Minutes from the Health & Public Policy Committee
August 14, 2003
Present: Drs. James Poulos, Cheryl Southern, Lois Lambrecht & Caitilin Kelly
Relevant ISMA Resolutions were discussed:
- Reimbursement for telephone wait time w/insurance carriers
- Tax deductions for discounted care
- State mandated credentialing introduced by Dr. Southern
- CLIA legislation
- Physical fitness programs for adolescents and children
- Child abuse or resolution (written by the health & public policy committee)
Dr. Southern discussed her experience with the new Medicaid Management Program for chronic diseases. The federal government has approved Indiana's plan to establish the Indiana chronic disease management program for Medicaid patients whose health care needs place them in the top 10 percent of Medicaid expenditures. Patients will receive regular medical assessments, education about the diseases, dietary information to help manage chronic disease and instructions on how to manage their own care. State health records show that chronic diseases were the cause of more than 75% of the deaths in Indiana in 2000. Cardiovascular disease, cancer and diabetes accounted for more than 65% of total deaths. Dr. Southern notes that she is paid $4 a month per patient as a case management fee. She attended a 2 day symposium in June for orientation. Currently, diseases included are diabetes and congestive heart failure. Asthma will be added next year. There have been delays in receiving the software necessary to complete the requirements of the program. Monthly reports are required on each patient including medications, time spent on counseling, labs performed and the planned next visit. All of this information has to be entered into a computer. In addition, there are monthly noon teleconference meetings. Dr. Southern noted that the reimbursement for this amount of work is obviously woefully inadequate, and will force all primary-care providers, not associated with an institution, out of caring for these patients.
41.2 million Americans were not protected by health insurance at some time during 2001. Of that group, 21% were Asian-American, 35% Hispanic, 22% African-American and 12% were White.
Dr. Kelly noted that the Florida Medicaid program will offer providers access to a drug information program available on personal digital assistants in an effort to cut Medicaid spending. Dr. Poulos noted that this information currently is available on the Medicaid website but is not easy to access. Dr. Southern noted that some states currently do have pocket-sized formularies for both Medicaid and private insurance. Dr. Poulos is going to look into the possibility of drug companies sponsoring publishing a small pocket sized formulary for Medicaid allowed medications.
Dr. Poulos notes that the President of the Arnett clinic has met with lawyers of the ISMA to discuss presenting Medicaid concerns to legislators.
Dr. Kelly noted that the Center for Medicare and Medicaid services was offering a special open door forum on August 15th to provide an overview of the recently issued proposed rule, updating payment rates to hospitals under the outpatient prospective payment system.
Additional health and public policy news:
A congressional committee launched a formal investigation into hospital billing practices that often require uninsured patients to pay rates that far exceed what other payers are charged. Twenty hospital systems nationwide are being asked detailed questions about their finances and billing practices. The committee expressed concern that the uninsured have become the victims of the sophisticated and complicated forces driving health-care financing, including government entitlement programs, managed care and rising costs. The American Hospital Association, last month, sent out a special alert urging its 4,800 member hospitals to reform their billing and collection practices. The Congressional committee noted their rates are often inflated far beyond the hospital's actual costs and reasonable profit. Some payers are able to negotiate discounts and pay less, but individual uninsured patients are expected to pay this full undiscounted sticker price. In some cases, the committee notes, it appears that the very people who can least afford it are paying the full sticker price for hospital services. The congressional letter also cited the case of a California chain that had less than 2% uninsured patients. This small sliver of patients accounted for a much as 35% of the chain's total profits. Hospitals have responded that government regulations make it hard for hospitals to offer discounts to the uninsured. Medicare regulations require strict adherence to a system under which hospitals can't bill anyone less than they bill the federal government. As a result, hospitals run the risk of violating Medicare regulations if they slash rates to the uninsured patients. Recently, HCA and Tenet sought government permission to offer discounts to the needy uninsured. The responses from the government were far from clear cut.
In a class-action lawsuit, Aetna has reached an agreement with representatives of 600,000 doctors. The agreement includes a hundred million dollar cash settlement and a number of changes in how Aetna does business practice. These include: stopping automatically down coding evaluation and management codes, working with physicians to adopt mutually acceptable claim-editing software, establishing an external billing dispute review board, disclosing complete fee schedules to its doctors, adopting a definition of medical necessity that is based on generally accepted medical standards and investing at least $10 million in the establishment of a physician services service center to speed responses to inquiries.
Both the House and Senate passed versions of the Medicare reform legislation include extensive sections that should provide regulatory relief for physicians. There will probably be a carrier medical director for every state. Both bills would require contractors to respond to physician inquiries with a general written response within 45 days. Physicians who reasonably rely on that guidance would be protected from sanctions and repayment requirements even if that guidance was in error. Both bills also set aside funding for more physician Medicare education. Both the House and Senate bills seek to prevent the issuance of evaluation and management documentation guidelines without physician input. Both bills would require the Bush administration to continue to look for ways to reduce paperwork hassles.
What's New
Contact Information
Indiana Chapter Governor:
Michael C. Sha, MD, FACP
Shelly Symmes
Chapter Administrator
Ph: 317-261-2060
Email: ssymmes@ismanet.org