Washington Highlights: April 18,
2008
Contents
Prior Issues
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Committee Unanimously Passes Medicaid Moratorium
Bill
The House Energy and Commerce Committee April 16 approved
(46-0) a substitute version of the AAMC-supported "Protecting
the Medicaid Safety Net Act of 2008" (H.R.
5613). The amendment was offered by Committee Chair John Dingell
(D-Mich.) and preserves language that would prohibit, until April
1, 2009, any CMS actions related to the Medicaid GME proposed rule,
the Medicaid Cost Limit/Unit of Government ("IGT") final
rule, and several other recently issued Medicaid rules. The Health
Subcommittee passed a similar version of the bill on April 9 [see
Washington Highlights,
April 11]. Chairman Dingell expects a floor vote on H.R. 5613
during the week of April 21.
Four Republican amendments
were offered during the mark-up, including language offered by Rep.
Mike Burgess (R-Texas) to extend the current Medicare physician
payment update (0.5 percent ) through Dec. 31, 2008. When Chairman
Dingell agreed to schedule a full committee meeting "at the
earliest possible time" to discuss alternative legislative
vehicles for the amendments, they were either defeated or withdrawn.
Also during the mark-up, Ranking Member Joe Barton (R-Texas) and
Rep. Cliff Stearns (R-Fla.) voiced concerns that the teaching hospitals
in their districts would be adversely and unfairly affected by the
Medicaid rules. Ranking Member Barton stated that the cuts in Medicaid
GME funding were his "greatest concern," and asked Chairman
Dingell to work with him to pass legislation this year that "clearly
permits" GME payments under Medicaid. The legislation would
also establish "accountability" for how the payments are
spent. Chairman Dingell agreed to work with Ranking Member Barton
on the bill.
The following members did not record their votes: Ed Markey (D-Mass.);
Bobby Rush (D-Ill.); Jane Harman (D-Calif.); Anthony Weiner (D-N.Y.);
Ralph Hall (R-Texas); Barbara Cubin (R-Wyo.); John Shimkus (R-Ill.);
Heather Wilson (R-N.M.); Charles Pickering (R-Miss.); and Michael
Ferguson (R-N.J.).
Information:
Christiane Mitchell, Senior Legislative Analyst
AAMC Government Relations
cmitchell@aamc.org
(202) 828-0526
Leavitt, Grassley Voice Opposition to House Medicaid
Bill
Secretary of Health and Human Services (HHS) Michael Leavitt April
15 sent a letter
to House Energy and Commerce Committee Chair John Dingell (D-Mich.)
and Ranking Member Joe Barton (R-Texas) stating that the President's
"senior advisors would recommend that he veto" the AAMC-supported
"Protecting the Medicaid Safety Net Act of 2008" (H.R.
5613). The bipartisan legislation, which was adopted April 16 by
the full Energy and Commerce Committee, is sponsored by Chairman
Dingell and Health Subcommittee member Tim Murphy (R-Pa.) and would
prohibit, until April 1, 2009, any CMS actions related to the Medicaid
GME proposed rule, the Medicaid Cost Limit/Unit of Government ("IGT")
final rule, and several other recently issued Medicaid rules.
According to the letter, "watchdog agencies" such as
the HHS Office of Inspector General (OIG) and Government Accountability
Office (GAO) "have sounded the alarm about improper State [Medicaid]
expenditures for years." Leavitt expresses concern that "ignoring
their findings and recommendations for another 12 months will put
billions of dollars in federal funds at risk."
Speaking on the Senate floor April
16, Finance Committee Ranking Member Charles Grassley (R-Iowa)
was similarly critical of H.R. 5613. Sen. Grassley accused the House
of ignoring "well documented problems." Referring to the
current moratorium in place until May 25, Sen. Grassley said that
Congress "had plenty of time, if they wanted to make new policy."
