DECEMBER 1, 2005 -- Want to know if the nurses respond faster to the call button if you're a hospital patient at Georgetown or GW? If the rooms and bathrooms are cleaner at Sibley or Johns Hopkins? If you are more likely to get pain medication at Holy Cross or Shady Grove?

Some time in 2007, visitors to Medicare's Hospital Compare Web site may be able to get answers to those questions, not only for hospitals in the Washington area but for facilities around the country.

The key to those kinds of comparisons is the release of the "HCAHPS" survey, a 27-item questionnaire hospitals are expected to begin administering to their patients next year, said Philip Dunn, spokesman for the National Quality Forum (NQF.)

The survey is in the final stages of clearance at the White House Office of Management and Budget after an extensive period of consultation with hospital and other groups in which the number of questions was pared down from 68 to 27.

The survey was developed by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services and was approved after a consensus-forming process conducted under the auspices of NQF. The process included not only hospitals and government agencies but also consumer groups, professional associations, and others.

NQF released a report Wednesday that includes the new survey.

The survey will allow "meaningful and useful information about patients' experiences in hospitals," said John Rother, policy director for the senior lobby AARP.

The survey "will improve the quality of care in American hospitals by ensuring that the patient's voice is heard and understood," said NQF President Kenneth Kizer. The survey's standardized questions will allow reliable comparisons, he emphasized.

Other questions probe how carefully doctors and nurses listen to the patient, how well they explained treatments, and the extent to which patients are treated with "courtesy and respect."

DECEMBER 1, 2005 -- Medicare "dual eligibles" who are not automatically enrolled in the new Medicare drug benefit or have not selected a plan for coverage by Jan. 1 will still be able to have their prescriptions filled, government officials said Thursday.

The Centers for Medicare and Medicaid Services has contracted with Wellpoint, which has a pharmacy network that covers all 50 states, to manage a single national account for payment of drug claims for what is expected to be a limited number of dual eligibles who have not picked a plan or been automatically enrolled in one by the time the new Medicare drug benefit begins.

CMS' plan, according to documents released Thursday, would allow beneficiaries who can present proof of eligibility for both Medicare and Medicaid—but who are not enrolled in a Medicare drug plan—to have their claim for medication submitted to a single account for payment, with the CMS contractor immediately following up to validate eligibility and enroll the beneficiary in a drug plan.

"CMS and its contractor will provide a uniform and straightforward set of instructions that all pharmacists can follow no matter which plan network they are in or where they are in the country," according to a CMS fact sheet on dual eligible coverage.

CMS has been under fire for its plans to move the dual eligibles, who qualify for both Medicaid and Medicare, into Medicare for their drug coverage, as required by the new drug law (pl 108-173). On Nov. 17, Sen. Max Baucus, D-Mont., said preliminary findings from a Government Accountability Office report he had requested showed problems with CMS' plans to switch dual eligibles from Medicaid drug coverage to the new Medicare prescription drug benefit. In addition, eight consumer and health care advocacy groups have sued the federal government, charging that its plans for dual eligibles drug coverage are inadequate.

CMS Administrator Mark B. McClellan said Thursday that CMS' plan to provide drug coverage to duals who either had not enrolled in a drug plan or had not selected one "does not have any specific relationship to the lawsuit" and has been under development for months. "It's absolutely being finalized today. It's not a late add-on," he said in a conference call with reporters.

Deene Beebe, director of communications for the Medicare Rights Center, one of the groups suing CMS, praised the announcement but said her group remained concerned that duals be able to get access to the drugs they need.

"We just want to be sure that every dual that walks into a drug store with a prescription to be filled walks out with their medication," Beebe said. "If CMS can foresee all the troubles and find remedies for all of them, that would be terrific."

NOVEMBER 28, 2005 -- The effort to reconcile House and Senate spending cut plans next month will include a health care debate that not only pits conservatives against moderate Republicans—as expected—but will force Congress to choose between the nation's two major entitlement programs: Medicaid and Medicare.

At issue is whether to trim the federal-state program that provides health care to the poorest Americans—especially just months after Hurricane Katrina—or whether to tamper with one of the president's top initiatives, the Medicare prescription drug program, which goes into effect Jan. 1.

Medicare Drug Coverage by Region
In their orders to trim spending for fiscal 2006, House and Senate committees were encouraged by the White House and GOP leaders to find ways to cut Medicaid. But moderate Republicans and Democrats, particularly in the Senate, instead opted to look at ways to rein in spending on the health program for the nation's elderly.

The Senate's version of the fiscal 2006 reconciliation bill (S 1932) does just that, targeting one particular fund that some say has become extraneous since the Medicare prescription drug law (PL 108-173) was enacted two years ago. But that fund—designed to encourage private insurers to administer the drug benefit—was one of the sweeteners that persuaded reluctant House Republicans to support the drug law.

By hammering out their separate reconciliation plans over the last month, House and Senate leaders already have had to negotiate health care spending to get the individual measures through their respective chambers.

