VOLUME II OF II
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The following proceedings were held in the Marriott
Denver City Center, Denver, Colorado, on Thursday, May 16,
2002, commencing at 8:05 a.m.
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COMMITTEE PARTICIPANTS
DOUGLAS L. WOOD, M.D., Chair
Mayo Clinic
Rochester, Minnesota
MR. JEFF BLOOM
AIDS Patient Advocate
Washington, D.C.
G. KRISTEN CROSBY, M.D.
Vice President and Chief Medical Officer
Olympic Health Management Systems, Inc.
Bellingham, Washington
MR. BRUCE DEVEREUX CUMMINGS
President and CEO
Olean General Hospital
Olean, New York
GARY C. DENNIS, M.D.
Howard University Hospital
Washington, D.C.
MS. MICHELE M. EVINK
Director of Pharmacy
Clarke County Hospital
Osceola, Iowa
NOTE: SUSAN DESMOND-HELLMANN, M.D., MR. RONALD W. DOLLENS, MR. THOMAS R. HEFTY, MR. GARY MENDOZA, MR. LEONARD D. SCHAEFFER, and MS. KAREN B. UTTERBACK were not present.
MR. EUGENE A. FAY
Vice President of Reimbursement
and Government Affairs
Province Healthcare Company Health
Brentwood, Tennessee
MR. GARY B. REDDING
Commissioner
Department of Community
Atlanta, Georgia
MR. JOHN FINAN, JR.
President and CEO
Franciscan Missionaries of Our
Lady Health System, Inc.
Baton Rouge, Louisiana
MR. JACK A. ROVNER
Michael Best & Friedrich,
LLC
Chicago, Illinois
LISA GIGLIOTTI, J.D.
Human Services Policy
Coordinator
Office of the Governor
Lansing, Michigan
MS. JUDITH A. RYAN
President and Chief
Executive Officer
The Evangelical Lutheran
Good Samaritan Society
Sioux Falls, South Dakota
MS. HEIDI MARGULIS
Senior Vice President,
Government Relations
Humana, Inc.
Louisville, Kentucky
MS. PATRICIA O. SHAFER,
R.N., M.N.
Beth Israel Deaconness
Medical Center
Boston, Massachusetts
MS. MARY M. MARTIN
Chairman of the Board
The Senior Coalition
Crofton, Maryland
MS. JUDITH G. SUTHERLAND
Visiting Nurses
Association
Littleton, Colorado
HONORABLE STEPHEN H. MARTIN
Senator, 11th District of
Virginia
Chesterfield, Virginia
MR. WILLIAM TOBY, JR.
Healthcare Consultant,
Retired
Rockville Centre, New York
NANCY H. NIELSEN, M.D.
Internist
Buffalo, New York
MS. PATRICIA M. WALDEN
Southington Care Center
Southington, Connecticut
ERIK OLSEN, M.D.
Member, Board of Directors, AARP
Mesa, Arizona
KERN C. WILDENTHAL, M.D.
University of Texas
Southwestern Medical
Center at Dallas
Dallas, Texas
MS. SUZANNE R. PATTEE,
Consultant, Public Policy and
Patient Affairs
Cystic Fibrosis Foundation
Bethesda, Maryland
TABLE OF CONTENTS
Committee Business
Panelists:
Hal Prink
Rosemary Pike
Alan Lazaroff, M.D
Lena Archuleta
Leslie Fried
Eileen Downs-Jacobs
Public Comments:
Alan Canner
Helen Thompson
Ellen Caruso
Beverly Hirsekorn
Jane Orient, M.D
James Dean
Virginia Fraser
Jeff Jerebker
Linda Gorman
COMMITTEE BUSINESS
DR. WOOD: Good morning, everyone. We have a half-day agenda, and there's perhaps a little more than we might be able to accomplish in terms of intense discussion about some of the items from yesterday. I will be needing to leave at noon so that I can get a plane for the next big meeting, which is on evaluation and management and documentation guidelines, which I'm chairing in Washington tomorrow and Saturday. So we'll have to try to finish our May 30, 2002 work mostly by noon, unless I can find a willing executive committee member who will chair the last half hour of the meeting.
So far, we have -- actually, yesterday we accomplished a great deal in terms of things that we adopted. We also accomplished a great deal in terms of items that we identified for additional discussion. And I think that is helpful to not only the members of the committee but the subcommittee to manage our time today.
We have about an hour and a quarter here for discussion before we have a patient provider relationship panel, and then public comment and some other committee discussion.
In looking at what is left over from yesterday, we need to begin by having a discussion about EMTALA, so we can give advice to the subcommittee to get its work done and 223 finalize a set of recommendations that we can then adopt in Minneapolis. This gives us a chance, actually, to also look through the notice of proposed rule-making in detail and see where the recommendations that have been made now by CMS staff in that notice are in concert with the recommendations that we had made from the subcommittee, and which you have seen here, but ones that we obviously have worked on since Miami.
After that, I'd like to then spend some time, if we can, to go back to some of the pieces that we had left over from yesterday. I will put the Coordination Subcommittee's work on HIPAA last, because that actually needs to be coordinated with some of the things that we heard yesterday in terms of HIPAA transactions, especially HIPAA security. And so I would like them to take the testimony from yesterday and put that together and come back in Minneapolis with, then, a set of recommendations that we can incorporate.
There are a couple of important things too that we need to consider, although we have been focused on immediate things appropriately, because that has been an interest of the secretary. We need to now start thinking too about some of the longer-term process things, and the HIPAA discussion yesterday I think begins to highlight why that becomes important, because if we don't think about how we're going to maintain these systems, we run a significant risk of having some serious system breakdowns that will cause really 224 potentially rather substantial consequences, including the possibility of not being able to take care of patients or not getting paid.
So those are things that we need to really address. And there may be some things that are important, in terms of committee structures and CMS and industry interactions, that we have to think about. In the summertime in particular is a good opportunity for us to do that.
Now, for Minneapolis, we're anticipating that the secretary will be joining the committee, and he'll be anxious to hear in detail some of the things that we have covered. It would be helpful, too, for each of the subcommittees, based on the work that we've done today in terms of -- yesterday, I should say, in terms of adopting recommendations, if you could go back through those recommendations and begin to prioritize them for things that you would like to see done literally at all costs, and which others might be a little less important, so that we can give HHS a sense of where the priorities lie, even in the list that we've given them.
There are a lot of things there. I was thinking last night about what we're asking them to try to accomplish. If you think about the work of making sure that there is a prospective payment inpatient system, outpatient system, home health, nursing home, the physician fee schedule, the unfinished business of HIPAA, that's a lot of work. And so we 225 have to be a little sensitive, I think, to what the limitations are in terms of going back and making some revisions.
So if we could help by giving some indication about priority, that would be, I think, much appreciated. So I'll ask the subcommittee chairs to try to go back and think about that in the next few weeks, before we get to Minneapolis.
Christy, anything you want to say about the agenda this morning?
MS. SCHMIDT: What will be coming to you is a summary of all the work that you did yesterday, with a clean copy of what was adopted, what was deferred, and so forth. What we're going to ask you is, if you have comments on that, or corrections, to get those to us by COB Monday. Then we'll turn it around by Wednesday COB. That will be a final document, so it will be clear what has been adopted.
Also, if there are areas where you have concerns or there are issues you want to learn more about, please flag those for us also in your e-mail to us, and we will try and get either clarifications out on a subcommittee briefing call, or an all-committee briefing call, or via e-mail to expedite your work on all of that.
DR. WOOD: Are there any other items that any of you would like to make sure we cover in the two hours that we have as a committee this morning? 226
MR. MARTIN: Mr. Chairman, not today, but I'm looking forward to Minneapolis and maybe the next meeting. I'm concerned that we're not hearing from the states yet as much as I'd like to. And the fact is, if we're going to be successful with this, ultimately, I think they're going to have to be partners in it. And I'd like to see us, in meetings here in the future, start hearing from a few more states.
DR. WOOD: Are there some specific topics that you would like to cover?
MR. MARTIN: I'm meeting with our Health and Human Services, the secretary, when I get back in town. I think I need to flush that out, and I think some of us should do that. I'm not prepared to say exactly what subject matters right now, but they are ultimately on some of these programs that we're trying to address, are the guys on the front lines, they and their local units.
DR. WOOD: Now, in Minneapolis, we're planning on some of that activity in terms of a duals panel. Lisa, would you like to comment about the subject? What are your thoughts?
MS. GIGLIOTTI: Sure. The dual eligible issues come out of our Coordination Committee. And part of coordination also is coordination between the federal government and the states. As you know, states are sometimes the biggest 227 provider of healthcare in a state. And for a panel, we had recommended that there be some state Medicaid directors available to be on a panel, actually giving us testimony, for us to be able to ask questions to.
MR. MARTIN: Okay.
DR. WOOD: Gary Redding.
MR. REDDING: Yes. Mr. Chairman, Lisa and I spoke briefly about this yesterday. I took a to-do from that to contact maybe that state Medicaid director's association and see about getting participants there.
DR. WOOD: Bill Toby, this is an area I know of interest to you. Your thoughts about how we should approach the states issue?
MR. TOBY: One of the issues that I'm very interested in, and of course is being covered, is dual eligibles. I think that's an area in which all of us would like to see more guidance and more activity as well. I know the Medicare + Choice program -- at least, a lot of the plans are very interested in the dual eligibles. So in terms of my interests, the dual eligible issue is one that I'd like to see covered, and I'd like to get the state perspective on it, as well as CMS.
MS. RYAN: Mr. Chair.
DR. WOOD: Judith.
MS. RYAN: I was going to say, the interface between 228 CMS and the states around issues of survey and certification might be a related issue.
DR. WOOD: Lisa.
MS. GIGLIOTTI: I forgot to mention that, in advance of our hearing, I had planned to circulate a draft, a briefing draft, similar to some of the other ones that our Coordination Committee has given out on dual eligibles. And I'd really appreciate any feedback, as well as feedback from who you might want to be on a panel.
I notice today we have a letter from, it seems, the Developmental Disabilities Coordinating Council for Colorado, and I'll make sure that we contact those for public testimony too, so they're aware that we'll be meeting in Minneapolis.