Instead, he believes the House is "trying to kick the can to
next year" and make the regulations "go away." He
urged Congress to "get to work solving the problems the regulations
try to solve."
Information:
Christiane Mitchell, Senior Legislative Analyst
AAMC Government Relations
cmitchell@aamc.org
(202) 828-0526
CMS FY 2009 Medicare IPPS Proposed Rule Affects
Stark, EMTALA, Wage Index
The Centers for Medicare and Medicaid Services (CMS) April 14 released
the proposed fiscal year (FY) 2009 Medicare hospital inpatient prospective
payment system (IPPS) rule. The rule is scheduled to be published
in the Federal Register on April 30, 2008, and will be implemented
Oct. 1, 2008. The proposed
rule would implement the current law requirement that base payments
be increased by the full market basket increase, which is currently
estimated at 3 percent.
While there are no proposed changes to the graduate medical education
and indirect medical education adjustments, the IPPS proposed rule
affects:
- The Physician Self-Referral ("Stark") rule, including
the "stand in the shoes" provision, gain-sharing, and
the Disclosure of Financial Relationship Report (DFRR);
- the Emergency Medical Treatment and Active Labor Act (EMTALA),
the "anti-dumping" law;
- the post-acute care policy; and
- the wage index.
Stark Rule
Previously, CMS issued a moratorium - effective Dec. 4, 2008 - on
the "stand in the shoes" provision in the Stark rule due
to unintended negative consequences of the rule on academic medical
centers and other entities. CMS now proposes a "more refined
approach" that involves two alternatives. First, physicians
will not be deemed to "stand in the shoes" of their physician
organization if the arrangement between the physician organization
and the physician meets the any of the 3 following exceptions: bona
fide employment, personal services arrangement, or fair market
value compensation. Under this approach, it also is necessary to
examine arrangements between designated health services (DHS) entities
and physician organizations to determine if they create an indirect
compensation arrangement. If so, the arrangement would need to satisfy
the requirements for the exception for indirect compensation.
As a second alternative, CMS proposes that only physician owners
of a physician organization would stand in the shoes of that organization.
According to CMS, "a physician would not stand in the shoes
of his or her physician organization (for example, a faculty practice
plan) when the referral for designated health services meets the
requirements of the Academic Medical Center exception."
CMS requests comments on whether the agency should establish an
exception for gain-sharing arrangements. Generally, these are arrangements
under which a hospital gives physicians a share of the reduction
in the hospital's cost savings attributable in part to the physician's
efforts.
CMS is proposing to send to 500 hospitals the DFRR, which is intended
to collect information concerning the ownership and investment interests
as well as compensation arrangements between hospitals and physicians.
The proposed rule discusses the potential burden associated with
completing the DFRR, which is now estimated to be 31 hours on average.
The estimate is based on the agency's belief "hospitals should
already be keeping [the information] in the normal course of business
activities," so that most of the time will be spent by administrative
staff. Comments are requested on the accuracy of this estimate.
EMTALA
The IPPS proposed rule includes a major expansion of hospitals'
EMTALA obligations. Under the proposal, if an individual who comes
to a hospital's emergency department is admitted as an inpatient
but later needs to be transferred to a hospital with specialized
capabilities, the second, receiving, hospital will have an EMTALA
obligation to accept the patient as long as the hospital has the
capacity to treat the individual. CMS admits that this revision
"may raise concerns among the provider community that such
a clarification in policy could hypothetically result in an increase
in the number of transfers."
Post-Acute Transfer Policy
The IPPS proposed rule extends from 3 to 7 days the time frame for
application of the post-acute transfer policy. This policy applies
to cases with hospital patients that are discharged and recieve
home health services. Discharges that are subject to the post-acute
transfer policy must satisfy specific criteria and are paid on a
per diem rate, not to exceed the full diagnosis-related group payment.
