mathematica Policy Research, Inc.