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April 3, 2006

Washington Health Policy Week in Review Archive 6334a5cb-b943-4426-b1cf-5bca60ad6460

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Democrats Urge Bush to Extend Medicare Transitional Drug Coverage Period

MARCH 31, 2006 -- Ten Senate Democrats have asked President Bush to extend transitional drug coverage now set to expire April 1 for millions of Medicare beneficiaries, so seniors and the disabled have access to necessary drugs.

"We're very concerned that many elderly and disabled citizens will not be able to obtain the drugs they desperately need if the transition policy ends," the senators wrote. "There has still been little or no education as to what happens when the transition policy ends, including how to file appeals."

The transitional coverage for beneficiaries enrolled in the drug benefit, which began Jan. 1, had originally been designed to last just 30 days. On Feb. 1, the Department of Health and Human Services extended that period to April 1 because of confusion among some beneficiaries over which drugs were covered by specific health plans and concerns that beneficiaries needed to maintain their drug regimens as they and their physicians determined if they could switch to another drug listed on a plan's formulary.

Beneficiaries whose transitional assistance expires April 1 will have to file for an exception or appeal with their health plan to get coverage for a drug not listed on the plan's formulary. Some health care analysts say Medicare drug plans have done a poor job of informing beneficiaries who qualify for the special coverage that it will end April 1. They also say the lack of a standardized form to appeal a coverage decision makes it difficult to get coverage for drugs not covered by a particular plan.

Centers for Medicare and Medicaid Services (CMS) Administrator Mark B. McClellan said Friday that CMS has told plans they need to take steps to help beneficiaries successfully transition to a formulary drug or take action needed to help beneficiaries maintain their current medication. McClellan also said CMS is monitoring how plans act on requests for exceptions and appeals requests and will impose fines and other penalties if plans have acted inappropriately. "Well under half" of beneficiaries who used transitional coverage have not transitioned fully to drugs covered by their health plans, McClellan said.

In a March 30 memo to drug plan sponsors, CMS warned that "the end of the transition period could produce a significant increase in exceptions and appeals requests." Drug plan enrollees, CMS said, should not discover at the pharmacy counter that they have to obtain prior authorization for a drug not covered by their plan, nor should they face delays because appeals or exception requests have not been resolved.

In situations where plans are unable to meet specific time frames for an exception or appeal request, enrollees should be given a temporary supply of the drug in question until the case is fully resolved, CMS said.

As the 90-day transition period ends, the insurance industry is "reaching out to beneficiaries, their physicians and pharmacists to provide information about plan processes for exceptions and appeals and alternatives to non-formulary drugs," Karen Ignagni, president and chief executive officer of America's Health Insurance Plans, said in a statement.

McClellan said beneficiaries who enroll in the drug benefit after April 1 qualify for 30 days of transitional assistance. That period increases to 90 days for beneficiaries enrolled in institutional settings or who are moved from one facility to another, such as from a hospital to a nursing home.

McClellan also said a standardized form for coverage appeals and exceptions would be posted on the CMS Web site within days.

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From the CQ Newsroom: House Budget Would Meet Bush Discretionary Cap, Nick Mandatory Spending

MARCH 29, 2006 -- The House Budget Committee on Wednesday began work on a fiscal 2007 budget resolution that would endorse President Bush's proposed discretionary spending limit and seek $6.8 billion savings over five years from mandatory spending.

The plan presented by Chairman Jim Nussle, R-Iowa, would stick to Bush's proposed $873 billion discretionary spending cap, a 3.6 percent increase over fiscal 2006, and assumes a $347 billion deficit. Although appropriators allocate the spending under the overall cap, Nussle's mark assumes they will fully fund the president's request for a 7 percent increase in Defense spending while making cuts to domestic discretionary programs.

But GOP moderates have already put leaders on notice that they will fight reductions in those programs, and amendments seeking to add spending are expected to be offered Wednesday afternoon.

Nussle's $6.753 billion proposal for savings from mandatory spending would give reconciliation instructions to eight committees, including $4 billion from the Ways and Means Committee. Although it is up to the committees to determine where to find the savings, the assumed savings would not come from Medicare, Medicaid, or student loans, according to Republican staff.

Bush had proposed $65 billion in reconciliation savings over five years, with more than half coming from Medicare, but that was quickly dismissed by congressional Republicans facing mid-term elections at a time when the president's popularity is low.

The Nussle blueprint assumes that existing tax cuts will be extended at a cost of $227 billion over five years, but it provides no reconciliation instructions to do so. Ways and Means Chairman Bill Thomas, R-Calif., said Tuesday that tax cut instructions could end up in the final resolution.