Wage Index
CMS also proposes changes to the wage index stemming from recommendations
contained in the June 2007 Medicare Payment Advisory Commission
(MedPAC) Report to Congress. Mandated by the "Tax Relief and
Health Care Act of 2006" (TRHCA, P.L. 109-432), the report
includes recommendations for a new wage index. The TRHCA requires
CMS to take MedPAC's report into account and include proposals to
revise the hospital wage index in the FY 2009 IPPS proposed rule.
In view of MedPAC's findings that the numerous wage index exceptions
have created major complexities and "troubling anomalies,"
CMS is proposing changes that would tighten the criteria to qualify
for reclassifications. The IPPS proposed rule changes the comparison
criteria for both individual hospitals seeking to reclassify to
a different labor market area, as well as county group geographic
reclassifications. In addition, CMS proposes to apply the rural
and imputed rural floor budget neutrality adjustments to the wage
index at the state rather than the current, national level, thereby
redistributing payments among hospitals within the state, rather
than adjusting payments to hospitals in other states.
If finalized, changes in the reclassification criteria would apply
only to new reclassifications beginning with the FY 2010 wage index.
Changes in the application of the rural and imputed rural budget
neutrality adjustments would take effect Oct.1, 2008. CMS is specifically
seeking comments with regard to its wage index proposed changes.
Comments on the proposed rule are due June 13.
Information:
Ivy Baer, Director & Regulatory Counsel
AAMC Health Care Affairs
ibaer@aamc.org
(202) 828-0490
Diana Mayes, Specialist
AAMC Health Care Affairs
dmayes@aamc.org
(202) 828-0498
CMS Releases Proposed Inpatient Prospective Payment
Rule for FY 2009 Quality Provisions
The Centers for Medicare and Medicaid Services (CMS) April 14 released
the proposed fiscal year (FY) 2009 Medicare hospital inpatient prospective
payment system (IPPS) rule (see related story).
The rule proposes changes to quality provisions related to hospital
acquired conditions, present on admission coding, reporting of hospital
quality data, and the Medicare Hospital Value- Based Purchasing
(VBP) Plan.
The IPPS proposed rule refines and expands select hospital acquired
conditions not eligible for additional payments, originally published
in the FY 2008 IPPS Final Rule [see Washington
Highlights, Aug. 3, 2007]. Under the FY 2008 Final Rule,
effective Oct. 1, 2008, hospitals will no longer receive additional
payments for hospital acquired conditions if they were not present
on admission. In the FY 2009 IPPS Proposed Rule, CMS clarifies two
of the previously selected conditions; Foreign Object Retained after
Surgery and Pressure Ulcers. CMS also expands the list of selected
conditions to include the following:
- Surgical Site Infections Following Elective Procedure
- Legionnaires' Disease
- Glycemic Control
- Iatrogenic Pneumothorax
- Delirium
- Ventilator-Associated Pneumonia
- Deep Vein Thombosis (DVT/Pulmonary Embolism)
- Staphylococcus aureaus Septicemia
- Clostridium Difficile Associated Disease
CMS plans to monitor the Present on Admission (POA) coding by looking
at the frequency and appropriateness of the codes submitted by hospitals.
CMS has proposed to not pay for Hospital Acquired Conditions under
the "U" designation (Medical record documentation is insufficient
to determine whether the condition was present at the time of admission).
CMS believes that not paying for these cases is expected to foster
better medical record documentation. CMS is soliciting comments
on how to improve the Hospital Acquired Condition program including
the use of risk adjustment among other possibilities.
For the Reporting of Hospital Quality Data for Annual Hospital
Payment Update (RHQDAPU), the IPPS proposed rule requires submission
of 43 new measures to quality for a full payment update in FY 2010.
The measures are in the areas of stroke, venous thromboembolism,
nursing care, surgical care improvement, re-admission rates, cardiac
surgery and AHRQ quality and patient safety indicators. A full list
of the measures can be found in the proposed rule. CMS also proposes
several new procedures for operating the RHQDAPU program including
retiring of measures, updating measure specifications and data submission
requirements among others.