DR. WOOD: Good. I'd like to begin to review the EMTALA issues so we can help the Communications Subcommittee. We had a preliminary discussion of that yesterday. So Erik, I will give you the floor to start.
DR. OLSEN: Thank you, Mr. Chairman. Obviously, so we all start at the same place, we had a series of recommendations. And instead of going through these, we did listen to the new regulations that have been put forward. In discussions with the members of the subcommittee that are here, we agreed that these were certainly steps in the right direction in what we were trying to accomplish. But, you know, I guess we argued whether it was halfway or 229 three-quarters or whatever it might be.
So what we thought we would like to do is to determine, probably based upon our recommendations, what isn't in the new regulations, if that's possible. And then we would, so to speak, work from that point forward for further recommendations. And I hope I'm saying approximately the right thing by my subcommittee here. And we'd work towards that for Minneapolis.
So we'd almost like a discussion or a briefing, should we say perhaps, of what points maybe we still need to work on to get to where we -- now, this was not approved by the committee, I understand, but this is what we were proposing for the committee. Gary or Nancy, is that fair?
DR. WOOD: So the suggestion actually is that we take the original set of recommendations, reconcile against them what has been published now in the Notice of Proposed Rule-Making, and then make sure there are not additional concerns or issues that need to be then added to the recommendations from the subcommittee for Minneapolis.
Nancy.
DR. NIELSEN: I just wanted to comment that some of the issues that have not, as I understand it, been addressed in the proposed rule are addressed. There is an EMTALA task force of a variety of medical organizations. A letter written to the committee members came out May 8th. I've asked that 230 that letter be duplicated and given out to everybody. It raises some issues about on call and requesting clarification for call, and also asks for some clarification about urgent care centers, making some points that I think everybody ought to see.
I didn't particularly want to discuss those today. I just wanted to alert you that staff is duplicating that letter, and I look forward to a discussion, both in our subcommittee and in Minneapolis.
DR. WOOD: Gary Dennis.
DR. DENNIS: Yes. First of all, from our preliminary discussions, we thought we should go through our recommendations, and then we could have a discussion about whether there is any variation in what has been proposed, and then we would come back later with additional recommendations. So I would suggest that we do that.
DR. WOOD: Erik. If I understand Gary's point, is that he would like us to vote on the consent agenda that we have in front of us for adoption at this meeting and then go back to Minneapolis. Is that correct, Gary?
DR. DENNIS: Exactly, and address the proposed rule with some more comprehensive statements, where they need to be, because in my reading of the proposed rule, the proposed rule actually touches on a lot of the areas that we highlight. It just doesn't handle it the same way we'd recommended. 231
DR. WOOD: In reading the proposed rule as well, it is clear that CMS is asking for additional advice.
DR. DENNIS: Right.
DR. WOOD: So one of the things that we need to make sure that occurs in the Communications Subcommittee is that the Notice of Proposed Rule-Making be reviewed carefully. And for those specific areas where additional advice is asked, we should make sure that we provide it to help answer the questions that have been raised. So that's another charge, actually, that I would like to see the subcommittee accomplish.
Erik, do you want to move the adoption of the consent agenda, or should I ask for -- actually, I should ask first -- according to process, I should ask first if you will look at the Communications Subcommittee consent agenda II, the EMTALA recommendations. Are there any of those that any committee member would wish moved to a discussion agenda?
MS. PATTEE: Mr. Chairman, should we have clarification? In my notes last night, it looks like there are some that have been addressed already by the rule. Do we need to get that classification here?
DR. WOOD: I think, from the perspective of what Gary is asking, if we simply then move these, we can go back and reconcile them later. It really doesn't -- from my perspective, it seems not to make a lot of difference. It's 232 clear that in this process, CMS was listening pretty carefully. They heard exactly what was happening and took advantage of an opportunity that was available, and they've also kept the lines of communication open by asking for some specific additional advice. So from my perspective, it's a great opportunity. If we adopt these, I think it's just a move in that direction. Judith.
MS. RYAN: I would ask, Mr. Chairman, that I and II be removed from the consent agenda for further discussion.
DR. WOOD: Okay. Jeff.
MR. BLOOM: I'd ask for No. 5, and I think Dr. Nielsen may have a clarification that will solve the issue.
DR. WOOD: Nancy?
DR. NIELSEN: Jeff very appropriately pointed out yesterday that in No. 5, the way we worded No. 5, the phrase at the end of the first sentence, "prior to screening and stabilization," is not only unnecessary but is actually -- it would be illegal to provide ABNs prior to screening and stabilization. And that is true. We checked with Ms. Norwalk. And we would like to remove that phrase, because it clearly isn't needed and ain't right.
DR. WOOD: We could simplify the sentence, actually, to --
MR. BLOOM: Mr. Chairman, pending that correction, I 233 have no problem with No. 5.
DR. WOOD: Where do you want to make the correction, though, Jeff and Nancy? Do you want to stop it at the end of "eliminate requirement for ABNs to be provided in the emergency room," period?
DR. NIELSEN: I don't think you need the "include government"; do you, Leslie? I think that makes it sound awkward.
MS. NORWALK: Well, typically, ABN is not submitted in an HMO setting, so it's not technically accurate, but I would say that from our reading, ABNs are in fact prohibited from being provided prior to screening. So not only is there not a requirement; in fact, there's a prohibition. So to say eliminate the requirement that they be provided, well, it's already prohibited. So the entire first sentence is a bit -- I mean, we prohibit ABNs from being provided prior to screening, in the beginning of stabilization.
DR. NIELSEN: But we disagree with that. We think there still is, as we read it, a requirement for ABNs to be provided after screening and stabilization if there's some reason to believe that --
MS. NORWALK: -- the service wouldn't be covered.
DR. NIELSEN: And we are opposed to that. How does this sound, if we just simply, as the Chair suggested, stop the sentence after "emergency room"? I think that is what we 234 really want.
MS. NORWALK: Okay.
MR. MARTIN: Mr. Chairman, I would move that after the word "room," we strike the comma from "stabilization," which is what she just said.
DR. WOOD: Right.
MS. GIGLIOTTI: I second.
DR. WOOD: Jeff?
MR. BLOOM: That's fine.
DR. WOOD: Reasonable? Other comments or questions about No. 5? So does everybody understand how No. 5 has been amended? It is "to eliminate the requirement for ABNs to be provided in the emergency room," period.
MS. SHAFER: The rest of that second sentence, "provide guidance," is that out?
MS. WALDEN: No.
MS. SHAFER: That's still there.
DR. WOOD: I think that solves the question about No. 5, but are there other items on this consent agenda that anyone would like to move to discussion? Mr. Cummings?
MR. CUMMINGS: No. 8, please.
DR. WOOD: No. 8. Okay. Are there any others?
DR. OLSEN: Mr. Chairman, I move Nos. 3, 4, 5 as amended, 6, 7, 9, and 10.
DR. WOOD: We don't have a 10. Oh, you put the new 235 one, the long term. Okay.
MR. MARTIN: Is that before us right now? Because it doesn't have anything written beside it. It doesn't say that it was deferred to 5/16. I thought it was. But No. 10 on this document, everything else says deferred to 5/16, but that's blank.
MS. SCHMIDT: We were taking notes this morning.
MR. MARTIN: It was deferred to today as well?
MS. SCHMIDT: Yes.
MR. MARTIN: All right. Thank you.
DR. WOOD: Erik, again, you're moving approval of the consent agenda?
DR. OLSEN: Yes. I'm sorry, 3, 4, 5, 6, 7, 9, 10.
DR. NIELSEN: I second.
DR. WOOD: Okay. Is there a second?
MR. ROVNER: Second.
DR. WOOD: All those in favor, aye. (Several say aye.) Those opposed, nay. Those are adopted. Let us return to the discussion agenda to give some advice to the subcommittee. Let's begin with 1 and 2. Judith.
MS. RYAN: I was the one that asked that they be lifted up for continuing discussion. In reading the proposed rules, I was still confused about the relationship of the decision that is described in No. 2 and the place or space that is described in No. 1. And so I still did not find it 236 clarified sufficiently. Where was the setting that was holding itself out to be the offer of the urgent services? So it was confusion between 1 and 2.
DR. WOOD: Okay. Are there other comments about 1 and 2? Jeff?
MR. BLOOM: Yes. This is another one that Dr. Nielsen may have an answer to also, and it's No. 2-C, an emergency which requires transfer to another facility, and it doesn't say who's responsible for the patient once they're being transferred to another hospital. I believe, and Leslie might be able to help us with this, that the Medicare -- the conditions of participation might cover that transfer for the patient in that ambulance while they're being transferred, but someone has to be responsible, and obviously, the ambulance company is not going to do it.
MS. NORWALK: Here's how I think it both works today, and I don't think there's a change in the proposed rule. And the concept is this: You can transfer -- either the patient is stable or not stable on transfer, so you approach it from two perspectives. If the patient is not stabilized, you can only effectuate the transfer if the benefit outweighs the risk.
So inasmuch as you're reviewing for whether or not the EMTALA obligation was followed, a surveyor would have to look at that, presumably from the decision-maker's point of 237 view: Gee, if it wasn't stable, did the benefit outweigh the risk? Was the patient stable would be the second prong. So it's determining whether or not the patient is actually stable enough to be transferred without a material deterioration in his or her condition.
So those are the two prongs. Either the patient is or isn't, and that's really the question. If the patient -- and the obligation at this point is really the hospital that's actually doing the transfer.
Now, the obligation doesn't end -- so this is sort of your point in a way. The obligation of EMTALA does not end until the patient is either stabilized, in which case the transfer is fine. Now, if the patient becomes unstable along the way to the next hospital, the question is: Gee, was the decision made in a way that any patient would have been -- it didn't make any difference in terms of the payment method, but the patient was transferred because the physician thought it was the right thing to do.
