- Email: [email protected]
Medicare, Managed Care Top Congress' Agenda
H E A L T HC A R S
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t
a uoca e
Medicare, Managed Care Top Congress’ Agenda David Lusk
n addition to balancing the budget, reigning in the growth of entitlements, and “saving” Medicare, expanding payments to health care providers and tempering the affects of managed care will add to a full agenda piling up before the 105th Congress, which recently resumed session. With pledges of greater cooperation from both President Bill Clinton and Republican leaders, nurses can watch for health care programs to take center stage in balanced-budget efforts, particularly if savings are to be created by cutting entitlement programs, such as Medicare and Medicaid. Medicaid’s restructuring centers around reforms that would slow the program’s recent 5 years of unsustainable double-digit growth. While the 104th Congress proposed Medicaid savings of $50 billion to $80 billion over 7 years, tightened disproportionate share spending and expanded managedcare coverage slowed Medicaid’s 1996 growth rate to 3 percent. This year, however, Congress will still need Medicaid savings of $35 billion to $50 billion to satisfy balanced-budget enthusiasts. Most observers say proposed Medicaid reforms this time around should lack the most controversial measures proposed during the last Congressional session. Republicans are backing off block grants and plans to end the federal entitlement. Democratic support for per capita caps has also diminished. Of note, bipartisan consensus exists for allowing states to move forward with managed care and David Lusk is legislative assistant to Ann Langley, Director of Health Legislation and Policy at the law firm of Foley, Lardner, Weissburg & Aronson in Washington, DC.
February 1997
other innovations without requiring federal waivers. In fact, some legislators may try to replace waiver requirements with managedcare standards.
Saving Medicare While Medicare has experienced some baseline reductions, its growth has not slowed as quickly as that of Medicaid. A two-tiered approach of short- and long-term solutions is anticipated in creating Medicare savings. Shortterm proposals should center on reduced provider reimbursements, with savings around $124 billion during the next 5 years. Long-term solutions must address the pending insolvency of the Medicare Trust Fund, and may be entrusted to a bipartisan commission. Republicans have vowed to wait for the President to submit recommendations for Medicare reform before acting. In the context of Medicare reforms, a number of proposals may be considered. Graduate Medical Education funding-a subset of Medicare funding-should surface again. Most proposals should allow for some broader use of Graduate Medical Education dollars, such as the availability of funds for health professionals other than physicians. The addition of Medicare direct pay for nurse practitioners, nurse clinical specialists, and physician assistants is also expected this session. Finally, look
for the revamping of home health and skilled nursing facility provider reimbursements from their current cost-based systems to those implementing prospective payment.
Follow-up Care The Kassebaum-Kennedy bill, which required technical corrections, failed to pass during the 104th Congress and is expected to be brought up again, with some senators indicating they have an interest in revisiting the follow-up provisions of the maternal lengthof-stay legislation when the technical corrections to the bill are offered. Follow-up care may also find its way into separate legislation this session. Rep. Maurice Hinchey (D-NY) is expected to reintroduce the Patient
Lifelines
47
Safety Act, and legislation providing a minimum hospital stay requirement for patients being treated for breast cancer should be reintroduced in both the House and the Senate. Buoyed by a raft of new statistics, Democrats will seek incremen-
enhance Medicaid enrollment for one-third of the children currently eligible for the program but lacking coverage. Already, a plethora of state and federal legislation has been introduced in an atempt to control the
Bipartisan consem exists f e r a l k g states to mow fornard with managed wra and other innovations without requiring federal waiven. I
tal steps to provide coverage for the increasing number of families who can't afford private insurance and are not eligible for Medicaid. This could mean assisting unemployed families with the cost of insurance premiums for COBRA coverage, subsidizing coverage for uninsured children, streamlining voluntary purchasing alliance requirements for small businesses, and protecting retiree health benefits. The administration may also look at ways to
effects of managed care. Legislation prohibiting restrictions on physicianpatient communications, or "gag rule" clauses, should be reintroduced. The President has promised a commission probing managedcare quality and inhibited service delivery. Commission members should be named shortly, and its work will help determine the scope and structure of any legislation protecting patients under managed-care plans. Watch for Congress to reautho-
rize numerous health ptogram~, including the Nursing M u a t i o n Act programs and National Institutes of Health. Although the Nursing Education Act reauthorization is not controversial, it has been the victim of a controversial amendment prohibiting any accreditation requirements for training in abomons, even those allowing for individual matters of conscience. The lack of authorization may eventually present Nursing Education Act programs with appropriation difficulties. Reauthorization of the Physician Drug User Act, which determines the length of drug approval times, must be completed by August of next year to avoid a funding gap for the Food and Drug Administration. In addition to reauthorization, appropriations for Food and Drug Administration programs will be under intense scrutiny. Because its jurisdiction includes the domestic discretionary programs, diminished Food and Drug Administration funding would hit these programs particularly hard.
+
A Call for Sites & Site Coordinators AWHONN's 3rd
Research Utilization (RU3) Project
The RU3 Project: Women's Continence will focus on women across the lifespan who are living with the problem of urinary incontinence. 'I
The most exciting aspect of this project is the fact that there is ample nursing science now available to develop a nursing protocol. Nurses can make a significant difference with their patients who have urinary incontinence and do not know it or do not report it."
