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House Bill Heading for Senate Not Your Father's 'Doc Fix'

By John Reichard, CQ HealthBeat Editor

March 28, 2014 -- The "doc fix" bill has become a routine part Congress's annual to-do list. But this year's version shows how members are using it for considerably more than standard adjustments to Medicare payments.

Lawmakers also have inserted language addressing controversies such as the switch to the ICD-10 billing system and the payment levels Medicare assigns to different types of physician services. The bill (HR 4302) also takes on the "two-midnight" rule hospitals complain puts them at risk of providing costly care for free.

It addresses consumer concerns such as exposure to radiation in CT scans, and assistance to the parents of children with complex medical conditions as they try to line up services to meet their needs. The bill even tinkers around the edges of the health law (PL 111-148, PL 111-152), despite the widespread belief the law can't be tweaked without procedurally exposing it to wholesale changes.

The most pressing piece of business is heading off the 24 percent cut in Medicare payments to physicians scheduled to take effect April 1. The bill does that by delaying any cut through March 31, 2015, offsetting the $15.8 billion cost of this one-year doc fix and the other extensions in the measure with $22.1 billion in health-related spending reductions.

The House passed it by voice vote last week and the Senate plans to take up the measure this week. Although it appears headed toward congressional approval, its road has been rocky. To get it through, House Republican and Democratic leaders struck a closed-door deal to bring up the measure and pass it by voice vote while many members were not in the chamber. Late last week the American Medical Association (AMA) and the American College of Surgeons urged senators to reject the House bill, instead backing a complete overhaul of Medicare's physician payment formula.

The AMA said that if Congress has to enact another patch, it should be limited to the period needed to work out an agreement on offsets for a complete overhaul.

With uncertainty about whether Congress will pass the one-year patch and prevent the 24 percent cut by April 1, Medicare officials have instructed their payment contractors to hold Medicare claims for physician services filed after March 31 for two weeks.

The bill would repeal section 1302(c) of the health law, which caps allowable deductibles for small group insurance plans. The caps currently are $2,000 for individual coverage or $4,000 for family policies starting Jan. 1, 2014. But employers complain that only about a third of small group customers choose plans with deductibles lower than the caps. That means the rest would be forced to raise premiums, increase copays or strip benefits to comply with the cap, according to the National Retail Federation and a coalition of other groups.

Though the Department of Health and Human Services (HHS) will allow plans to exceed the statutory cap when there is no other reasonable way to provide an actuarial value at a given tier of coverage, the waiver applies only for three years and can be modified or rescinded at any time, the groups charged in a letter last year. The language in the House bill would drop the cap as a matter of law.

The exposure of patients to radiation in CT scans has become a growing concern in recent years amid reports that the technology is overused and can't keep excessive doses of radiation from being administered. The bill would require doctors ordering CT scans to state in their Medicare payment claims whether they have consulted HHS-approved guidelines developed by specialty societies in deciding whether to order an image. Those who repeatedly order scans counter to those guidelines may be required to obtain prior authorization from Medicare in order to be paid.

The House bill would cut Medicare payments by 5 percent in 2016 to doctors who use equipment that didn't have "dose optimization" features and by 15 percent in 2017 if they lack equipment with such features. Combined, the guideline and equipment provisions will save an estimated $200 million over 10 years.

Another provision of the bill extends funding for six months of a health law program called the Maternal, Infant, and Early Child Home Visiting Program." The voluntary program provides grants for visits to the homes of pregnant women, expectant fathers or primary caregivers of children to improve parenting skills and prevent child injuries and child abuse.

And the House bill also extends through fiscal year 2015 "Family to Family Health Information Centers." The centers are non-profit, family staffed organizations in which families of children and youth with special health care needs help each other navigate the maze of programs and services to assist such children.

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