Now, the receiving hospital has an obligation in the first instance, which is to say when the patient is unstable. If the receiving hospital has the capability to accept that patient, the capability and the capacity to accept the patient, to then treat the patient when the patient arrives at the new facility, then that obligation would attach at the point of arrival. 238
So I think that basically, the concept is EMTALA would cover the transfer generally. Then it's the first hospital that has the obligation, unless the patient is stabilized, in which case the obligation ends. And that's true whether or not there's a transfer or discharge or they're admitted as an inpatient and they're stable.
The ambulance in and of itself is not unique. It's the fact the patient is stable. If the patient isn't stable, it's up to the receiving hospital that would pick up the obligation when it gets there, and it's the sending hospital that is obligated to ensure that the benefit outweighs the risk. Does that make sense?
MR. BLOOM: Somewhat. So would the first hospital be responsible until the second hospital receives the patient under EMTALA?
MS. NORWALK: It depends on the stability of the patient. I'm presuming what happens in the real world -- and perhaps all of you around the table who get to deal with this, since I'm not in a hospital setting, but those of you who are more in an ER setting can tell me. The concept is that when -- if the patient is -- I lost my train of thought. If the patient is stable and at some point becomes unstable, where was that judgment made, and where was there a mistake in judgment, and who should -- is it an EMTALA issue, or is it simply malpractice or something other than an EMTALA? It's 239 not a dumping issue, but it's a malpractice issue.
So from my perspective, in terms of looking at it as malpractice versus EMTALA, which is a dumping issue, it's the perspective in which you look at the case, because from an EMTALA perspective, you should really be looking at from the time of the transfer, not what the result was but what was all the knowledge that the doctor had before saying that the transfer was okay and to actually make the transfer. That's what a surveyor ought to be doing, looking at it from the perspective of the doctor as opposed to looking back: Well, this person had a heart attack and died. It's certainly unfortunate and perhaps malpractice, but it may not be a dumping issue, because the doctor may have taken everything he or she knew and made the best decision.
DR. NIELSEN: I just want to be clear that there is another scenario that is not dumping and not malpractice, and it is that bad things sometimes happen. So I want to really be clear that it isn't one of the two; there is yet a third alternative, given all the facts available to the most prudent, careful emergency room physician, who makes a decision given the information available to him or her at that time, and something happens in an ambulance on the way. Just as a traffic accident could happen, something else could happen. So I just want to be sure that malpractice was not your only other alternative in there. 240
MS. NORWALK: No, certainly not. I certainly didn't mean to imply that, and thank you for the clarification. It's the altitude.
DR. CROSBY: I have a question that was prompted by our site visit to Denver Health yesterday, where they have a large, excellent emergency room, and then about 15 feet away there is an urgent care center, where they more economically provide for situations that are not emergencies.
And they asked me some questions that I'd like to pass on to you. If the patient registers -- and it's an issue at Denver Health, because there's no co-pay for the emergency room, but there's a small co-pay for the urgent care center, $3 or whatever, and sometimes --
MS. EVINK: 20.
DR. CROSBY: $20? There were a variety of figures cited, but there is a co-pay for the urgent care center, and often patients -- given that they serve those of limited economic means, sometimes patients will state that there is an emergency so that there is no co-pay, but there's a determination that actually the urgent care center would be fine.
And it's not an uncommon scenario. Many hospitals have established adjacent urgent care centers. Are they violating EMTALA even under these new regs, proposed regs, if they say: You have a sore throat. Why don't you go to the 241 urgent care center rather than coming here and occupying a major trauma triage room?
MS. NORWALK: A couple of points to that. First, I'll start with the language of the statute, which says if you come to the emergency department for a medical condition, then the EMTALA obligation would attach. So while it's perhaps counterproductive in this particular setting, the fact is the statutory language -- I don't really know how you define it any other way.
You come to an emergency department. So if you walk into that department and say: I have a medical condition -- now notice, the statute doesn't say emergency medical condition, which perhaps it was a drafting error, but there you have it -- the obligation attaches to screen the patient.
So a qualified -- whatever the statutory or whatever the definition for qualified medical personnel, I think it is, qualified medical personnel needs to do the screening. If it's determined that there is not an emergency medical condition, and I'm going to assume a sore throat is not one, then the obligation ends.
So there's no doubt that there are individuals who will use this to their financial advantage, and much to the detriment of the emergency room setting. And perhaps that's part of the reason why we have overcrowding. But it's unfortunate that the statute is written in that particular 242 way, because we all have to live with it, me included. I mean, I can't write a regulation that I think is contrary to the statute.
However, we have defined something in our regulation called the dedicated emergency department, and we have asked for comments about what that ought to entail, whether or not we ought to loop in, say, an urgent care center that's 15 feet away or however far away, if that's appropriate. So the EMTALA obligation may attach in either instance, whether or not there's a co-payment, for example.
And I'd be actually interested to hear from anyone who's got some experience in those settings, what really happens, because we'd like to consider as much real-life scenarios as possible so that it actually works when we put it out in final.
DR. CROSBY: What often happens is that there is a triage nurse who takes a brief history and perhaps some vital signs, and then ideally -- and maybe some help from those of others who work more in emergency rooms more recently than I. But the triage nurse makes a determination that this needs a major emergency care; this person can go to urgent care.
MS. NORWALK: A couple of comments on that. It has been, from what I understand from staff, that from a survey perspective, a triage does not equal screening, but a triage nurse, if the hospital so defines, could be qualified medical 243 personnel and would have the capability, if the hospital so chose, to allow that -- to make the screening decision whether or not there's an emergency.
So it really depends on how the hospital sets it up. Now, that's how it's actually currently in effect. This is the same way. So that's not a change one way or the other between the current rule now and the proposed rule. But I think lots of hospitals are hesitant to have a triage nurse be that qualified medical personnel for reasons unrelated to EMTALA, but perhaps toward other malpractice issues, maybe state licensing issues for that matter. I don't know.
DR. WOOD: Are there other questions about these two items? Jack.
MR. ROVNER: Mr. Chairman, on item 2, the way it's written, it says that the EMTALA requirements end when the ER physician has made a decision. As I read the statute, it is not a requirement that an ER physician make the determination of a medical or an emergency condition; it's qualified medical personnel. And I would suggest we change that to reflect the statutory term, which I believe the rules have them defined as whatever the hospital bylaws or medical staff bylaws say is the appropriate personnel.
There is, however, one complication as I read the statute, and that is under item C. If there's a transfer, then you do need a physician to authorize the transfer, either 244 in person or by signing off.
MS. NORWALK: Yeah. A physician has to make the benefit risk, has to do that weighing of the benefits and the risks.
MR. ROVNER: In transfers.
MS. NORWALK: That's exactly right, if the patient is unstable. So yes, that's true. And you might want to clarify whether or not the patient is stable.
MR. ROVNER: I guess we need to do a little bit of wordsmithing on that No. 2.
DR. WOOD: Do you want to work on that now, or would you like to send that back to the subcommittee for work for Minneapolis?
DR. DENNIS: Could I ask a question about that?
DR. WOOD: Gary, go ahead.
DR. DENNIS: It doesn't matter, really, whether the patient is stable or unstable, because the patient may be unstable in the risk benefit, because that's already clear in the existing regulation, I thought. You could say the patient is stable or unstable, because in the case of the transfer, the patient may be stabilized in transfer. The patient may be unstable in transfer because of the risk benefit.
MS. NORWALK: My point is that the way that the statute reads and the way that the regulation currently is, as well as in the proposed rule, once a patient is stabilized, 245 then that obligation ends, because the EMTALA obligation is to screen and to stabilize. So once the patient is stable, then the EMTALA obligation goes away. So whether that's stable for transfer or discharge or admission or whatever, stability is the key.
So if the patient isn't stable and there's a transfer, that's when you have to be concerned about the risk benefit analysis and a physician signing off on the transfer. Does that make sense?
DR. DENNIS: Yes, that makes sense.
DR. WOOD: Mr. Cummings.
MR. CUMMINGS: Through the Chair, I wanted to ask Ms. Norwalk a question about a matter that probably dovetails with No. 2, but it's not squarely touched upon in No. 2. And it may be part of the proposed rules that were distributed yesterday and that I have not had a chance to read. But we understand that sometimes there's a problem with local medical review policies after the patient has presented, after the appropriate diagnostic tests have been ordered by the qualified medical professional and then later are not allowed for payment purposes. Is that something you've contemplated or addressed in the proposed rules?
MS. NORWALK: It is not addressed in the proposed rules, mainly because it doesn't fall naturally in that category, because the EMTALA statute doesn't talk about LMRPs 246 or ABNs, which is really the confluence of -- your issue is the confluence of the requirement of an ABN and an LMRP in EMTALA. But I am working on that particular issue outside of the rule. So if you wanted to make a recommendation -- by the way, a number of these recommendations are certainly excellent ones. Just because it's not addressed in the rule doesn't mean that we didn't think, gee, that's a pretty good idea and we ought to do that. It's either the rule wasn't appropriate, or there are any number of other things. But there may be other avenues to effectuate a number of these changes outside of the rule-making process, or this particular rule-making process, and that is one of them.
MR. CUMMINGS: Mr. Chairman, would it be helpful if I submitted to the committee -- I'm just thinking about the interests of time and realizing there's a full agenda today -- language that would speak to the confluence, particularly around the LMRP issue, and make that available to the committee?
DR. WOOD: Yes. It should go to the Communications Subcommittee, as they're working on recommendations for Minneapolis. Ms. Evink.
MS. EVINK: Yes. Thank you. I was just thinking that if our intent is saying that -- as opposed to saying an ER position has made that decision, that if the language of the rule already says that it can be qualified medical 247 personnel -- and that's deciding who's qualified to make the decisions, we may be able to just say qualified medical personnel and see if it falls under a physician has to be a qualified medical personnel that makes the decision to transfer. So we may not need any language change there.
DR. WOOD: Nancy.
DR. NIELSEN: I just wanted to clarify one thing, Mr. Chair, and I guess it requires an answer both from you and Ms. Norwalk. Although we've already -- or have we agreed to the consent calendar? I think we did. The issue that comes up is item No. 4. And our concern, of course, was patients who go to the emergency room, and it picks up on what Leslie said earlier, that unfortunately the statute says, with a medical -- how does the statute read?