Carolyn Sampselle and the RU3 team
Project Goal: Provide a systematic process for use b y nurses in women's primary health care settings *:*Help identify the problem with a specific assessment strategy *:*Provide a teaching intervention if indicated *:*Provide appropriate referral For more information, please call Corinne Haslett at 1-800-673-8499, ext. 1613. 48
Lifelines
February 1997
d
t
a uoca e
Medicare, Managed Care Top Congress’ Agenda David Lusk
n addition to balancing the budget, reigning in the growth of entitlements, and “saving” Medicare, expanding payments to health care providers and tempering the affects of managed care will add to a full agenda piling up before the 105th Congress, which recently resumed session. With pledges of greater cooperation from both President Bill Clinton and Republican leaders, nurses can watch for health care programs to take center stage in balanced-budget efforts, particularly if savings are to be created by cutting entitlement programs, such as Medicare and Medicaid. Medicaid’s restructuring centers around reforms that would slow the program’s recent 5 years of unsustainable double-digit growth. While the 104th Congress proposed Medicaid savings of $50 billion to $80 billion over 7 years, tightened disproportionate share spending and expanded managedcare coverage slowed Medicaid’s 1996 growth rate to 3 percent. This year, however, Congress will still need Medicaid savings of $35 billion to $50 billion to satisfy balanced-budget enthusiasts. Most observers say proposed Medicaid reforms this time around should lack the most controversial measures proposed during the last Congressional session. Republicans are backing off block grants and plans to end the federal entitlement. Democratic support for per capita caps has also diminished. Of note, bipartisan consensus exists for allowing states to move forward with managed care and David Lusk is legislative assistant to Ann Langley, Director of Health Legislation and Policy at the law firm of Foley, Lardner, Weissburg & Aronson in Washington, DC.
February 1997
other innovations without requiring federal waivers. In fact, some legislators may try to replace waiver requirements with managedcare standards.
Saving Medicare While Medicare has experienced some baseline reductions, its growth has not slowed as quickly as that of Medicaid. A two-tiered approach of short- and long-term solutions is anticipated in creating Medicare savings. Shortterm proposals should center on reduced provider reimbursements, with savings around $124 billion during the next 5 years. Long-term solutions must address the pending insolvency of the Medicare Trust Fund, and may be entrusted to a bipartisan commission. Republicans have vowed to wait for the President to submit recommendations for Medicare reform before acting. In the context of Medicare reforms, a number of proposals may be considered. Graduate Medical Education funding-a subset of Medicare funding-should surface again. Most proposals should allow for some broader use of Graduate Medical Education dollars, such as the availability of funds for health professionals other than physicians. The addition of Medicare direct pay for nurse practitioners, nurse clinical specialists, and physician assistants is also expected this session. Finally, look
for the revamping of home health and skilled nursing facility provider reimbursements from their current cost-based systems to those implementing prospective payment.
Follow-up Care The Kassebaum-Kennedy bill, which required technical corrections, failed to pass during the 104th Congress and is expected to be brought up again, with some senators indicating they have an interest in revisiting the follow-up provisions of the maternal lengthof-stay legislation when the technical corrections to the bill are offered. Follow-up care may also find its way into separate legislation this session. Rep. Maurice Hinchey (D-NY) is expected to reintroduce the Patient
Lifelines
47
Safety Act, and legislation providing a minimum hospital stay requirement for patients being treated for breast cancer should be reintroduced in both the House and the Senate. Buoyed by a raft of new statistics, Democrats will seek incremen-
enhance Medicaid enrollment for one-third of the children currently eligible for the program but lacking coverage. Already, a plethora of state and federal legislation has been introduced in an atempt to control the
Bipartisan consem exists f e r a l k g states to mow fornard with managed wra and other innovations without requiring federal waiven. I
tal steps to provide coverage for the increasing number of families who can't afford private insurance and are not eligible for Medicaid. This could mean assisting unemployed families with the cost of insurance premiums for COBRA coverage, subsidizing coverage for uninsured children, streamlining voluntary purchasing alliance requirements for small businesses, and protecting retiree health benefits. The administration may also look at ways to
effects of managed care. Legislation prohibiting restrictions on physicianpatient communications, or "gag rule" clauses, should be reintroduced. The President has promised a commission probing managedcare quality and inhibited service delivery. Commission members should be named shortly, and its work will help determine the scope and structure of any legislation protecting patients under managed-care plans. Watch for Congress to reautho-
rize numerous health ptogram~, including the Nursing M u a t i o n Act programs and National Institutes of Health. Although the Nursing Education Act reauthorization is not controversial, it has been the victim of a controversial amendment prohibiting any accreditation requirements for training in abomons, even those allowing for individual matters of conscience. The lack of authorization may eventually present Nursing Education Act programs with appropriation difficulties. Reauthorization of the Physician Drug User Act, which determines the length of drug approval times, must be completed by August of next year to avoid a funding gap for the Food and Drug Administration. In addition to reauthorization, appropriations for Food and Drug Administration programs will be under intense scrutiny. Because its jurisdiction includes the domestic discretionary programs, diminished Food and Drug Administration funding would hit these programs particularly hard.
+
A Call for Sites & Site Coordinators AWHONN's 3rd
Research Utilization (RU3) Project
The RU3 Project: Women's Continence will focus on women across the lifespan who are living with the problem of urinary incontinence. 'I
The most exciting aspect of this project is the fact that there is ample nursing science now available to develop a nursing protocol. Nurses can make a significant difference with their patients who have urinary incontinence and do not know it or do not report it."
Carolyn Sampselle and the RU3 team
Project Goal: Provide a systematic process for use b y nurses in women's primary health care settings *:*Help identify the problem with a specific assessment strategy *:*Provide a teaching intervention if indicated *:*Provide appropriate referral For more information, please call Corinne Haslett at 1-800-673-8499, ext. 1613. 48
Lifelines
February 1997