To simulate the impact of the proposed VBP plan, CMS plans to conduct
a test program that would utilize the clinical process measures
and the Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey data. The testing will generate new information
not available before including financial impacts. CMS is seeking
comments on how to take full advantage of the information generated
through the test program.
Information:
Jennifer Faerberg, Director, GME Track/Health Care Quality Liaison
AAMC Health Care Affairs
jfaerberg@aamc.org
(202) 862-6221
AAMC Urges Senate Support for Genetic Nondiscrimination
Bill
AAMC President and CEO Darrell G. Kirch, M.D., April 16 sent a
letter
to all members of the Senate urging support for the Genetic Information
Nondiscrimination Act (GINA). The bill seeks to prohibit discrimination
on the basis of genetic information with respect to health insurance
and employment. Approved unanimously by the Senate in the 108th
and 109th Congresses, the measure has not progressed past the Jan.
31, 2007, approval of the Senate Health, Education, Labor, and Pensions
Committee in the 110th Congress. The House passed its version of
the bill (H.R.
493) by a vote of 420-3 in April 2007, and last month approved
mental health parity legislation (H.R.
1424) that included the text of H.R. 493 [see Washington
Highlights, March 14]. The AAMC letter notes that "if
patients, researchers, clinicians, and industry are to realize the
promise of personalized medicine and the use of genetic information
in health care, Congress must pass GINA."
Information:
Tannaz Rasouli, Senior Legislative Analyst
AAMC Government Relations
trasouli@aamc.org
(202) 828-0525
House Panel Increases Funding Tap for Small Business
Innovation Grants
The House Committee on Science and Technology April 17 approved
legislation to increase the set-aside from federal science agency
budgets used to fund the Small Business Innovation Research (SBIR)
program and the Small Business Technology Transfer Research (STTR)
program. The committee approved the "Science and Technology
Act of 2008" (H.R.
5789), which reauthorizes the SBIR and STTR programs through
2010. The bill increases the SBIR set-aside from 2.5 percent to
3.0 percent and the STTR set-aside from 0.3 percent to 0.6 percent
of any federal agency that spends more than $100 million in research
per year. The panel's Subcommittee on Technology and Innovation
approved the bill April 16.
In an April 17 letter
to the House, AAMC President and CEO Darrell G. Kirch, M.D., expressed
opposition to the increased set-aside for the SBIR program, stating
"Increasing the SBIR set-aside at a time when congressional
appropriations for agencies such as the National Institutes of Health
and the National Science Foundation have stagnated for the past
several years will result in funding cuts for these agencies, further
hampering the nation's efforts to sustain innovation in the biomedical
and physical sciences."
The U.S. Small Business Administration (SBA) opposes the increase
in the set-aside. In a letter to Science Committee Chair David Wu
(D-Ore.), SBA Administrator Steven Preston cited both the lack of
an "empirical basis for an increased set-aside for the SBIR
program" and noted "increasing this set-aside effectively
reduces funding available for agencies' core research programs."
In addition, the White House is expected to issue a Statement of
Administration Policy (SAP) "strongly opposing" the bill.
The bill is expected to go the House floor the week of April 21,
which has been designated "National Small Business Week."
Information:
Dave Moore, Senior Director
AAMC Government Relations
dbmoore@aamc.org
(202) 828-0525
IOM, Senate Panel Examine Long Term Care Workforce
The Senate Special Committee on Aging April 16 held a hearing examining
the future long term care workforce, three days after the Institute
of Medicine (IOM) released a report
on the same topic. The IOM report, "Retooling for an Aging
America: Building the Health Care Workforce," forecasts "an
impending health care crisis" in light of a rapidly aging population
and gaps in the current health care workforce.
