Washington Update: House Passes Health Reform Proposal

House Passes Health Reform Proposal; Senate Leader Calls for Christmas Deadline

In a close 220 to 215 vote, the House of Representatives approved a landmark healthcare reform bill in early November, shortly before this issue of Annals of Long-Term Care went to press. The bill, expected to cost $1.1 trillion over 10 years, would extend healthcare coverage to 36 million currently uninsured Americans and includes important provisions that would significantly improve healthcare for older adults—provisions for which the American Geriatrics Society (AGS) and its members have long advocated.

Among other things, the House bill would help address eldercare workforce shortages by establishing a Workforce Advisory Committee, redistributing unused Graduate Medical Education (GME) slots to boost access to primary care residencies, and creating training programs for direct care workers and family caregivers. The bill also would begin to tackle serious problems with Medicare payments that are disincentives to caring for older adults. It would, for example, make geriatricians eligible for a proposed primary care incentive payment of 5-10% by adding “specialization in geriatrics” to a list of qualifications for designation as a primary care practitioner. In addition, the bill calls for the reevaluation of Medicare payments for physician services that may be inappropriately valued. The House legislation would also improve care coordination for older patients through "medical home" and related pilot programs, and through the extension of Medicare Special Needs Plans.

Within days of the House approval, Senate Majority Leader Harry Reid (D-NV) announced that he planned to bring his chamber’s health reform proposal to the floor the following week and to finish work on the bill by Christmas. Key Senate lawmakers earlier merged the two Senate reform plans—one drafted by the Senate Finance Committee, the other, by the Senate Health Education Labor and Pensions (HELP) Committee—but had yet to release details about the resulting proposal as of mid-November. As of mid-November, the Congressional Budget Office (CBO) was still analyzing the cost of the proposal. Sen. Reid cannot bring the proposal to the Senate floor until the CBO completes this analysis. Most observers said it was unlikely that the legislation would reach President Obama’s desk before year’s end.

The Senate Finance and HELP reform plans include a wide array of provisions—championed by the AGS—that would also significantly enhance Medicare and eldercare. Like provisions in the House bill, these would offer bonuses to geriatricians and other primary care practitioners and reevaluate inappropriately valued Medicare payments for physician services. As with the House bill, the Senate plans include provisions that would establish an agency to address eldercare workforce shortages, redistribute unused GME slots to boost primary care residency slots, and create training programs for direct care workers and family caregivers. In addition, Senate provisions would evaluate and expand new provider payment models, including those covering care coordination for seniors at high risk of functional decline, and create a pilot program in which physicians and nurse practitioners would direct home-based care teams to provide coordinated care to such seniors. Other provisions in the Senate plans would focus on reducing hospital-acquired infections and preventable hospital readmissions. Senate provisions would also expand the Geriatric Academic Career Awards program; fund Geriatric Career Incentive Awards for junior medical faculty pursuing academic careers in geriatrics; enable Geriatric Education Centers to offer courses in geriatrics, chronic care management, and long-term care; and establish federal traineeships to prepare healthcare providers for advanced degrees in geriatric nursing, long-term care, and geropsychological nursing.

The AGS continues to advocate for these important provisions in the House and Senate proposals. If you haven’t already done so, please join these efforts by registering with the Society’s Health in Aging Advocacy Center, at https://capwiz.com/geriatrics/home/. The center makes advocating for needed reforms that will help ensure older adults access to high quality, cost-effective healthcare quick and easy.

House Proposes Legislation to Block SGR Cut and Institute New Medicare Payment Formula

As this issue of Annals went to press in mid-November, the House also was considering proposed legislation that would block the Sustainable Growth Rate (SGR) formula–mandated 21% cut in Medicare payments to physicians that is slated to take effect January 1, and replace the SGR with a new reimbursement formula. Word on the Hill was that chamber could vote on the legislation—the Medicare Physician Payment Reform Act of 2009—as early as the third week of November.

Opponents of a Senate bill to eliminate the SGR blocked that legislation in late October, objecting to the measure because the cost of implementing it was not offset by spending cuts or increased taxes. The House measure, however, is tied to statutory “Pay as You Go” rules and would require Congress to pass a binding law that would force it to offset new spending in any bill.

Under the House proposal, expenditures for most physicians’ services could increase as much as gross domestic product (GDP) plus 1% each year. To encourage primary and preventive care—which could result in earlier diagnosis and treatment of illnesses that can be more costly if treated later—Medicare payments for preventive and primary care services could increase as much as GDP plus 2%. AGS strongly supports the proposal and launched an advocacy campaign urging its passage in November.

Final CMS Physician Pay Rule Includes Many Changes AGS Endorsed

The Centers for Medicare & Medicaid Services (CMS)–finalized 2010 Physician Fee Schedule, released in late October, includes many changes the AGS endorsed in written comments to the agency. These include changes that will help prevent SGR–mandated cuts in future years—should Congress fail to find an alternative to the formula (see story above)—and better align compensation for geriatricians, geriatrics nurse practitioners, and other primary care providers starting this coming year.

Among other things, the new rule will remove medications from the SGR calculation of allowed expenditures for physician services, retroactive to 1996-1997. As a result, it will reduce the number of years during which physicians will likely face SGR–mandated pay cuts in the future, should the formula remain in place. AGS strongly supported this provision in its comments to CMS.

AGS also supported a policy, included in the final rule, that will ensure that the Physician Practice Information Survey better reflects geriatricians’ practice expenses. Previous surveys have understated practice expense relative value units (PE RVUs) for geriatricians and other primary care providers. For geriatrics, the change will result in an overall increase of 6%, which will be phased in over four years.

AGS likewise endorsed a proposal, now part of the final rule, to change the equipment usage assumption from the current 50% rate to a 90% rate. The provision will benefit physicians this coming year and in future years. In another change that AGS supported, CMS’ final rule for 2010 will increase payment for the Initial Preventive Physical Examination, boosting work RVUs to 2.3 from 1.34.

The new rule will also eliminate the use of all consultation codes and require physicians to bill instead using an initial hospital care or initial nursing facility care code for their first visit during a patient’s admission to the hospital or a nursing facility. This measure will “eliminate unnecessary regulatory burden or concern,” noted AGS, which supported the provision, in its comments to CMS. AGS will provide its members with support materials regarding the use of appropriate initial and subsequent care codes.