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May 23, 2005

Washington Health Policy Week in Review Archive e7c03cf2-dae1-4aa7-8d39-c815dc896378

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Frist-Bingaman Bill Would Allow Uninsured Children to Enroll in Medicaid, SCHIP

MAY 17, 2005 -- Senate Majority Leader Bill Frist, R-Tenn., and Sen. Jeff Bingaman, D-N.M., introduced legislation Tuesday that would provide $100 million in grants over two years to states, local communities, schools, faith-based organizations, and others to enroll eligible children into Medicaid and the State Children's Health Insurance Program (SCHIP).

The bill would allow the Department of Health and Human Services (HHS) to award grants to organizations that conduct "innovative" outreach and enrollment programs for uninsured children. To be eligible, organizations must conduct assessments of the effectiveness of their activities and collect and report enrollment data to the HHS secretary.

The $100 million in funding would be evenly split in fiscal 2006 and fiscal 2007, with 10 percent set aside for grants to the Indian Health Service, tribal organizations, and urban Indian programs for outreach and enrollment for American Indian children, according to documents detailing the bill. Funds also could be carried over into subsequent fiscal years until all $100 million is awarded.

The HHS secretary would be required to make public the enrollment data and other measures that demonstrate the effectiveness of the outreach programs. The secretary also would have to submit an annual report to Congress detailing how the programs are working to expand coverage for uninsured children.

Approximately six million uninsured children are eligible for coverage through Medicaid and SCHIP, the lawmakers said in a news release. "Covering children is not only the right thing to do, but by ensuring that children have access to preventative care, it is also one of the best ways of reducing long-term strain on America's health care system," Frist said.

Many parents "simply don't know these program exist or how to enroll their children in them," Bingaman said. "This legislation shines a spotlight on this serious problem, setting aside $100 million to sign children up for the benefits they need to be healthy."

The measure would also give states the option of using income and resource eligibility determinations made under other government programs to fast-track enrollment in Medicaid and SCHIP. That step, the lawmakers said, would simplify state administrative processes, reduce paperwork burdens for families and the government, help increase insurance coverage, and potentially reduce costs of a number of federal programs.

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Helping Aging Baby Boomers to Help Themselves

MAY 17, 2005 -- The Bush Administration remained mum about the specifics, but said Tuesday that its most important goal in the upcoming reauthorization of the Older Americans Act is modernizing long-term care for the Baby Boomer generation.

Among the elements of modernization: more individual responsibility for financial planning; greater emphasis on managing one's health; and fostering home- and community-based care to reduce favoritism toward nursing home care.

"We will pursue changes that recognize that we cannot wait until people are old and frail and poor to begin to address their long-term care," Assistant HHS Secretary for Aging Josefina Carbonell told the Retirement Security Subcommittee of the Senate Health, Education, Labor and Pensions Committee.

"This will require that those who are not old should plan for their own long-term care. It will require the elderly who are not poor to make creative use of their existing resources to finance and support their care, with limited government assistance, to prevent poverty and the loss of independence."

Carbonell told Subcommittee Chairman Sen. Mike DeWine, R-Ohio, that the administration may announce more detailed goals for reauthorization of the 40-year-old legislation in the next month. The legislation pays for nutrition, health care, and employment assistance programs assisting the elderly through community senior centers, Meals on Wheels programs, and other means.

Reauthorization of the Act in the year 2000 added the National Family Caregiver Support Program to provide respite care and other assistance to individuals acting on their own to provide long-term care.

Carbonell said reauthorization should promote awareness and use by individuals of long-term care insurance and home equity programs to finance their own long-term care.

"Home equity instruments such as reverse mortgages enable older people to tap into the equity in their homes," she said in written testimony. "It is estimated that 45 percent of households at financial risk of 'spending down' to Medicaid could take advantage of a reverse mortgage to help them pay for long-term care."