MS. NORWALK: If you come to the emergency department asking for treatment or for a medical condition.
DR. NIELSEN: So it doesn't say emergency medical condition, and that is really critical. That is really critical. My question is, to deal with that as we want done in item No. 4, what this really means, for the people who are not working in emergency rooms, is a patient who has a medical condition, that needs a transfusion every three weeks and, you know, they go in on Saturday. The blood bank is closed. And they receive this on a schedule in the emergency room. Clearly not an emergency but in fact a medical condition. And 248 right now, screening is required.
So in order to accomplish No. 4, is it your feeling, Ms. Norwalk, that that would require a statutory change, or could it be done some other wonderful creative way?
MS. NORWALK: My thought is really the former, although if someone had a really creative way -- I have not thought of a very creative way that wouldn't contravene the statute. If there were such a way, I would be delighted to entertain the thought, and I would hope that you would put it in your comments to us so that we can consider it.
DR. WOOD: Actually, didn't you ask for guidance or comments about that specifically?
MS. NORWALK: We asked for comments on all sorts of things, so I suspect that was one of them.
DR. NIELSEN: Thank you.
DR. WOOD: Erik, are you prepared to move No. 1 and No. 2?
DR. OLSEN: I'm prepared to move No. -- I think we should do -- I'd move No. 1.
MR. MARTIN: Addressing No. 1, Mr. Chairman, it just seems to me as if -- I know that the subcommittee was trying to get at the difficult problem with No. 1, but it just seems to me, with the approach that's being taken by the proposed rule to date dealing with nonmedical personnel, using the reasonable person rule is a better approach. This seems like 249 it's very difficult. Changing a definition as to what is hospital property is a rather awkward approach. So I just would prefer that we not adopt 1, but --
DR. WOOD: Okay. Are you ready to move, Erik?
DR. OLSEN: I move it.
DR. WOOD: Is there a second?
MS. EVINK: Second.
MR. MARTIN: I'm sorry. I shouldn't have spoken till after the second. I'm sorry.
DR. WOOD: We appreciate the comment. Any other discussion? All those in favor, aye. (Several say aye.) Those opposed?
MR. MARTIN: Nay.
DR. WOOD: It would be recorded that Mr. Martin is opposed. We should go to No. 8, and the question there was raised by Mr. Cummings.
MR. CUMMINGS: Yes, Mr. Chairman. Right now there's -- to the best of my knowledge, there's no due process mechanism for a provider that has undergone an EMTALA review and then receives the typical 23-day fast-track notice. And so I would like to suggest that, or move, with respect to item 8, that it be amended after the word "outcome," add a comma and say "and provide for appropriate due process."
DR. WOOD: Go through that again.
MR. CUMMINGS: After the word "outcome," instead of a 250 period, substitute a comma and then add the phrase "and provide for appropriate due process."
MS. EVINK: Second.
DR. CROSBY: I'm not sure I fully understand what you mean by --
MR. CUMMINGS: Well, what will happen is the hospital receives a notice saying: "You're going to be terminated from the Medicaid program within 23 days unless you provide a satisfactory response," which is a very short interval of time. And the hospital may well want to contest whether, indeed, an EMTALA provision occurred in the first place. It has really no appropriate mechanism to do that.
DR. CROSBY: So would this entail a development of a lengthy process, or would -- is that doable?
MS. NORWALK: Well, it would require a statutory change to give them any more due process than is aleady -- obviously, when a hospital is terminated from Medicare, there is due process there, but the issue is really what additional process can there be prior to a 23-day termination notice.
I mean, what happens in the real world is that hospitals are so concerned about losing their participation that they just do a corrective action plan and submit it and don't really worry about whether or not there was actually a violation. It's just much easier to do the corrective action plan, because to fight the violation in basically three weeks 251 is awfully difficult. But that's, again, I think a statutory issue, unfortunately, more than one that we can resolve on our own.
DR. WOOD: Now, part of the solution to that, if you remember the discussion we had in Miami for No. 9, was we reviewed the algorithm for how the investigation should proceed. And we emphasized that rather than having -- I should say an optional PRO review early and then a mandatory one that occurs immediately before the case is referred for the legal action that would result in the enforcement, the rationale behind No. 9 was that you would make PRO review mandatory immediately in the process, which would in effect, I think, create a different set of due process opportunities under the existing structure.
MS. NORWALK: It depends on the reason for the termination, because you could be terminated for either a technical violation -- you didn't have the signage up. There are a number of things under EMTALA that are beyond screening and stabilization, that are more technical in nature, in which case a doctor reviewing the technical violation is not particularly appropriate, and we don't use the PRO for that purpose.
But if it was a medical judgment question whether or not the correct decision was made, then the PRO would be involved. I think that actually, that's what the statute 252 contemplates.
DR. DENNIS: Could I make a comment? I understand what you're saying, Mr. Cummings. I agree with your concerns. I'm not sure that's where to place that in 8. I think that 8 is requesting that there be notification of completed investigations. What you are talking about is looking at the whole due process itself.
Now, one aspect of it we took out is something that could be changed, modified a little, because there was already a PRO review that was being done, optional versus mandatory, since it was a mandatory review being done late. That's nothing we thought could be done without having major statutory changes.
This sounds like something that needs to be an overhaul, because I think there is a response deadline which is very short. The process doesn't allow the hospital to respond efficiently. And if you brought the PRO in early, that might help in some of the physician-related issues, but it wouldn't in the others.
So maybe that is one of the subjects that can be taken up under long-term reform and added to it, that a review of the due process, with recommendations for improvement or something like that, can be added to No. 10, because I don't believe you're going to be able to get what you want by adding it to No. 8. 253
MR. CUMMINGS: I appreciate the suggestion, and I would be happy to withdraw the amendment, with the understanding that we'd look for a more appropriate vehicle to attach the due process concern to.
DR. WOOD: I think the consideration here is that if we withdraw the amendment, we give direction, too, to the Communications Subcommittee to incorporate your concern into the work being done for the next meeting. Okay. So everyone understands, then, that we're back to No. 8 as it was originally written?
MS. RYAN: Move it.
MR. BLOOM: Second.
DR. WOOD: Any other discussion? All those in favor, aye. (Several say aye.) Opposed, nay. It is adopted. Now, let's see. Did I forget No. 2?
MR. MARTIN: Yes.
MR. ROVNER: I think we deferred No. 2 for Minneapolis so they can reword it.
DR. WOOD: A couple of members have suggested that perhaps a rewording is not necessary. Is there a quick sense around the committee about whether we should defer or reword?
MR. MARTIN: Mr. Chairman, if we agree to the -- I don't know the name, the lady's recommendation over here that we strike "ER physician" and insert "qualified medical personnel," would that address the concern? Because if it 254 would address the concern, then I would move that.
DR. WOOD: Yeah. I think that the question actually is that it would address the concern.
MR. MARTIN: It would? I would move.
DR. WOOD: What's the sense --
MR. MARTIN: I will move that we strike "ER physician" and insert "qualified medical personnel."
MR. ROVNER: Second.
DR. WOOD: Leslie's going to suggest -- go ahead, Leslie.
MS. NORWALK: From a technical perspective, in the clause B, I would suggest that you strike "and the patient requires admission."
MR. ROVNER: In fact, if I could pick up on that, Mr. Chairman, I would suggest the following additional changes too. I would suggest it read that "ER physician" be changed to "qualified medical personnel," per the motion. Second, that in A, everything after "exists," in other words, the words "and the patient may be dismissed," be struck. So it would just say that no emergency exists.
In B, I would suggest that all the wording after "stabilized" be struck, so that you would strike "and the patient requires admission," and I would suggest we change "and" to "or." And if the rest of the committee is comfortable understanding qualified medical personnel would 255 mean that the physician would have to approve the transfer, I would be supportive of this provision as changed.
DR. WOOD: So listening to the amendments, let me read to you what I understand the language to be: "Define limits of EMTALA by clarifying that EMTALA requirements end when qualified medical personnel have made" --
MR. MARTIN: No. It should say "a qualified."
DR. WOOD: "A qualified medical person." I was just trying to be consistent. "When a qualified medical person has made a decision A) that no emergency exists; B) that an emergency exists, and the patient is stabilized; or C) that an emergency exists which requires transfer to another facility." Because that would be a qualified person. Right. That's who the qualified person is who's made the decision. Does everyone understand the language?
DR. DENNIS: The only question I have for Leslie: Do you think that provides more guidance or less guidance?
MS. NORWALK: Well, I think it's more. Well, I think it's just more accurate.
DR. DENNIS: Okay. That satisfies me.
DR. WOOD: Nancy.
DR. NIELSEN: But the question comes up with what may be a misperception on the part of unqualified personnel that when the patient is admitted, even if they're admitted under someone else, their EMTALA obligation does not cease, and we 256 wanted to clarify that. That's why we said "requiring admission." So the question is -- I mean, if it is going to hurt us, not help us, fine; we won't -- I mean, you know, I don't want to put it in. On the other hand, that was the reason we wanted to include it.
MS. NORWALK: Once the patient is stabilized, regardless of what happens thereafter -- transfer, admission, discharge, etcetera, then the obligation would end under the proposed rule. If the patient is not stable and is admitted, EMTALA would continue under the proposed rule.
DR. WOOD: That's actually the language written in the Notice of Proposed Rule-Making. It's I think a fairly clear piece of language. Dr. Crosby.
DR. CROSBY: Well, I was going to ask that question. The patient is not stabilized. They need surgery. They're admitted and operated upon. And you're saying that EMTALA continues to apply until they're stabilized post-op or die. Does that accomplish the subcommittee's --
DR. WOOD: That's the way the proposed rule-making is currently written. If that's a concern, then the subcommittee needs to address that. I mean, that's an area where advice has been asked.
DR. CROSBY: I am concerned about how the surgeon would be feeling, to be a continual obligation. What if they're not so stable after surgery and have a long, stormy 257 course in the ICU, and then three weeks later get sent to another facility, and inadvertently they forget to fill out the EMTALA form?