Among the savings proposals assumed in the blueprint is a sale of tungsten, changes to various fees, elimination of a flood insurance subsidy for second homes, and changes to pension laws.

Committees given reconciliation instructions were: Agriculture, $55 million; Armed Services, $175 million; Education and the Workforce, $1.323 billion; Financial Services, $400 million; International Affairs, $250 million; Judiciary, $500 million; and Transportation and Infrastructure, $50 million.

Nussle also is proposing a new rule that would require appropriators to get approval from the Budget Committee or its chairman for some emergency spending. His mark sets aside $4.3 billion to cover natural disasters other than Hurricane Katrina relief. Any natural disaster spending beyond that amount would have to be approved by the committee or its chairman.

But appropriators are already resisting the proposed restrictions.

"We support the concept of budget for emergencies but the Budget Committee's proposal is ill conceived and would have the effect of slowing down Congress' response to natural disasters," said House Appropriations spokesman John Scofield.

Nussle's proposal is one of several that would curtail the powers of appropriators, with Nussle and House leaders also pledging to move line-item rescission authority and so-called "earmark reform."

Nussle's mark also assumes a $50 billion reserve fund for Defense for the war in Iraq and Afghanistan. Additional emergency funds for that purpose could be added without Budget panel approval.

Jim Cooper, a conservative Democrat from Tennessee, said he would offer an amendment with Chris Chocola, R-Ind., to use accrual accounting methods to calculate the size of the budget deficit instead of a cash basis.

Cooper noted that fiscal 2005 ended with a $319 billion deficit on a cash basis, but the accrued deficit was much higher, $760 billion.

Other Democrats were expected to offer amendments to restore billions of dollars for education, health, and community development that would be cut under the assumptions in the Republican budget plan.

Update: The markup wrapped up Wednesday evening, and House floor consideration will likely take place this week.

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Groups Issue Report Card on States' Colorectal Cancer Programs

MARCH 27, 2006 -- The number of states that require insurance companies to cover colorectal preventive screening according to the "best clinical guidelines" has grown to 15, while five states have more limited provisions for colorectal cancer screening, according to an analysis compiled by colorectal cancer groups.

While three states encourage insurance companies to provide coverage, they do not require it; 28 states do not address the issue, according to the 2006 Colorectal Cancer Legislation Report Card.

Colorectal cancer is the second-leading cause of cancer death for both men and women in the United States, causing more than 55,000 deaths each year, even though it is one of the most preventable cancers with a higher than 90 percent cure rate through early detection, the groups said in a news release.

More extensive screening for colorectal cancer would help reduce the $6.5 billion spent annually to treat the disease, said the groups, which include the American Gastroenterological Association, the American College of Gastroenterology, the American Cancer Society, and the Entertainment Industry Foundation.

Screening, such as colonoscopy, is considered critical in reducing the death rate from colorectal cancer because the disease grows slowly and can be prevented or cured in most cases if directed in the early stages.

In the report card, "A" grades went to states whose coverage laws include reference to the screening guidelines developed jointly by the American Cancer Society, the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy.

States that received "B" grades require coverage but do not mandate it follow the professional guidelines, while states that received "C" grades have legislation that addresses preventive cancer screening, but the legislation is vague and does not specify the types of screening that are covered, the groups said.

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House Panel Urges Caution on Standards for Reporting Hospital Infections

MARCH 29, 2006 -- While praising state laws designed to increase public disclosure of infection rates in hospitals, House Energy and Commerce Committee Chairman Joe L. Barton, R-Texas, also voiced concern at a Wednesday hearing of the Oversight Subcommittee about the impact on consumers and hospitals.

Barton said varying state laws could confuse consumers and impose wasteful administrative costs on hospitals.

Rep. Edward Whitfield, R-Ky., who chaired the subcommittee hearing, noted that six states have passed laws to increase public disclosure and that another 20 to 30 have legislative proposals pending. More experience with those laws is needed before any federal action is taken to bring uniformity to such reporting, he said.

Among the problems that need to be addressed is the development of reporting approaches that ensure valid comparisons between hospitals. Some facilities will report they have higher rates because they have sicker patients than hospitals with lower infection rates, he noted.

But that argument shouldn't be an excuse for not measuring infection rates, said Richard P. Shannon, an executive with Pittsburgh's Allegheny General Hospital. "The correct approach is for each hospital to demonstrate consistent progress" toward the goal of having no infections, Shannon said. "To those that argue that their patients are sicker, I say, 'then all the more reason to perfect your processes, as no critically ill patient gets better with a superimposed hospital-acquired infection,' " he said.

