Back-to-School Update

Medicare Surveyors' Guide to Pressure Ulcers Remains Under Review

    At press time, the Centers for Medicare and Medicaid Services (CMS) had not completed the internal review and clearance of the Guidance to Surveyors of long-term care facilities for pressure ulcer requirements (Tag F314). An expert panel met and made numerous changes based on the review of the comments received on its second draft. The document will not be considered final until the internal review and clearance process for issuance is completed. Once this process is accomplished, the final document will be posted on the CMS web site. No specific final date for its publication has been released.

Congress to Consider Legislation for Colorectal Cancer Screening

    Colorectal cancer is the second leading cause of cancer deaths in the United States, yet it is one of the most preventable cancers. The American Cancer Society (ACS) estimates that more than 146,000 new cases will be diagnosed this year and that 57,000 Americans will die from the disease. A report by the United States General Accounting Office (GAO) investigated the extent to which private insurers (ie, plans available through small and large employers, individuals, and federal employee health plans) covered all four ACS-recommended screening tests for colorectal cancer (fecal occult blood test, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy) and the extent to which plans covered them when no symptoms were evident.

    Laws that require private health plans to cover these screening tests vary by state. As of May 2004, the GAO found 20 states had laws in place to cover colorectal screening tests for screening purposes (see "States with Laws Requiring Private Insurance Coverage of Colorectal Cancer Screening Tests"). However, further investigation into the small, large, and federal employee health plans found inconsistencies in what tests were covered, the frequency under which the tests could be conducted, and if they were covered solely when a patient presented symptoms rather than as a screening tool. More than four-fifths of the small employer plans, three-quarters of the individual plans reviewed, two-thirds of large employer plans, and half of the plans offered to federal employees covered all four tests. Double-contrast barium enema and colonoscopy were least likely to be covered.

    Medicare Part B, on the other hand, provides coverage for all four tests as screening tools. Fecal occult blood tests are covered once a year for individuals and do not require a copayment or deductible. Sigmoidoscopy is covered every 4 years and is subject to copayment and deductible. Beneficiaries at high-risk for colon cancer are covered every 2 years for colonoscopy, average risk beneficiaries are covered every 10 years for colonoscopy, and both are subject to copayment and deductible. Barium enema, also subject to copayment and deductible, is covered as a "substitute" for colonoscopy or sigmoidoscopy.

    Congress is considering legislation that would require coverage of all the tests for screening purposes among all private health insurance plans in all states. To view the entire report, go to: www.gao.gov/cgi-bin/getrpt?GAO-04-713.

CMS Taps RTI for Competitive Bidding Program

    The Research Triangle Institute (RTI), a North Carolina-based company, has been contracted by CMS to assist with the implementation of the competitive bidding program. The Research Triangle Institute is an independent, international, nonprofit corporation as well as a preapproved, federally qualified vendor that specializes in scientific research and technology development. In the health arena, RTI provides services for drug discovery and development, outcomes research, public health, and health policy research. One of the company's first project tasks will be evaluating the nominees submitted for the final selection of members to serve on the DME Program and Advisory Oversight Committee (PAOC) as mandated under the Medicare Modernization Act. The Research Triangle Institute assisted CMS in evaluating demonstration DME competitive bidding projects in Florida and Texas and will provide its own recommendations about competitive bidding as the program moves forward.

HHS Announces Revised Medicare Obesity Coverage Policy

    On July 15, the US Department of Health and Human Services (HHS) announced revision to Medicare coverage policy that would remove barriers to covering anti-obesity interventions. Recognizing obesity as a critical and astronomically expensive health issue, CMS has removed verbiage in the Medicare Coverage Issues Manual that states obesity is not an illness. By removing this language, Medicare beneficiaries will be free to request a Medicare review of medical evidence to determine whether specific obesity-related treatments improve health, are medically necessary, and should be covered by Medicare.

JCAHO Hospital Accreditation and CMS Hospital Surveys at Odds

    The CMS considers hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to be in compliance with Medicare participation requirements. The GAO investigated the extent to which JCAHO's pre-2004 hospital accreditation process identified hospitals that were noncompliant with Medicare requirements as well as the potential of JCAHO's new process to improve the detection of Medicare deficiencies. A study of 500 JCAHO-accredited hospitals (conducted 2000 to 2002) found that JCAHO's accreditation process did not identify most of the hospitals found by state survey agencies to have Medicare deficiencies. The potential of JCAHO's new hospital accreditation process to improve identification of Medicare deficiencies is unknown as the process was implemented in January 2004. However, JCAHO has plans to move to unannounced surveys in 2006. As a result of this report, the GAO recommends that Congress gives CMS the same authority over JCAHO's hospital accreditation process as it has over other accreditation programs. The full report can be reviewed at: www.gao.gov/cgi-bin/getrpt?GAO-04-850.