MS. NORWALK: Again, this is something that we've asked for comments on, but I think the intention was to not permit a hospital to admit a patient, only then to dump the patient. They have the EMTALA obligation. You get around the obligation -- certainly no one around this table would ever do that, but inasmuch as there may be a concern that that could happen in some setting. So that was what that was intended to address.
MS. SHAFER: I think the comments here have been extremely helpful in providing insight here, but I think No. 2 has so many different pieces in it, particularly with the stability and non-stability, that I'd like to see that go back to the subcommittee to really fix it. I think the wording changes have been very helpful, and I like those, but it still leaves this whole other issue of stability and when it ends, and it needs much more discussion.
DR. OLSEN: The committee is listening to all of this and agrees with that.
DR. WOOD: Then you have it. We will send it back.
MR. ROVNER: Do we need to have the motion withdrawn and refer it back to the committee? If so, I would so move that the current motion be withdrawn and that this matter too 258 be referred back to the subcommittee.
DR. WOOD: To be technically correct and parliamentarily precise, I presume we need to do so. Is there a second?
DR. CROSBY: Second.
DR. WOOD: All those in favor. (Several say aye.) All those opposed? Now, we have a couple of other things to accomplish. We have our experts on the phone for some questions that were left over for Mr. Fay's subcommittee for credit reporting and other things. We'll get them back on the line and then go to those items. Mr. Rovner.
MR. ROVNER: One more item, please, before we leave EMTALA. It's a request that I have both for Ms. Norwalk and for the subcommittee to look at and hopefully give us some guidance in Minneapolis. As I look at the proposed rule, there's this standard of a prudent lay person observer that would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment. And I'd sure like to have a better understanding of what that is supposed to mean. I'd ask that the subcommittee try to examine it.
DR. WOOD: Does everybody understand that?
DR. OLSEN: He seems to be asking counsel. The subcommittee is requesting counsel to provide that information for us so that we can bring it back, because I don't know how 259 to read your mind.
MS. NORWALK: Well, the issue with this is if we didn't do a good enough job in the NPRM, what you need to do is have us clarify that in your recommendation or whatever it would be, in written comments back to us, because whatever I say to you, I can't do anything unless you've asked for clarification. So I can't do anything in the final rule unless you ask for clarification in written comment, to be specific. So please do so.
DR. WOOD: Okay. We had some questions from yesterday for a couple of items in Mr. Fay's subcommittee, and we have our experts on the line who promised to get answers by today. You have the floor, Tony.
MR. FAY: Mr. Chairman, would you like me to begin from the beginning of the consent agenda?
DR. WOOD: No. There are a couple of ones where we had the questions. And if you look at what we've handed out this morning for the discussion agenda, the first one is the Medicare credit balance report, and the other one is on the cost reporting, alluding to generally accepted accounting principles of reporting.
MR. FAY: The first one, the Medicare credit balance report, the subcommittee has made a recommendation to eliminate that report. That report goes back to the mid-'80s and was introduced out of concern that Medicare beneficiaries 260 had primary coverage from another insurance company, like an employee retirement plan or something of that nature. And this was an attempt to, you know, address that issue and to recoup any double payments that were made by Medicare.
Since then, Medicare's adopted the MSP, Medicare Secondary Payer questionnaire, which is a questionnaire the hospital fills out in an attempt to collect secondary payer information, which is really a lot more all-inclusive than what the Medicare credit balance report purports to do.
It's the committee's view that, since we now have the MSP questionnaire, it's really duplicative to keep the Medicare credit balance report around, and that we should do one or the other but not both.
DR. WOOD: Are there questions for that one? Do you want to move approval?
MR. FAY: I move approval.
MR. CUMMINGS: Second.
MS. BENSON: This is one of the CMS staff that is listening in. Can we make a comment on that?
DR. WOOD: Yes, please.
MS. BENSON: This report really does not deal just with MSP. Over 40 percent of the report deals with billing errors and other non-MSP items. We believe that the report is still needed in order for us to identify where billing errors have occurred, not just in MSP but for duplicate payments for 261 services that maybe were rendered to other patients. This is typically what we see on that report.
We believe that it is needed in addition to the MSP questionnaire that is out there. If there are no credit balances, that the provider -- the only thing they need to do is sign the report and check one box that says there are no credit balances.
And we believe that this report needs to stay so we can have a method of identifying what credit balances are out there. We've had numerous recovery firms that have come in and talked to us recently, telling us how many credit balances are out there, not just for Medicare but for other insurances. We've actually entered into two contracts recently, and basically at the risk of the contractor, where they will go in and take a look at the credit balances of a provider and pay them only if they identify credit balances that have not been recorded.
We also do believe that this is happening. And because they are willing to do this, basically at no cost to us if they don't find any.
DR. WOOD: This is Dr. Wood, the Chair. Could you please identify yourself so we can make sure we get it in the record.
MS. BENSON: My name is Charlotte Benson, from CMS.
DR. WOOD: Great, Charlotte. 262
Mr. Fay, would you like to respond?
MR. FAY: Yes, Mr. Chairman. The subcommittee considered CMS's comments in this regard, and we have a couple of thoughts on that. No. 1, the credit balance report is a quarterly report. It's a snapshot in time. It's not particularly, in our opinion, useful for credit balance recovery.
If there was going to be a focused audit of a provider done, the first and most important step would be to get a list of the credit balances at the time of the effective date of the audit as opposed to just warehousing these quarterly credit balance reports, which are in most cases done in a paper format and not an electronic format, so there's not a good way to cross-match the credit balances to Medicare's database.
The second issue with the Medicare credit balance report is, at least in the hospital setting, you can often have credit balances because you did not apply your contractuals correctly. So you could have gotten paid the right amount by Medicare. There could be no secondary or primary insurance at play. But because the hospital's computer system did not write off the contractual allowance correctly, that could create a credit or debit balance.
And that's something in a hospital business office that they do on a routine basis. Once a month or once a week, 263 they'll go through their credit balance report and work them and find out that most of those are indeed accounting adjustments that just simply need to be made. They're not truly overpayments or credit balances.
However, if you require a quarterly report, which is a snapshot in time at the end of the quarter, and that process hasn't been done, it's likely that this report is going to contain vast amounts of extraneous data, which are not really going to be that useful to any outside auditing firm.
MS. BENSON: Oh, if I can respond to that. The credit balances that you're talking about, the contractual allowances, if they were not paid to Medicare, they would not have to be reported on the credit balance report. And as far as a snapshot in time, what they need to do is report any credit balance debt. And truly, it is just the debts that are due to Medicare that would arise during that quarter, that they had not previously paid back. If they had paid back the debt -- identified it, they paid it back, they would not have to report it, so long as the transaction had been completed. If the adjustment had not been completed, they would put it on the report and pay it back.
DR. WOOD: All right. Do any of the committee members have any questions of Mr. Fay? Trish.
MS. WALDEN: This is also an issue for long-term care, and I don't know if the committee looked at that at all, 264 but particularly for dual eligible. And I'm not familiar enough with the detail of it, but I know that I sign one of these reports on a quarterly basis, and that it really does not reflect duplicate billing issues as much as it does issues having to do with the dually eligible. And I wondered if your committee had taken a look at that.
MR. FAY: We had not looked at the long-term care side of this, although I will note, for the record, the OIG's recently published Orange Book recommends extending credit balance reports to long-term care facilities and nursing facilities, which I guess, I'm hearing from you, you're already doing.
MS. WALDEN: Yes, we are doing them, and we've had a secondary problem with the state of Connecticut coming in and taking a look at these reports through one of their contracted groups and then deciding that there are payment problems with the state as well.
And so erroneous information or misrepresentations of credit balances have dovetailed into issues with the state as well. So I think the whole thing needs to be looked at, and perhaps it would make sense for us to defer this as well to Minneapolis and just look into the problems that exist in all realms.
MR. FAY: Would you be acceptable to the idea of looking or having the Data and Information Committee do a 265 separate look at credit balance reports in the long-term care setting, because of the different issues that they have, versus the hospital setting?
MS. WALDEN. Yes, I think that would be worthwhile.
DR. WOOD: Are you prepared to move this for approval, Mr. Fay?
DR. CROSBY: Can I ask a clarifying question that I'd like the committee -- subcommittee to address? The issue statement we received mentions that both Medicare and non-Medicare credit balances are reported, which is different from what we heard from the CMS representative. And so I'm wondering: How extensive is the reporting? Is it only Medicare or not?
And then another question raised by the discussion in my mind, that I would love to hear back from the subcommittee, is: Is this really the only way that they can tell if monies are still owed? We've heard many tales of multiple extensive audits, and it seems to me there might be other ways where this credit balance is apparent other than requiring a special format once a quarter.
DR. WOOD: I think that's the point of the recommendation.
MS. BENSON: I can answer your question on does it require non-Medicare credit balances to be reported. And the instructions specifically say for Medicare credit balances. 266
DR. WOOD: Okay. Are you now prepared to move for approval?
MR. FAY: So moved, Mr. Chairman.
DR. WOOD: Is there a second?
MS. RYAN: Second.
MR. ROVNER: Question: Is this then being limited to -- for credit balances for hospitals?
DR. WOOD: Yes, right. It is limited to hospitals. All those in favor, aye. (Several say aye.) Any opposed, nay. It is adopted, and then with the instruction that the subcommittee take up the question of the credit balance reporting for long-term care.
MS. SUTHERLAND: Mr. Chairman, I would also like for the subcommittee to take that up for home care, because we have the same situation.
DR. WOOD: Okay. We have about five minutes before we need to move to our patient provider relationships panel. The next one, Tony, could you do the Medicare cost reports?
MR. FAY: Thank you, Mr. Chairman. We approved most of the recommendations regarding a streamlined Medicare cost report yesterday, as well as E-filing of an electronic cost report that would be quickly available to all stakeholders.
The remaining issue is whether or not to recommend a GAAP-based Medicare cost report as a long-term solution. We originally had this as an intermediate-term solution. After 267 consultation with CMS and MedPAC, we realized there are some obstacles to doing it quickly, and therefore we didn't want to hold up the notion of a streamlined cost report or an electronic cost report while we tried to resolve the GAAP report issue.
