Washington Update: Healthcare Policy News
Following AGS Member Advocacy Efforts, and With Help of Sen. Jeff Bingaman, Geriatrics Is Included Among Eight Fields Eligible for New GME Funding
American Geriatrics Society (AGS) member advocacy efforts, along with the help of Sen. Jeff Bingaman (D-NM), have resulted in geriatrics being included among the eight primary care fields eligible for new Teaching Health Center Graduate Medical Education (THCGME) funding, the Health Resources and Services Administration (HRSA) announced in late December.
Authorized by the healthcare reform law, THCGME funding covers direct and indirect costs of training residents who fill new positions in primary care residencies sponsored by a community health center or graduate medical education (GME) consortia.
Health centers must sponsor training in primary care and must be accredited “sponsoring institutions” to receive funds under THCGME. GME consortia can qualify for funds if their health centers are a “central component” of the consortia and THCGME payments “directly support the [teaching health center] ambulatory training site.”
The eight primary care fields eligible for the funds include geriatrics, internal medicine, pediatrics, family medicine, obstetrics and gynecology, psychiatry, and general or pediatric dentistry. Applications for 2011 were due on December 30, 2010.
Advocacy by AGS and Support From Sens. Herb Kohl and Sheldon Whitehouse to Speed Pain Relief for Long-Term Care Residents
In response to advocacy efforts led by the AGS and other groups, and due to the leadership of Sens. Herb Kohl (D-WI) and Sheldon Whitehouse (D-RI), the Justice Department announced in January 2011 that it would draft legislation to expedite the provision of controlled pain medications to long-term care facility residents in need of such medications.
In December 2010, Sen. Kohl, who chairs the Senate Special Committee on Aging, put a hold on Michele M. Leonhart’s nomination as chief of the Drug Enforcement Administration (DEA), blocking a floor vote on her confirmation. The senator announced that his hold on the nomination would remain in effect until there was progress ensuring long-term care residents’ timely access to controlled pain medications. His announcement followed a November 2010 Senate Judiciary Committee confirmation hearing for Ms. Leonhart, at which the senator expressed his disappointment that the DEA had yet to address the long-standing problem. Sen. Whitehouse echoed Sen. Kohl in calling for a much-needed solution. The Justice Department agreed on January 4, 2011, to draft legislation revising the Controlled Substances Act to address delays in the administration of controlled pain relief drugs in long-term care. In response to the Justice Department’s move, Sen. Kohl then lifted the hold on Ms. Leonhart’s nomination. She was later confirmed by the Senate.
“Based on our agreement, I am releasing the hold on Michele Leonhart’s nomination, and I look forward to introducing a mutually acceptable legislative fix in the opening days of the 112th Congress,” Sen. Kohl announced. “Time is of the essence for nursing-home residents who need immediate pain relief.”
In response to requests from the AGS, AMDA-Dedicated to Long-Term Care Medicine (formerly the American Medical Directors Association), and other eldercare organizations, the DEA had made some changes to its policy regarding the prescribing of controlled pain relievers in long-term care in October 2010. Those revisions, however, didn’t eliminate key obstacles to timely pain relief for residents, and the AGS and other organizations called for additional changes.
The AGS and like-minded organizations began urging changes in the DEA policy in 2009, when the agency began enforcing the policy more tightly. Last March, then-AGS President Cheryl Phillips, MD, testified before the Senate Special Committee on Aging, noting that obstacles to timely pain relief in nursing facilities could be addressed if DEA policy regarding narcotic pain relief in these facilities were aligned with the agency’s policy regarding the use of these pain relievers in hospitals.
AGS CEO Jennie Chin Hansen and Leadership of Other Key Eldercare Organizations Meet With NIH, Call for Adequate NIA Funding
AGS CEO Jennie Chin Hansen, RN, MSN, FAAN, and leaders of other organizations met with National Institutes of Health (NIH) Director Francis Collins, MD, in December 2010 to discuss the pressing need for adequate financing of the National Institute on Aging (NIA).
The AGS, Gerontological Society of America, Alliance for Aging Research, Alzheimer’s Association, Alzheimer’s Foundation of America, and other key groups are calling for $1.4 billion in funding for the NIA in fiscal year 2012. In a recent letter to Dr. Collins, Ms. Hansen and other leaders noted that this level of funding, which represents an increase of $300 million, is essential to sustain research aimed at combating chronic diseases, which are common among older adults and continue to drive massive increases in national healthcare spending. The organizations asked Dr. Collins to reach out to the administration for support of the request for $1.4 billion for the NIA in FY 2012 and offered to help support a broader effort to increase NIH funding in general.
During the meeting, she and other leaders noted that:
•Current, historically low compensation for NIA investigators is inappropriate given the need and opportunity for research concerning age-related health and health problems. Healthcare spending for the nation’s 77 million baby boomers—the eldest of whom turn 65 this year—will spiral out of control if the United States doesn’t increase investment in research and medical innovations for age-related conditions now.
•Funding deficits threaten the future of aging-related and Alzheimer’s disease research. These deficits will inevitably affect clinical aging research and the availability of an adequately trained eldercare workforce.