Promoting better health is another way of modernizing health care for the elderly, she said. The HHS Administration on Aging aims in part to do that by enrolling seniors, particularly those with low incomes, in the upcoming Medicare prescription drug benefit.

It seeks the "active support of at least 10,000 of our community-based aging services provider organizations in helping older people learn about and take full advantage of the new coverage," Carbonell said. Meals on Wheels and other volunteers will assist in the effort, she said.

Another goal of the reauthorization is to foster "evidence-based" health promotion and disease prevention programs and practices "that delay and prevent the chronic conditions that are known to result in disability among the elderly."

Examples include a six-week training program to help people with chronic conditions better manage their own health in a way that reduces use of hospital and doctor care and a program developed at Yale University that trains the elderly to reduce falls by improving balance, gait, and posture; managing their medications; and removing hazards in the home such as slippery rugs.

Some 8.2 million Americans are assisted by the network of state and local government offices, local organizations, and volunteers carrying out programs under the Older Americans Act. Of these, 3 million are getting services in their home that keep them out of nursing homes, Carbonell said.

The network "manages almost two-thirds of this nation's Medicaid investment in community-based long-term care for the elderly, she said. The Act "should now be modernized to help this network and the country adapt to the challenges of sustaining community-based long-term care."

Carbonell agreed under questioning by Sen. Barbara Mikulski of Maryland, the ranking Democrat on the subcommittee, that the National Family Caregiver Support Program has become one of the "pillars" of the system created by the Act. In addition to giving caregivers a break by funding limited care for the frail and disabled by other individuals, the program provides counseling and training and information on local long-term care resources.

The Administration on Aging originally projected that 250,000 caregivers would find assistance through the program, but the total in 2003 reached almost 600,000. Mikulski said she aims to double funding of the program from $125 million to $250 million.

Questioning by DeWine and Mikulski suggested that their reauthorization priorities include greater help for elderly Americans in finding work in the private sector, including those in the auto and steel industries who have been abruptly laid off. DeWine said he plans a series of hearings on the reauthorization and that part of the process will be reviewing recommendations expected later this year from the White House Conference on Aging.

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Lawmakers Express Anger over Leavitt Medicaid Commission

MAY 20, 2005 -- The Medicaid commission that Health and Human Services Secretary Michael O. Leavitt outlined Friday bears little resemblance to the panel some lawmakers asked Leavitt to create.

Leavitt, rather than the bipartisan leadership of the House and Senate, would have the power to appoint the commission and he did not give the National Academy of Sciences' Institute of Medicine the power to administer the panel as the legislators had sought.

Leavitt will appoint up to 15 voting members to the commission, while lawmakers of both parties will appoint eight members to serve in non-voting positions.

In a statement, Leavitt said he looks forward to "working with this commission in an open and bipartisan manner to reform and modernize Medicaid," a program that Leavitt said is "rigidly inflexible and inefficient, and worst of all, it is not financially sustainable."

Sen. Jeff Bingaman, D-N.M., said Friday Leavitt's panel was not what he had in mind when he proposed legislation along with Sen. Gordon H. Smith, R-Ore., to create a bipartisan commission to recommended changes to Medicaid. Bingaman and Smith were among the lawmakers who wrote to Leavitt with specifics about the Medicaid commission.

"We already know the Bush administration supports deep cuts in Medicaid, and it concerns me that the Health and Human Services secretary will be appointing all of the voting members of the panel," Bingaman said in a statement. "I had hoped for a commission that could produce a report that both sides of the aisle could buy into. I have serious doubts about whether that will happen under this scenario."

Rep. John D. Dingell, D-Mich., another lawmaker who had made recommendations to Leavitt, also expressed his disappointment Friday.

"The commission appears to be a fig leaf for ten billion dollars in Medicaid cuts rather than an independent and credible source of recommendations for changes in the program," he said in a statement. Dingell is the ranking member on the House Energy and Commerce Committee.