So we made that as a long-term recommendation. And basically, that recommendation is that generally accepted accounting principles be used for the preparation of a detailed cost report. That would still include step-downs and ratio costs and charges and so forth for providers who are no longer subject to cost reimbursement. For those providers who continue to receive cost-based reimbursement, they would continue to use the Medicare cost report with the principles of cost reimbursement set forth in Medicare regulation and interpretive guidance.
DR. WOOD: So that would be a long-term recommendation. Are you prepared to move?
MS. SCHMIDT: The reason that we ask that this be moved to here for more discussion is that issue about what will appear as a Medicare payment being inadequate by six percent. And if you think of the size of the Part A trust fund, adding additional payments of six percent on top of that is obviously a very large amount of money in order to do that. So this needs to be a long term, because we would be then recommending that we increase the Part A payments by six 268 percent, and that's billions of dollars a year.
MR. FAY: Well, actually, if the provider who's filing these cost reports received prospective payment reimbursements not tied to that GAAP-based cost report, then that in and of itself would not increase reimbursement. Now, the logical next step is, well, MedPAC's going to be using this GAAP data to set update recommendations for Congress. The reality there is statisticians all the time have to use -- look at data sets. And they can use adjustment factors to make the leap from a cost-based universe to a GAAP-based universe and create an adjustment factor that will correct for that.
I would also go on to say that if you read the current MedPAC reports, they are relying more and more on GAAP-based data, the total margin data, which is a GAAP-based number, and the CMS market study that was recently published relating to the hospital industry. The MedPAC margins in that report were all based on GAAP data and not Medicare cost report data.
So it is long term, I agree, but I think we are seeing a move even within the regulatory bodies of recognizing GAAP is more the industry standard for reporting of revenues and expenses.
DR. WOOD: Mr. Redding.
MR. REDDING: One thing to consider, Tony, and the 269 committee, is that this is an area where a lot of states, if you will, will use the Medicare cost report to piggyback off of it for reimbursement purposes. And it may be worthwhile to hear from some of those folks as to how this recommendation might impact what they're doing in terms of reimbursement.
MR. FAY: We actually did consider that at great length. We realize a lot of states -- California, for instance, is completely cost-based for rural hospitals on the inpatient side. And in those situations, the states could continue to require that Medicare cost report -- that streamlined cost report to be filed, which in my view would look a lot like the GAAP cost report; you just wouldn't have those cost-based adjustments. Or they could create their own cost report, such as Alabama has done and a select few other states.
So we realize that this may lead to a situation where certain states will require their own Medicaid cost report, but I think, towards the goal of getting a GAAP-based cost report for providers no longer subject to costs, that would have GAAP numbers, which are universally recognized in terms of their presentation, available to not only MedPAC and HHS, CMS, but also to the general public so that they can make decisions about how the hospital industry is doing. It is of importance, but we certainly would not recommend any impediments to the state's ability to continue to collect 270 cost-based data.
DR. WOOD: Clearly, that was something you were thinking about in terms of making it long term. Suzanne.
MS. PATTEE: Mr. Chairman, I'd also like clarification on the last sentence of this. I guess it's a discussion comment. I'd like to get a better sense of how this will affect the reimbursement for new technology and children's facilities.
MR. FAY: That's another reason it's a long-term recommendation. There continue to remain certain cost-based elements in the reimbursement formula. Corneal transplants come to mind. If you had, let's say, a hospital that was 99.5 percent reimbursed on a prospective basis but they did some cost-based corneal transplants, there would have to be a formula developed to account for that.
And whether that requires them to do this full-blown cost report that takes 2500 to 4,000 hours to prepare or whether that can be done in a much more streamlined sidebar calculation, I think that's a question that needs to be worked out. But I do recognize what you're saying is there are, and probably will remain, tiny vestiges of cost-based reimbursement in the foreseeable future.
DR. WOOD: All right. Are you prepared to move that?
MR. FAY: So moved, Mr. Chairman.
DR. WOOD: Is there a second? 271
MS. RYAN: Second.
DR. WOOD: All those in favor, aye. (Several say aye.) All those opposed, nay.
MS. PATTEE: Nay.
DR. WOOD: And that is Ms. Pattee. We will need to stop here and move to our panel. Let's take a five-minute break while we set the panel up.
(A recess was taken from 9:20 a.m. to 9:45 a.m.)
DR. WOOD: We have had some concerns on the Executive Committee about the impact of regulation on patients and consumers as they go through the system, because we well know that there is not an easy way to segment how care is given. In fact, an episode of care from the patient's perspective is related to the nature of the condition, and it may not begin and end with the physician's visit but rather may start well before and end well after a physician visit or a hospitalization, for example.
So we hope to be able to get the perspective of several people in terms of this patient-provider relationship and where regulation might interfere. So we have several who have joined us this morning, and we're anxious to get their perspectives. In your agenda are the list of panelists. There is one change, however, and that is that Ms. Eileen Downs-Jacobs is replacing Ms. Evie Rosen. So with that little change, then what we'll do is go ahead. 272
Mr. Prink, I'll ask if would you start.
PANELIST HAL PRINK
MR. PRINK: Thank you. I'm speaking today as someone who's worked with Medicare beneficiaries, over 500 in the past two years. And myself, unbelievable to me, is preparing for Medicare in about three months, because I will be that magic age.
And I don't dispute the Medicare program has provided benefit to millions of senior citizens and disabled persons since 1965, but it has grown into a two-headed monster that needs serious regulatory and statutory change.
In working as a Medicare patient advocate, I have seen Medicare beneficiaries that are unable to understand the complexities of the Medicare program and how it affects them in such simple things as understanding the statement of Medicare benefits, finding a primary care physician who accepts Medicare, or what they can do if a claim or service is denied.
Now, I understand you want to focus on regulatory reform, but I think it's necessary for this committee to understand issues that need to be brought to the attention of Congress that require statutory change.
One of these is the access to primary care physicians. In a recent survey I conducted as part of a project with the Colorado Division of Insurance SHIP Program, 273 we found that only 36 percent of the primary care physicians, or 191 out of 527 surveyed, were accepting new Medicare patients, and only 31 were accepting new Medicare/HMO patients. There's a rather extensive article in the business section of the Denver Post on Monday that addresses this issue in more extensive discussion.
In addition, Medicare HMOs in the Denver Metro area are extremely limited, with Kaiser, Rocky Mountain HMO, and Secure Horizons, and Kaiser has frozen their membership, which leaves seniors with only two options and the traditional Medicare program. If the Bush administration wants more private sector participation in Medicare, such as Medicare HMOs, the annual increase of payments of two percent will not cut it.
What is needed to stem the flow of physicians leaving Medicare -- the reimbursement formula needs to be changed to reflect the true cost of operating a physician practice and not based in the gross national product in a plugged formula. This of course requires statutory change, but I think this committee, HHS, and CMS can address their concerns to Congress to support statutory change on this if they want the Medicare program to survive.
Beneficiaries are having extreme difficulty finding a primary care physician in the Front Range, which consists of Denver, Boulder, Colorado Springs, and Fort Collins. In 274 addition, fraud and abuse regulations, which you have some control over, seem onerous to physicians and impacts their decision to accept Medicare patients. They're afraid to take Medicare patients and fear that they'll be sued because they did some inadvertent error.
And we understand these regulations are for those who are deliberately attempting to defraud the program and not an inadvertent coding error, but I think this really needs to be communicated to physicians so they can back off on this concern and come back into the program.
One item requiring regulatory change, I see, is a Medicare buy-in. Under current Medicare regulations, you must elect Part B coverage and pay a 54-dollar premium, if you are on Social Security, prior to turning age 65. It is not really clear in publications and discussions with SSA representatives or other folks what the consequences of not collecting Part B coverage are.
I personally have seen two beneficiaries have serious financial problems, one for about $125,000 and the other for about $30,000, for not electing this coverage. I was able to help them, though, and get some relief for them.
In addition, if you deny to elect Part B coverage, you can only sign up the following January for an effective date of July 1. Then, to add insult to injury, they must pay a ten percent premium increase for each year they don't sign 275 up. I can't understand why they're penalized for this on something they don't really completely understand.
So my recommendation is change the regulations to allow the buy-in at any time, or at least shorten the time frame after the application is completed, and add coverage and eliminate the penalty.
Now, we have another issue, Medicare HMOs and their benefits over and above the traditional Medicare program. And it's my understanding that if a Medicare HMO offer benefits over and above what Medicare pays, CMS and HHS have little or no jurisdiction over how these benefits change over the years. And we've seen some pretty drastic changes here in Colorado, with co-pays going from $10 to $250, restricted drug formularies, and pretty sizable increases in premiums.
I think CMS needs some oversight in this area, and it would help relieve some of the frustration of the beneficiaries. I've got two examples. Just this last week, a person went in for a CAT scan, was told by their HMO that they had two views, one visit. They had to pay two co-pays of $250 each. That was wrong. They were told incorrectly. We're trying to get that $250 back.
Then another plan has a pod system. And this person went to a clinic across the street from a hospital that accepted Secure Horizons patients, but -- oh, I wasn't supposed to say that. And they had to -- because this 276 hospital was not in the pod for the internal medicine group, they had to go to a hospital ten miles away for a bone density test, a 75-year-old woman, didn't have a car, had very little transportation opportunities.
And I really think that Medicare beneficiaries do not fully understand the consequence of joining a Medicare HMO. They have to change PCPs when the PCP leaves the plan. And I don't think it's explained to them, in straightforward conversation, what these consequences are over a Medicare fee-for-service plan. Many join for drug benefits. That's history nowadays.
And I understand that -- as I said before, that in 2003, Medicare HMOs are only scheduled for a two percent increase. This is just to reiterate what I said earlier. It needs to be greater than that so we get more Medicare HMOs in the program.
Some of the benefits not included in the program: annual physical exam. I consider this is a preventive medicine that can result in early detection before medical problems become serious. Medicare, and I commend them for this, has recently added a number of preventive benefits, but more is needed.