•The costs of Alzheimer’s disease account for a staggering share of Medicare/Medicaid spending. As experiences with polio, heart disease, HIV/AIDS, and cardiovascular and other diseases demonstrate, medical research and breakthroughs can significantly reduce healthcare costs. Medical advancements significantly increase national productivity and prosperity, but such benefits are possible only if the NIA has sufficient funding to invest in research aimed at preventing, treating, and curing age-related diseases and promoting health in later life.
•The time for action is now. The aging and Alzheimer’s disease community is more powerfully mobilized than ever, and intends to continue campaigning for adequate NIA funding next year and beyond.
Following the December meeting, the AGS launched an advocacy campaign urging supporters to call their lawmakers and urge them to adequately fund the NIA.
In Letter to CMS, AGS Calls for Reconsideration of Value Assigned Subsequent Observation Care
The Centers for Medicare & Medicaid Services (CMS) should reconsider its recent decision to value subsequent observation care at a lower level than subsequent inpatient hospital care services, the AGS argued in a recent letter to the agency. In the January 2011 letter, the AGS asked CMS to consider reversing that decision and making payments for the former equal to those for the latter. The 2011 Medicare physician fee schedule, published in January 2011, reflected the agency’s decision.
“AGS wishes to point out that the issue of admission to observation care as opposed to admission to inpatient care has potentially significant consequences for the care of the frail elderly,” the letter explained. “Even though CMS states that physicians are responsible for writing the orders for placing patients in observation or admitting them as inpatients, the reality is that all hospitals have policies that may result in patients who require a stay in a Skilled Nursing Facility [SNF] being denied Medicare payment for the SNF stay because they did not have the required three-day inpatient hospital stay before transfer to the SNF…. There are also beneficiary coinsurance issues because outpatient care has a 20% coinsurance and inpatient care does not.”
CMS’ decision runs counter to that of the American Medical Association (AMA) Relative Value Scale Update Committee (RUC), the AGS letter noted. The RUC recommended that subsequent observation care be valued at the level of subsequent inpatient hospital care services. But CMS rejected this recommendation, valuing observation care at roughly 75% of inpatient care. When CMS disagrees with the RUC recommendations, it usually does so based on differences regarding data on which recommendations are based, the processes and analyses the RUC uses, or related issues, the AGS wrote. But in this case “the CMS disagreement appears to be based on clinical and policy concerns related to observation care in general and on a disagreement over physician work.”
In the letter, AGS took exception to CMS’ rationale for valuing observation care at a 25% lower level than hospital care. In its ruling, CMS argued that patients in observation care have a lower “acuity level” than inpatients by way of justifying the disparity in values. But the AGS letter noted that the agency “never explains how the reduced ‘acuity’ is connected to or justifies a 25% payment reduction.” The agency also argued that payment should be reduced for observational care because “if the patient’s acuity level is determined to be at the level of the inpatient, the patient should be admitted to the hospital as an inpatient,” to which the AGS responded that this is an unsupported conclusion that would have “ramifications for the valuation of services other than subsequent observation care.”
“We believe that the values determined by the (valuation) survey process and later recommended by the RUC are correct,” the AGS letter concluded. “(C)ollected survey data show that subsequent observation services closely approximate subsequent hospital services. If CMS wishes to establish a new payment policy for observation services it should do so through notice and comment rulemaking and not through the guise of a disagreement with the RUC,” the letter added. “The current articulation and process of adjudicating CMS disagreements with the RUC through a refinement panel is insufficient in this case. If CMS elects to not revise the interim values, at a minimum CMS should send the codes back to the RUC for the purpose of having an open discussion about the proper valuation of observation services, with this interim final rule as a background and context for such a discussion.”
AGS Offers Recommendations for Enhancing Medicare’s New “Physician Compare” Site
In a November 2010 letter to the CMS, the AGS offered suggestions for enhancing the agency’s new Physician Compare website (http://tinyurl.com/4dqxfbv). The site, which launched in January 2011, is designed to help Medicare beneficiaries choose physicians and other healthcare professionals who treat Medicare patients.
Among other things, Physician Compare notes whether an individual doctor has participated in the voluntary Physician Quality Reporting System (PQRS; formerly known as the Physician Quality Reporting Initiative). If a physician has participated in the voluntary quality improvement program, the website notes this in his or her listing. If the physician has not participated, the website includes no information about the program in his or her listing.
AGS Clinical Practice & Models of Care Committee Chair Matthew McNabney, MD, and AGS consultant Chandra Branham, Esq., of Arnold & Porter LLP, attended a late October 2010 CMS “town hall” meeting at which the agency solicited comments about the website from physicians and consumers. In a follow-up letter to CMS regarding the Physician Compare site, AGS offered these and other comments:
•CMS should include a disclaimer on the website specifically stating that the PQRS is a voluntary program and that a physician may have valid reasons for not participating or reporting quality information.
•Physicians should be able to update some of the information on the website; for example, the ability to add a link to their listing.
•Quality measures should take into account comorbidities and should be designed so providers are not penalized when they honor patients’ preferences for care or their cultural or religious beliefs.
•CMS should continue to develop improved measures geared toward care of patients with multiple, chronic conditions and consider the benefits of developing geriatric measures.
•CMS should consider establishing a “team” level of reporting.
•Physicians should have the opportunity to review, verify, and, where appropriate, object to any data before they are posted on the Physician Compare website.
The letter is accessible via the AGS website (www.americangeriatrics.org).