Additional requests made by Dingell, Smith, Sen. Max Baucus, D-Mont., and other lawmakers included requiring that a super-majority of panel members agree on recommendations and that all meetings be open to the public.

According to a Federal Register notice, commission meetings "shall be open to the public except when closure is specifically allowed by statute, and after all regulatory requirements for doing so have been met." There will be public notice of all meetings.

Smith succeeded in March in stripping a provision from the Senate budget resolution that would have directed the Finance Committee to cut $15 billion over five years, almost all of it from Medicaid, the federal-state health care program for the poor and disabled.

In talks with the White House and Senate GOP leaders, Smith agreed to accept $10 billion in Medicaid cuts if a presidential commission was created to recommend ways to wring savings from the program without hurting beneficiaries. A Smith spokesman said the senator was traveling Friday and could not be reached for comment.

A Senate Democratic aide said that Leavitt's Medicaid commission design "didn't take a single recommendation" from members of Congress who sought to shape it.

"It would appear the secretary has ignored the priorities laid out by Sen. Baucus and Congressman Dingell," the aide said. "This clearly just doesn't pass the smell test."

The commission must submit two reports to Leavitt. The first, due Sept. 1, will outline recommendations for Medicaid to achieve $10 billion in savings during the next five years as well as "ways to begin meaningful long-term enhancements that can better serve beneficiaries," HHS stated in a news release. The first report will also consider potential performance goals for Medicaid.

The second report, due Dec. 31, 2006, will recommend ways to help ensure the long-term sustainability of Medicaid, addressing areas such as how to expand coverage to more Americans "while still being fiscally responsible" and how to provide long-term care to Americans who need it.

Voting members of the panel will include former or current governors, representatives of public policy organizations involved in major health care policy issues for families and individuals with disabilities, former or current state Medicaid directors, and federal officials who administer Medicaid programs.

The Republican and Democratic leaders of both chambers and the Senate Finance and House Energy and Commerce Committees will appoint members of Congress to serve in the non-voting positions.

That may be a tough job, the Senate aide suggested.

"What they did was the worst of all worlds, which is there's members of Congress but they don't get a vote," the aide said. "What member of Congress is going to want to serve on that panel?"

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Medicare Panel Discussion Focuses on Effect of Drug Benefit on Dual Eligibles

MAY 16, 2005 -- Audience members at a Monday panel discussion about the new Medicare drug law expressed concern that those enrolled in both Medicare and Medicaid will not make a smooth transition when the new drug benefit goes into effect in January.

The prescription drug benefit, or Part D of the Medicare program, was created as part of the Medicare drug law (PL 108-173).

While enrollment is optional, those eligible for both Medicaid and Medicare will have their drugs covered by Medicare once the drug benefit begins next Jan. 1. Some health care analysts fear that these "dual eligibles" could be hurt by the transition.

Congressional aides and representatives from various health organizations directed questions at panelists Tricia Neuman, vice president of the Kaiser Family Foundation, Linda Fishman, director of Centers for Medicare and Medicaid Services' (CMS) Office of Legislation, and William Scanlon, a senior policy advisor with Health Policy R&D. The Alliance for Health Reform and the Kaiser Family Foundation co-sponsored the event.

Neuman said that those with dual memberships will be contacted by the end of the year about the change in Medicare, either through CMS or their state government. She added that they will be assigned a plan under Part D to ensure that coverage continues through the transition, but they can change this to cater to their specific prescription drug needs.

"The worry is that not all seven million people will make this transition smoothly," Neuman said. "A lot needs to be done to make sure that there aren't any gaps and make sure no one falls through the cracks."

Neuman said that both the Kaiser Family Foundation and CMS are projecting roughly 29 million of the 40 million Americans on Medicare will enroll in Part D by January.

"The issue of participation is very important," she said.

Enrollment will be key to the success or failure of the new drug benefit. Scanlon said he was concerned about outreach initiatives thus far.