And then I'll talk briefly about the prescription drug benefit, which is nonexistent in Medicare for the most part for outpatient and, in Medicare HMOs, is becoming a thing 277 of the past. This again requires some statutory change, but I think, again, this committee can bring this issue to the secretary's attention and make sure that something happens in this area.
Several Medicare supplemental plans provide drug coverage, but these are very costly. And I think a drug benefit needs to be provided under Medicare based on ability to pay and beneficiary drug costs. Not everyone on Medicare needs this benefit, but it needs to be balanced against income and drug costs, as I know many patients that can incur drug expenses of 10 to 50 to $100,000 a year, and it bankrupts them, and they end up on Medicaid, which is another program.
And one of my major problems -- this is a little statement here -- with the original program, it was for everyone, regardless of income, assets, or medical expenses. If we give this drug benefit to everyone, it's just going to exacerbate the problem.
I'm sure I could say more, but due to time constraints and wanting everyone to voice their opinion, I will close with this comment. Simplify the program so the 75-year-old widow with no family can understand it and get benefits she deserves and needs, and knows where to get the answers.
There are great SHIP programs in this state, as well as patient advocacy organizations, such as CCHI, Family 278 Voices, Colorado Patient Advocates, and they can help. But they have trouble understanding them too, because I learn something new every day when I look at the Medicare regulations and talk to patients. Thank you.
DR. WOOD: Thank you very much.
Next, Rosemary Pike.
PANELIST ROSEMARY PIKE
MS. PIKE: Good morning, and I'd like to thank you for inviting me to come and speak to this committee. I am Rosemary Pike. I am representing the Centura Senior Health Centers, which is a physician group. Actually, we have three centers, and we do cater to seniors. Our population is over 50 percent Medicare. And I do have some issues to bring up which are similar to Mr. Prink but a little more from the primary care physician side, so I will address those.
First of all, I'd like to let you know that these Centura Senior Health Centers are one of the few groups in the Denver area that specialize in physician care for seniors. In the year 2000, Colorado had 416,000 seniors over 65, and there are only a very few groups that do cater to that population.
We are here and exist for the explicit purpose of caring for seniors and recognize that the need for our seniors is continually growing due to the ageing of the baby boomers. However, the Medicare regulations make it considerably more expensive to provide services to seniors than to a younger 279 population.
We operate as an outpatient hospital department, because we must be subsidized by the hospital in order to continue to exist. Rules are made for the hospital and are extremely difficult for smaller departments and clinics to administer. The three Centura Senior Health Centers see an average of 100 patients per day, 21,070 patients per year, and over 50 percent of those are Medicare.
I have outlined three issues, and I did prepare a handout, which hopefully will give you a little more background, but I'll go through those. The first issue that I wanted to bring up is for every Medicare patient -- and I did hear a little bit, in the committee discussion before, about a reference to the MSP questionnaire. We are required, as a part of the hospital, to complete that questionnaire. It is a 24-question questionnaire and must be completed by every one of our patients.
The requirement doesn't mandate that it be completed at every visit, but in reality, because of the way our clinic operates, the only way that we can comply with the regulation is to question every Medicare patient prior to every visit. This information then must be entered into a computer database. One-half staff member, one half-time staff member, is required to elicit that information from the patients and complete the questionnaire. 280
And although we recognize the need for the billing information, this information is secured by free-standing physician clinics and, I believe, can be secured in a much simpler and less costly way than the way that we're required to actually procure this information.
I will comment on that, that besides our staff time, many of our patients are suffering from memory disorders. It's extremely difficult to question them. They don't understand the questions, and many of them feel almost abused after a while, because we keep asking them these questions. So it's definitely a concern for our patient population.
The other area that I wanted to address is in regards to the hospital status, which we do need, again, to exist, but it makes it extremely complex. Our billing is a very involved process for our centers. The physician professional charges must be billed on a form HCFA 1500, which requires one type of medical software. The physician reimbursement is reduced because of the hospital place of service. Then the hospital facility use or technical component must be billed on a form UB-92, which requires another type of medical software.
For one patient visit, patient registration and charge entry involves inputting the data twice, once in each system, along with entering the patient responses to the Medicare questionnaire. The additional billing entry alone requires one full-time staff person above a regular practice's 281 equivalent for billing.
So really, the status that we operate under, and must because of the financial situation, requires one and a half staff members, even without considering the additional management and coding support needed to address the billing complexities. And that's a very large expense, given the number of visits -- that you can refer back to -- that we have in a year. So it increases our overhead.
The solution that I would recommend is to simplify the regulations for billing insurance requirements for the hospital outpatient clinics to make them a little more comparable, if possible, to a free-standing physician clinic, and simplify the regulations so that we are not totally considered in a full acute hospital regulation status.
The second issue that I did want to bring up is the billing system using the APCs or the ambulatory patient classification, which was created by Medicare and went into effect August 2000. It is extremely difficult to use. There are no definitions at this point for the levels of facility usage supplied by Medicare. We have been told those will be forthcoming.
But at this point, we've been given the information to use our own guidelines, create our own guidelines. We've worked with four different coding consulting firms, trying to create those guidelines and trying to get our answers to the 282 Medicare billing and APC billing confirmed. The answers to our billing questions have varied with every person questioned, whether they be consultants from the different groups or Medicare personnel, because the Medicare rules are either not yet written or very unclear.
If we make mistakes in billing -- which Mr. Prink had mentioned, and I certainly want to add that and emphasize. If we make mistakes, we are worried about fines or worse. We are, however, unable to get definite answers to guide our billing. Although we need to collect all reimbursements that we are entitled to, we, along with many other physicians, become very conservative in our billing due to the lack of confidence in the information given to us and our fear of repercussions.
In a climate where reimbursement is not sufficient, we need to maximize the amount which can be collected. So this is definitely a negative as far as continuing our care of the patients.
The solution that I could suggest is to define the guidelines more clearly for the APCs or the ambulatory patient classification; train Medicare staff to more thoroughly understand the rules and regulations; provide and designate a well-trained Medicare support person for outpatient departments to assist us with our questions.
And that is done by most of the managed care 283 facilities. They do designate one person to be the provider representative that you can go to, that's aware of your situation and can more accurately help you, but with Medicare, we haven't been able to access a person like that. And that would be a very definite benefit for all of us, I'm sure.
The third issue that I wanted to bring up was physician credentialing for Medicare. The process required by Medicare to credential a physician is extremely difficult and complex. The application forms are unclear, and the instructions are very little help. We hired a consultant to help us fill out the applications. We sent the application to Medicare for a physician in August of 2001. The U pin and Medicare numbers for this physician were not assigned to the physician until March 2002. That's a period of eight months that we had to wait to get this whole process completed.
During this time, the instructions we were given by Medicare personnel were very inconsistent. Each time more information was requested, we were required to have the physician and a corporate officer re-sign the application, which was a continuous holdup all the way through the process. This occurred at least five times, and we've had a similar experience with three other provider applications.
My solution or suggestion there would be to make the credentialing process simpler; possibly design more 284 streamlined applications; clarify the instructions; again, educate the Medicare staff to more clearly advise the providers; expedite the internal processing; and, as suggested, again, if we could have a specific Medicare person to support our process, it would certainly help us to follow from initiation to completion.
And in completion, in conclusion, I would say that clarifying and simplifying Medicare regulations to improve the physician clinic's ability to focus more time on patient care and reduce the administrative burdens would be a definite plus. Lowering clinic overhead would hopefully encourage more physicians to be available to serve the growing senior population. Thank you very much for your time and interest.
DR. WOOD: Thank you. Dr. Alan Lazaroff.
PANELIST ALAN LAZAROFF, M.D.
DR. LAZAROFF: Thank you and good morning. I thank the committee for coming to Denver this week, and I am grateful for the opportunity to appear here today. My name is Alan Lazaroff. I've practiced geriatric medicine in Denver since 1978. Currently, I serve as the Director of Geriatric Medicine for St. Anthony Hospital as a part of Centura Health, which is Colorado's largest healthcare system. Also, I am the founder and Chairman of Total Long-Term Care, which is Colorado's PACE provider. The opportunity to work both within the Medicare system and in PACE has given me direct experience 285 caring for similar patients within very different organizational contexts.
I am a primary care physician with a very atypical patient population. Individuals who seek care from a geriatrician are older, sicker, and frailer than the patients seen by other primary care physicians, even among their Medicare patients. My patients live with chronic diseases like diabetes, Alzheimer's disease, osteoporosis, and coronary artery disease.
Over time, each chronic condition exacts a toll of functional impairment. Sometimes a patient's course is punctuated by catastrophic losses caused by events like stroke, hip fracture, or heart attack. These are themselves the potentially avoidable consequences of chronic disease.
Among the most important goals of the geriatrician are the delay or prevention of such events by the application of best medical practice, thereby avoiding the disability that they otherwise would produce. Other key objectives include the amelioration of the symptoms of chronic disease, the maintenance of the highest possible level of function, and ultimately the palliation of final illness.
In preparing my testimony, I asked myself how well Medicare structure and regulation supported me in my efforts to achieve these kinds of outcomes for my patients. Last week, at the annual meeting of the American Geriatric Society 286 in Washington, a session addressed the issue of financial survival in geriatrics practice. A similar session has been held every year, with different speakers each time, the previous year's experts sometimes having already closed their practices.
Consider the situation of a physician who completes training in internal medicine and geriatric medicine and wishes to begin practice. He will open an office or join a small group and serve as the primary care physician for seniors, an office-based geriatrician with a focus on the frail or medically complex person. Perhaps he will do some hospital or nursing home work as well.
Many internists who are family practitioners work within this kind of a model, caring, though, for both seniors and younger patients. Such office-based geriatricians are virtually impossible to find in the United States. The American Geriatric Society has collected numerous personal accounts of unsuccessful attempts. It appears that free-standing, office-based geriatric practice is not an economically viable enterprise.
Geriatricians earn a living by working in nursing homes, working in academic settings, working in administrative roles, but practicing their craft in a traditional office setting is not feasible. Like myself, some geriatricians practice in hospital-based outpatient settings, but even these 287 opportunities are beset by serious problems which now threaten their survival.
