Working with the System

Medicare Program is Fiscally Unsustainable

    According to US Comptroller General David Walker's March 23, 2004 testimony before the Subcommittee on Legislative and Budget Process,1 the shelf-life of the current Medicare Part A and Part B programs is about 10 more years.

In his report, the Comptroller General predicts that the cash flow for the Medicare program will shift to a deficit status in 2013 and the same will happen to the Social Security program 5 years later. Due to the unprecedented demographic changes about to take place in our country as the baby boomers reach retirement age, the currently projected federal revenues may only be enough to pay the interest on our "large escalating and persistent deficits" (ie, national debt).

    Walker believes our nation is in great jeopardy unless realistic spending caps are implemented to deal with near-term and medium-term debts. Beyond that, he believes a "fundamental" re-examination of existing programs and activities must be undertaken. Because the major long-range federal cost drivers are Social Security and Medicare, it is reasonable to assume that they will be the targets of additional cost and benefit cutting, regardless of the political administration in office.

    This report calls the Medicare Prescription Drug Benefit "one of the largest under-funded commitments ever undertaken by the federal government" and estimates its cost to be an additional $7 to $8 trillion dollars over the next 75 years. As of September 2003, the federal government's gross debt was $7 trillion or $24,000 for every person in the country. This figure excludes the gap between promised and actually funded Social Security and Medicare commitments. The report states that if these were factored in, the burden for every American would escalate to more than $100,000. The Prescription Drug Benefit will add thousands more to that per capita tab.

    The Comptroller General offers three recommendations to stem the tide of out-of-control debts and maintain some form of the Social Security and Medicare programs: 1) restructure entitlement programs (Social Security, Medicare, and other similar programs); 2) re-examine the base of discretionary and other spending; and 3) review and revise the federal government's tax policy and enforcement policies.

    The entire report is available at: www.gao.gov.

Region D DMERC Offers Online Training

    Region D has initiated a series of online educational training programs. One of the first offered is "Group 2 Surfaces." The easy-to-use program with pre- and post-tests provides an overview of pressure ulcers and the clinical and medical necessity coverage criteria required for Medicare Part B coverage and payment for Group 2 support surfaces. The programs are available at: www.cignamedicare.com/webtraining.

CMS Rescinds Power Wheelchair Conditions of Coverage

    One of the provisions contained in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), is the establishment of clinical conditions of coverage for medical supplies and durable medical equipment. The intention of the provision was to target supplies/Durable Medical equipment (DME) that have been abused or over-utilized in the past. One of the first items to feel the clout of this provision was power wheelchairs. As a result of government fraud investigations, the four Durable Medical Equipment Regional Carriers (DMERCs) published revised clinical condition criteria for a Medicare beneficiary to be eligible for a power wheelchair. According to the new proposal, patients were to have been "non-ambulatory" - defined as only able to bear weight to transfer from bed to chair or wheelchair. As a result of an enormous outcry from the wheelchair community and Medicare beneficiaries, as well as their participation in the Centers for Medicare and Medicaid Services (CMS) listening sessions and Open Door Forums, CMS has retracted the clinical clarification.

    As MMA provisions convert from the written word to reality, it is heartening to see that CMS is listening to providers and consumers. More clinical conditions of coverage probably will emerge from MMA; therefore, ostomy, wound, and incontinence clinicians need to closely track these changes and become involved in the process when new policy or proposals negatively impact Medicare beneficiaries and healthcare professionals' ability to provide quality care. 

1. Walker D. Comptroller General of the US. Budget Process: Long Term Focus is Critical. Testimony before the Subcommittee on Legislative and Budget Process, House Committee on Rules. March 23, 2004. GAO-04-585T