"We're talking about the entire Medicare beneficiary population," he said. "It is going to be very important that the word get out to the beneficiaries so we can achieve these levels."

Fishman agreed with Scanlon and said that CMS has been focusing on letting people know about the new benefit throughout the year.

"Outreach is what CMS is all about," Fishman said.

The discussion also focused on how low-income participants would fare under the new drug benefit. Individuals dependent on food stamps and other federal government benefits could lose them if they opt to enroll in Part D.

"This benefit is so generous to those in the low income bracket that they will be better off," Fishman said in response.

Fishman added that those who will be losing their Medicare prescription drug cards currently covering their prescription drugs will be covered under the new program.

"The prescription drug card was always a temporary program that would be replaced by the Medicare Part D in 2006," she said.

Others pointed to how the drug benefit is going to be financed, a debate that has been going on in Congress since the release of President Bush's budget in February.

Scanlon pointed out that there is "constantly fine tuning going on" in the bill's implementation and financing.

However, he said there needs to be more debate over how to sustain the Medicare program for years to come.

"We need to have a discussion about how we are going to finance long-term care in the future," Scanlon said.

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"Pay-for-Performance" an Imperfect Cost-Control Tactic, Harvard Researcher Says

MAY 17, 2005 -- For all the excitement about "pay-for-performance" as the way to deliver better value in health care, the payment method in its current form isn't designed to deliver cost savings, a Harvard researcher testified Tuesday.

Congress should fund more research by the federal Agency for Healthcare Research and Quality to find approaches that increase the likely gains in savings and quality from pay-for-performance programs, Meredith B. Rosenthal, an economist at the Harvard School of Public Health, advised a House subcommittee.

Pay for performance pays a doctor or hospital more for higher scores on specific measures of performance, such as the percentage of heart attack patients who have been prescribed lifesaving beta-blocker drug therapy when they leave the hospital.

While Medicare appears to be heading full steam toward such a system, it is still new to health care and payers face a number of challenges implementing it, Rosenthal said in testimony before the Employer-Employee Relations Subcommittee of the House Committee on Education and the Workforce.

There is little solid research to guide payers and health plans in designing pay-for-performance systems, Rosenthal said, estimating that there are some 100 such programs nationwide. "Despite the hopes of some benefit purchasers, the current generation of pay-for-performance is not designed to reap cost savings, particularly since most of the quality measures it targets are measures of underuse."

Nearly all current measures aim to bring low levels of certain types of care, notably preventive treatment, up to a recommended level.

"Paying for performance almost always means rewarding physicians and hospitals for delivering more services, for which they may also be able to bill," Rosenthal said. She did not address the issue of cost savings potentially generated by higher levels of preventive care that might prevent hospitalizations.

"In my view, it would be desirable to enlist pay-for-performance in the service of enlightened cost control in order to preserve the availability of private insurance coverage," she said, adding there are signs, though, that payers are beginning to reorient their programs more toward cost savings through "increasingly robust" measures of the efficiency of care.

"Along these lines, payers could also greatly benefit from a public investment in the development of quality measures that capture the negative consequences of overuse" by doctors and hospitals of tests and procedures, she said.

Also needed to make pay-for-performance more effective is coordination among payers in using measures, Rosenthal said. "If only a few of the many payers that a provider contracts with are paying for performance, or if each payer focuses on a different measure set, the effects of pay for performance may be diluted."

The Centers for Medicare and Medicaid Services could go a long way toward solving this problem by leading the way in payment for performance, she said. That's because private payers often adopt key Medicare payment changes, she explained.

Rosenthal advised adopting pay-for-performance as just one element of a strategy to increase value in health care spending. Other tools she rated as promising included public reporting of cost and quality data associated with individual providers, benefit designs that use lower levels of out-of-pocket spending to steer patients to providers with lower costs and higher quality, and "shared risk" approaches in which group practices share in the profits or losses associated with delivering care.

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