It's not my intention simply to propose higher payments as a solution to this. Rather, I'll examine structural and regulatory aspects of Medicare that contribute to these results.
My patients have multiple chronic diseases. Many are functionally and/or cognitively impaired. Everything takes longer to do with these patients. They can't hear. They can't see. They can't remember. They respond more slowly. Their stories are more complicated. They take longer to get dressed and undressed. They need more careful explanations and instructions. I simply can't see as many of them in a day.
Medicare's evaluation management coding system recognizes history-taking physical examination and medical decision-making as the core evaluation in management services. Other activities, such as counseling and care coordination, occupy a subsidiary position.
The model is well suited for describing the care delivered to a person with a circumscribed acute problem who presents to the physician for evaluation of a complaint, but my patients usually do not come to me with a complaint. Instead, they need ongoing follow-up and management of their several chronic conditions. Medical diagnostic activities are 288 less important than these visits, which instead involve activities such as review and adjustment of medication, counseling regarding lifestyle changes; coping with the impacts of disease; establishing treatment goals and expectations; coordination of care among its many sources, including other physicians, caregivers, home health nurses, and therapists.
We have had great difficulty understanding how what we do can be made to fit into the evaluation and management coding system and fear that in fact a zealous auditor might conclude that what we do is not medical care at all.
My patients require a great deal of work before, after, and in between visits. I must talk to caregivers, other physicians, visiting nurses. I complete forms for oxygen, diabetic supplies, durable medical equipment, home health. I fill out papers for assisted living facilities, day care centers, and nursing homes.
Such responsibilities fall almost entirely upon the shoulders of primary care physicians rather than specialists. And complex patients with multiple problems make much more extensive use of such services than average patients, producing an increased administrative burden for those primary care physicians who care for them.
The evaluation and management coding system assumes that physicians will be compensated fairly using information 289 about resource inputs for average patients cared for by all physicians who provide these services. I believe this assertion is erroneous. Instead, the sicker and more complex the patient, the poorer an economic prospect that patient is for primary care.
Those primary care physicians who would focus their energies on the frail and complex are punished by Medicare's payment system. Most primary care physicians cross-subsidize these patients with younger, healthier patients, for whom they are paid more for doing less. In this market, physicians are increasingly unwilling or unable to accept the situation. Of course, the opportunity to cross-subsidize has never been available to geriatricians.
Problems with the payment system for primary care of the elderly are exacerbated by the explosive growth of regulatory mandates we face in everyday practice. Some examples include the requirement to assign an ICD-9 code for every laboratory test; the requirement that patients be questioned regarding possible alternative primary payers on every office visit; the multitude of forms from multiple sources which must be completed, including Medicare, Medicaid, housing facilities, nursing homes, assisted living facilities.
Each and every requirement was created for legitimate and worthwhile reasons, but each is time-consuming, and each is uncompensated. The National Chronic Care Consortium 290 reports that for every hour a geriatrician spends in direct patient contact, one hour is spent doing paperwork. Time is a limited resource, and time occupied by administrative work cannot be spent caring for patients.
Finally, the proposed direction of the E&M system, involving more explicit description of the content of physician office visits, and creating documentation requirements for specific elements to support payments, strikes terror in the geriatrician's heart. I am thankful that this direction is being reevaluated, but any assertion that we are only being asked to document better what we already do is untrue.
Instead, these kinds of requirements would mandate a radical change in our medical record, filling it with material irrelevant to our patient care mission and a radical change in the services we actually provide. Were requirements like these to be implemented, I doubt that it would be possible to continue our practice.
Solutions to these problems aren't simple. They reflect fundamental conceptual issues of the Medicare program. And a resolution would require changes, which will produce both winners and losers. Nevertheless, a payment system which rewards the avoidance of complex, challenging, high-cost patients is likely to result in both poorer patient outcomes and higher aggregate costs. 291
New payment mechanisms which address important work which is presently uncompensated would help to redress the imbalance. One possibility would be to develop a frailty adjuster payment, which would recognize the greater physician work and practice costs involved in caring for the frail and complex. Such a direction would parallel efforts to develop risk adjusters for the Medicare + Choice program.
Another approach would be to create a care management benefit for those with complex care needs. Payment would be made for a defined list of functions to be performed by a primary care provider, involving the maintenance of comprehensive records, the supervision of services like home health, and the coordination of services provided by various specialists and ancillary providers.
The Medicare payment system for physicians is supported by an enormous and intimidating body of research. Nevertheless, I dare to suggest that it is severely flawed. In spite of efforts to correct imbalances, every practicing physician knows that doing procedures pays much better relative to effort than does cognitive work. Such a system is grievously unsuited to the care of a population whose healthcare needs are dominated by chronic disease. Changing the system will be very difficult, but ultimately, we will have to do it.
Finally, any regulatory relief or even a slowdown of 292 the relentless growth of administrative burden would be enormously welcome. And I'll conclude, and I thank the committee for your attention.
DR. WOOD: Thank you, Dr. Lazaroff.
Next, Ms. Lena Archuleta.
PANELIST LENA ARCHULETA
MS. ARCHULETA: Thank you very much. And the doctor who just spoke, may your tribe increase. We need more geriatricians like you.
I was asked to come here today to talk about what my friends and acquaintances and I think is wrong with Medicare and what could be done to solve the problems. I live in a HUD senior high-rise with people ages 50 to 98, most of them really independent and pretty healthy, but here's what they had to say.
The first one said: Well, I guess it's okay. I don't have many problems with Medicare, so I guess Medicare is doing some things right. Well, another said: I have had trouble recently, because my primary physician retired, and I have to find another. That is not easy, because I noticed that many of the doctors listed who will take new patients are in the suburbs, and I don't drive anymore.
My primary physician is a real gatekeeper, said another. Even when I told him that I thought I should have a colonoscopy, he told me that it was not necessary. He said: 293 Just because you've seen the Barbara Walters show doesn't mean you have to have one of those.
Medicare's okay, said one person, but not enough these days. I really need help with prescription drugs. Another one said: My doctor constantly reminds me that he's sick and tired of the paperwork and that he is not reimbursed adequately for his services. It's not much fun to go to a doctor who's not happy.
Another said: I wish I knew the difference among the many prescription drugs advertised. Someone needs to give us the straight scoop on medications which are as good as another, even though there is such difference in cost. I would like Medicare to promote and cover even more preventive services.
Another said: I have a friend who is spending over half of his income on healthcare, because he is not eligible for Medicaid. I'm not 65, and now I have to pay high premiums for health insurance. I know people in our building, he told me, who are just waiting for their 65th birthday.
And the last person -- the last item I want to bring up is people often talked of waiting in line, waiting at the doctor's office, waiting at the hospital, waiting for -- you know, for everything that has to be done. And so people had a lot to say, as you can see.
Then I asked them what should be done to solve the 294 problems. In response to the problem of finding a new primary care physician, someone noted that, indeed, the list posted -- and I think this was in the newspapers, and then we had a list posted in our building -- that physicians taking new Medicare patients really were far from the center of town where we live. So the problem of transportation is something that we'll have to take care of some other way.
But Colorado is one of five states in the country affected by the shortage of doctors taking on new Medicare patients.
Others pointed out that their primary physicians were getting older and that they feared soon they would be retiring themselves.
In discussing the primary physician who was reluctant to okay services requested by a patient, we reminded her that under certain conditions, the patient can request tests, such as a colonoscopy and tests for glaucoma. I didn't know that was a frequent comment, so we still haven't gotten the word around.
Some of us talked about the fact that doctors sometimes complain about the paperwork and the inadequate reimbursement. And we read in the paper that, indeed, there had been a cut. I don't remember what it was exactly. And that they wondered, in view of the shrinking surplus, if there would be a change in that reimbursement. 295
Everyone had much to say about prescription drugs, and most of them said that they would be willing to pay a higher Part B premium, up to 25 or $30, in order to get a good benefit. But someone cautioned that he certainly didn't want to lose the drug benefit he already had, although through his HMO or his retirement employment plan. Whatever prescription drug benefit would be presented would have to be voluntary, and it would have to have value.
We all wondered if there would really be that much budgeted by Washington to bring about a good benefit. Some states have passed legislation to provide a drug benefit of some kind, but Colorado is not successful this year.
Still another conversation came up among a few people, and that is of the high cost of prescription drugs and the barrage of advertising by pharmaceutical companies. The fact that this advertising costs money, and that the drug companies spend a vast amount of money lobbying in Washington, and the drugs can be purchased in Canada for less, is very disturbing to many people. It certainly was to the people I talked to.
We believe that if a drug benefit were available through Medicare, that the cost of prescription drugs might go down. They also think that Medicare should help beneficiaries evaluate the many over-the-counter drugs that there are. For example, it took me several years to discover that I was 296 taking over-the-counter drugs for a cold which were inappropriate, because they were prescribed for symptoms I did not have. Actually, most of us have found out that for the common cold, lots of liquids, rest, and chicken soup is about the best thing you can do.
I personally think that Medicare could do much more in helping us with increased self-protection. Above all, Medicare must do all it can to intervene early in detecting and treating chronic illnesses. Beneficiaries should be encouraged to pursue prevention, and Medicare can do more to expand preventive services. Somebody's already mentioned that. It certainly would be a blessing if more people could be covered by Medicaid.
Medicare should take a more active role in this area to help people plan -- I missed a sentence here. One more issue that arose about experiences that some of the people in the building had had was when their respective spouses were approaching the end of life. Medicare should take a more active role in this area to help people plan and make choices for their last days and to make sure their choices are honored. Appropriate coverage and financing of hospice care is one thing Medicare could expand. Six months should not be the magic number. There is a woman who has completed six months in a hospice and has to get out or else pay $3,000, and I think there must be some remedy to this someplace. 297
I asked a couple of men what they would think about Medicare's raising the age of eligibility to 67. They thought that would be all right if you had a crystal ball. Generally speaking, this was not acceptable, an exceptional option to save money on Medicare. My reaction was this would just add to the number of uninsured.
I, for one, am interested in another issue, and that is of patient protections for those of us on managed care. I strongly think we should have the same protection as all other Medicare people.
One other concern is the fact from time to time, the