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Johnson Steps Gingerly into Drug Benefit Oversight Role

MARCH 31, 2006 -- House Ways and Means Health Subcommittee Chairwoman Nancy L. Johnson, R- Conn., sent a letter to the head of the Medicare program Thursday questioning him on various aspects of the sometimes troubled drug benefit enrollment process, a move into oversight Democrats say should have happened months ago.

The letter avoided criticism of Medicare's handling of the drug benefit while asking some two dozen specific questions seeking details on how the program is handling various aspects of implementation.

Some of the questions sought information on issues that the Centers for Medicare and Medicaid Services has either addressed publicly in the past or on issues that cropped up weeks ago, while others appeared aimed at ensuring proper planning for events already occurring or about to occur. Still other questions were more forward-looking, about whether Medicare is planning properly for future periods of heavy enrollment.

Johnson is facing what analysts say is a serious reelection challenge from Democrat Chris Murphy, a Connecticut state senator from New Britain. Murphy called for sweeping changes in the Medicare drug benefit in mid-March, calling it overly complex and confusing and naming reform of the program as one of his top priorities if he is elected to Congress.

In her March 27 letter to CMS Administrator Mark B. McClellan, Johnson praised CMS for its efforts, saying "premiums are very affordable and many seniors are realizing many thousands of dollars in savings."

The Medicare enrollment period for this year ends May 15. Johnson noted, "I know CMS is preparing for 2007 by updating and improving on your current educational materials. Continued success will depend on the availability of educational materials and assistance. Only clear and timely information will enable beneficiaries to enroll in the plan most useful to them."

Among Johnson's questions are: how CMS has expanded the annual handbook sent each fall to Medicare beneficiaries to reflect the new drug benefit, what the average wait times are for consumers calling the 1-800-Medicare consumer information line, and what the wait times are for pharmacists calling Medicare.

"As many as 700,000 [dual eligible] and low-income beneficiaries are utilizing one plan when CMS has a different plan as their 'plan of record,'" the letter said. "How is CMS addressing this situation?"

The New York Times first reported on the problem in a March 1 story. Complaints from pharmacists and beneficiaries about wait times surfaced months ago.

Johnson's March 27 letter also asked about CMS planning for the April 1 start of formularies taking effect for drug beneficiaries limiting or ending coverage of some drugs. "Are the plans prepared to implement the appeals process. Are forms easily available?" She also asks about planning farther down the road: "Are you prepared for a surge of sign-ups before the May 15th deadline, and what steps have you taken to be sure the plans are prepared?"

Johnson requested responses "no later" than April 21, saying "we intend to hold a hearing on implementation of the Part D benefit to focus on the steps CMS is taking to encourage beneficiaries to sign up." No date has been set for the hearing.

"The fact that they don't know the answers to these questions already shows how little oversight they have done," said a Democratic aide. "I think we know the answers to most, if not all, of these questions." The aide added that the questions "fail to get at many of the real problems," naming as examples difficulties of dual-eligibles getting prescriptions filled and ensuring access to drugs in drug classes required to be covered.

Phone calls seeking comment from Johnson aides were not returned.

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Survey Finds Support for Enzi-Nelson Insurance Bill

MARCH 30, 2006 -- Sen. Michael B. Enzi, R-Wyo., and Sen. Ben Nelson, D-Neb., made another pitch for their small business health plan bill (S 1955) on Thursday, unveiling a poll they said showed broad public support for their legislation.

The poll, conducted by Democratic pollster Celinda Lake and GOP pollsters Public Opinion Strategies, was done on behalf of the National Association of Realtors, a strong supporter of the bill.

The survey found a total of 89 percent of voters favored a small business health plan when presented as a bill that "requires congressional approval so that private health insurance companies can sell insurance across state lines to the self-employed and small businesses in multiple states." The survey also offered an argument for and an argument against the plans and found that 88 percent of voters found the favorable argument convincing, while 45 percent said the same for the argument against the bill.

The bill aims to make it easier for small businesses to join together to get better rates when purchasing health insurance by allowing them to bypass state coverage mandates. Business groups complain that a confusing array of state mandates make it too complex now to form purchasing groups that operate across state lines.

In an attempt to draw some Democratic support, Enzi's bill includes a provision that would allow insurers to sidestep state laws to design their benefit options only if they also sell a plan that matches a benefit plan offered to state employees of one of the five most populous states. But it will still be a tough sell. Democrats and state officials have argued that the proposal would compromise patient care and override the wishes of state legislatures.

Nelson, the only Democratic co-sponsor of the bill, said members of his party who are interested in learning more about the bill have approached him, and he said they "were continuing to work on it."

A timetable for bringing the bill to the Senate floor has not yet been set, Enzi said, adding, "Members of the coalition will be helping me push for the earliest possible date." He said he also has been talking to House members so that if the measure passes the Senate.

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