In the House, GOP leaders softened proposed cuts to Medicaid, as well as to the food stamp program, while the bill was being debated in the Rules Committee.

And in the Senate, moderate Republicans, led by Gordon H. Smith of Oregon and Olympia J. Snowe of Maine, threatened to derail the Senate's spending package if savings dipped into Medicaid benefits and affected care for the poor.

To win their support, Finance Committee Chairman Charles E. Grassley, R-Iowa, drew up a compromise provision that would eliminate the Medicare law's stabilization fund. The fund was created to provide incentives for preferred provider organizations, or PPOs, to offer regional health plans for Medicare beneficiaries. The fund is estimated to cost about $10 billion over 10 years.

Inclusion of the fund in the Medicare bill was key to gaining the support of House conservatives, who saw it as a way to encourage more involvement from the private sector in Medicare.

Democrats and some GOP moderates have argued that all but three of the 26 service regions designated under the Medicare law are served by more than two private health plans, making the fund superfluous. But conservatives argue that the government has to prove it can be a good business partner to health insurers and work hard to encourage more PPOs—which they say operate more efficiently and save more money than the government—to sign on to offer Medicare benefits.

Under the Senate reconciliation bill, eliminating the fund would save about $5.4 billion over five years.

But efforts to scrap the fund could encourage Congress to make other changes to Medicare and revive the bitter 2003 debate over the program. That could prove detrimental on the eve of the debut of the new drug benefit. The White House has threatened to veto any budget agreement that scraps the fund.

"Superficially, it's hard to argue we need it, given that so many plans chose to participate," said Joe Antos, a health policy expert at the conservative American Enterprise Institute. "But this is the old game of pulling the rug out from under [health care] plans. It's a smaller rug, but it's still pulling it out from under them."

In the House, Ways and Means Chairman Bill Thomas, R-Calif., refused to touch Medicare to reach his committee's spending reduction target, and the Energy and Commerce Committee found about $11.4 billion of its savings from Medicaid. In contrast, only $4.3 billion in savings from the Senate bill would come from Medicaid.

The Bush administration's budget proposal tracks more closely with the House sentiment and outlines broad changes to Medicaid, including giving more administrative flexibility to states, increasing cost-sharing and cracking down on fraud.

Conservatives had hoped to increase cost-sharing in Medicaid and inch toward a system in which consumers have more of a stake in their health care decisions.

"Today Medicaid lacks any meaningful co-payment for services, no matter the cost.," Energy and Commerce Chairman Joe L. Barton, R-Texas, wrote in a letter to colleagues earlier this month, arguing that the increases in his bill would "raise cost awareness and encourage beneficiaries to take more responsibility for their health care spending."

Resisting Medicaid Cuts
In the House, the plan was to raise the co-payment required of most Medicaid beneficiaries to $5 from $3 and allow states to add a drug co-pay for pregnant women and children, the first time either group would be charged any kind of cost-sharing. They also included measures to allow states to begin charging premiums for Medicaid programs.

But moderates, who made it a priority to avoid changes that would directly affect beneficiaries, fought the changes and kept the co-pay at $3. The drug co-pay and premiums, however, remain in the bill.

Moderates in the Senate also beat back increases to cost-sharing in their bill.

Although the House measure goes further than the Senate's in putting the brakes on Medicaid spending, the bill is far from the entitlement overhaul the White House and conservatives wanted, which would have given much more flexibility to states.

A Bush administration proposal to tighten restrictions on seniors who transfer assets in order to qualify for Medicaid's long-term care services also gets different treatment in the House and Senate bills.

The House bill would extend the "look-back" period in which states examine a senior's finances to determine if the person deliberately impoverished himself by transferring assets below market value from three years to five years. It also changes the way penalties are applied, by changing the start date of a penalty to ensure seniors have not exhausted the penalty period by the time it is applied.

The House also includes a provision that for the first time would count home equity against Medicaid eligibility and deny seniors with homes worth more than $750,000 Medicaid long-term care coverage.

Despite strong White House backing for the proposals, the Senate version contains none of these provisions. That reflects a belief among moderate Republicans and Democrats that asset transfer rules are unfair because seniors often legitimately transfer assets, for example by buying a car for their children or paying tuition for a grandchild. Conservatives, in contrast, refer to the "shell game" that seniors and their lawyers play with their savings that have resulted in Medicaid paying nearly half of the over $180 billion the nation spends on long-term care services. Little reliable data exists on the true scope of the problem.

Senate moderates are unlikely to abandon their stand on Medicaid cuts given the protracted negotiations earlier this fall, and House conservatives probably will have to yield ground to the more closely divided Senate.

DECEMBER 1, 2005 -- Advocates of linking health care providers' payments to the quality of care they give their patients received a boost Thursday when a new Institute of Medicine report called for a comprehensive, universally accepted system to measure and report on the performance of health care providers and organizations.

The IOM study, which was mandated as part of the Medicare prescription drug law (PL 108-173) and sponsored by the Department of Health and Human Services, urged Congress to establish a new board within HHS to coordinate the development of standardized performance measures and monitor the nation's progress toward improving the health care system.

"Performance measures are a fundamental building block for all quality improvement initiatives," said Steven Schroeder, professor of health and health care at the University of California, San Francisco, and chair of the IOM committee that wrote the report.

"One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system of assessing and reporting on the performance of providers and organizations," Schroeder said in a news release. "Leadership at the federal level is necessary to ensure that the effort to develop performance measures achieves overarching national goals for health care improvement."

Federal officials and health care analysts tout pay-for-performance as a way to improve medical care while reducing health care costs. Performance measures are benchmarks against which providers and organizations can determine their success in delivering care, such as patients' perceptions of care measured through quality surveys.

Benefits of pay-for-performance programs include everything from increased doctor visits for preventative services to helping physicians embrace information technology and electronic medical records, according to employers and insurers who have implemented such programs.

Pay-for-performance programs have also caught the attention of lawmakers on Capitol Hill. The Senate budget reconciliation package (S 1932) would require the secretary of HHS to develop and implement pay-for-performance programs for physicians and other Medicare providers. In the House, Rep. Nancy L. Johnson, R-Conn., has introduced legislation (HR 3617) that would replace the current Medicare physician payment formula with a pay-for-performance system.

Jack Ebeler, president and chief executive officer of the Alliance of Community Health Plans, said the IOM report was "well-timed to help inform the implementation of pay for performance in Medicare."

While the IOM report noted that many individual and private organizations, including health plans and consumer advocates, have instituted pay-for-performance programs, "they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well-coordinated."

The IOM panel urged Congress to authorize $100 million to $200 million in annual funding from the Medicare Trust Fund—less than one-tenth of 1 percent of annual Medicare expenditures—to pay for a National Quality Coordination Board, which would work with organizations already involved in developing measurement and reporting tools, and provide an annual report to Congress.

NOVEMBER 30, 2005 -- Rep. Henry A. Waxman, D-Calif., said Wednesday in a letter to the Centers for Medicare and Medicaid Services that two recent Government Accountability Office reports indicate "serious flaws" in the implementation of the Medicare drug discount card.

In a letter to CMS Administrator Mark B. McClellan, Waxman said the errors "have important implications for the new Medicare drug benefit."

The Medicare drug discount card was a temporary program that went into effect in June 2004 to assist Medicare beneficiaries with their drug costs until the new prescription drug benefit is enacted on Jan. 1.

An Oct. 28 GAO report found that CMS' oversight of the drug card sponsors was constrained because the program was implemented within a six-month time frame. CMS was not able to give adequate guidance to sponsors, the report said. For example, CMS developed the drug card sponsor application before the program's operational guidelines were finished, the GAO report found.

CMS did not finalize its guidance on how drug card sponsors should report data on price concessions from manufacturers and pharmacies until five months after the program began. As of August, the overall quality of the guidance "remained questionable," pointing to problems such as outliers and missing data, the report found.

The Price Compare Web site also had inaccurate information on participating pharmacies, listing some pharmacies on the site who were not participating in the drug discount program. Also, many pharmacies that were listed did not know they were participating pharmacies. CMS officials said that they worked with drug card sponsors to improve pharmacy awareness about the program. CMS also corrected errors on the site.

The report found that two pre-enrollment marketing packets were missing required materials or had materials that had not been approved by CMS.

The report also found that $1.3 million in Transitional Assistance funds were inappropriately used by drug card sponsors to pay for excluded drugs. The report said this happened because the comprehensive list of excluded drugs was not created until November 2004.

Beneficiaries also complained about delays in receiving drug cards, the report said.

CMS took 23 compliance actions against 15 drug card sponsors in warning letters or corrective action plans, the report said.

CMS used a noncompetitive solicitation process to get drug card sponsors in which all qualified organizations could participate, according to the report. There are 66 approved general drug cards, sponsored by 38 different organizations.

The report said that CMS has corrected some of the problems, but it has "some limitations with respect to the timeliness of oversight activities and the guidance provided to sponsors."

Another report, issued on Nov. 18, said that CMS was able to raise awareness for the drug card program but was not able to adequately inform and assist beneficiaries with its education and outreach efforts. These efforts did not provide information that was "clear, accurate and accessible," the report found.

About 6 million beneficiaries obtained drug discount cards, which was below the enrollment projection set by CMS, but was above the one set by the Congressional Budget Office.

The report said that beneficiaries were confused about the features of the discount card, which may have limited enrollment. Beneficiaries also have reduced ability to access information to navigate the different health care options, which is coupled with challenges in dealing with beneficiaries who are low-income and non-English-speaking.

A response letter from CMS Administrator Mark B. McClellan said that the report "did not create the full picture of the depth and breadth of the actual activities undertaken."

He said that the analysis was based on CMS' "lessons learned activities," which are "lessons that we applied early on to adjust our educational and outreach efforts for the Drug Discount Card and that we have clearly been applying with the Drug Benefit."

McClellan also said that the report focuses on the negative results, rather than the overall outreach and education activities of CMS.