At the hearing, John W. Rowe, M.D., professor at the Columbia University
Mailman School of Public Health, and chair of the IOM Committee
on the Future Health Care Workforce for Older Americans, testified
that "the current supply and organization of the health care
workforce will simply be inadequate to meet the needs of the older
adults of the future." In particular, Dr. Rowe noted the need
to increase the number of geriatric specialists but also highlighted
the importance of equipping the rest of the health care workforce
with basic geriatric principles. According to Dr. Rowe, "there
must be a commitment to help the entire workforce, with the sophistication
to recognize that different pieces of the workforce have different
problems and require different fixes."
Among the IOM report's recommendations are:
- Enhanced geriatric competence through improved educational
curricula and training programs for all health professionals,
more comprehensive licensure and certification standards, and
increased federal training requirements for direct-care workers;
- Increased recruitment and retention of geriatric specialists
through improved work conditions, enhanced and expanded support
for the Title VII Geriatric Academic Career Award (GACA) program,
and financial incentives such as increased payments for clinical
services and loan repayment for geriatric specialists; and
- Improved models of care emphasizing patient education, care
coordination, and interdisciplinary care.
A second panel of witnesses included Martha Stewart, founder, Martha
Stewart Living Omnimedia; Todd Semla, PharmD, president, American
Geriatrics Society, and associate professor in the Departments of
Medicine and Psychiatry & Behavioral Science, Feinberg School
of Medicine, Northwestern University; Mary McDermott, personal care
worker; and Sally Bowman, Ph.D., associate professor, Oregon State
University. Dr. Semla and Dr. Bowman both urged increased support
for the Title VII geriatrics training programs. Dr. Semla also noted
that the number of Medicare-funded graduate medical education (GME)
slots has been frozen since 1997, and expressed concern that recent
proposals to cut Medicare and Medicaid GME funding negatively would
impact teaching hospitals and would contribute to greater shortages
of geriatricians.
More information about the hearing, including witness testimony
and a webcast, is available on the Committee website.
The AAMC will be submitting a written statement for the record.
Information:
Tannaz Rasouli, Senior Legislative Analyst
AAMC Government Relations
trasouli@aamc.org
(202) 828-0525
Healthcare Acquired Infections Hearing
The House Oversight and Government Reform Committee April 16 held
a hearing
entitled "Healthcare Acquired Infections: A Preventable Epidemic."
In his opening remarks, Committee Chair Henry Waxman (D-Calif.)
stated the purpose of the hearing was to focus on what the Department
of Health and Human Services (HHS) was doing to prevent healthcare
acquired infections and whether they were taking enough leadership
in combating this public health threat. At the hearing, the Government
Accountability Office (GAO) released a report
entitled "Healthcare Acquired Infections in Hospitals: Leadership
Needed from HHS Prioritize Prevention Practices and Improve Data
on These Infections."
Peter J. Pronovost, M.D., Ph.D., medical director of the Johns
Hopkins Center for Innovation in Quality Patient Care, testified
before the committee on his work through the Keystone Project in
identifying causes of infection in the ICU and ways to prevent them.
Dr. Pronovost called for more support of the Agency of Healthcare
Research and Quality (AHRQ) to implement more programs like the
Keystone Project, increased funding for research to support these
programs, and development of new initiatives to train people who
can implement program similar to the Keystone Project.
Witnesses and Chairman Waxman agreed that HHS should provide assistance
to hospitals to implement infection prevention strategies such as
hand washing and basic checklists.
Information:
Jennifer Faerberg, Director, GME Track/Health Care Quality Liaison
AAMC Health Care Affairs
jfaerberg@aamc.org
(202) 862-6221
Department of Education Concludes Negotiated Rulemaking
The Department of Education April 14 concluded negotiations
on new regulations that implement the "College Cost Reduction
and Access Act" (CCRAA, P.L.
110-84). Effective July 1, 2009, the new regulations eliminate
the 20/220 pathway of the economic hardship deferment, define public
service for a new loan forgiveness program, and implement the income-based
repayment program.
The economic hardship deferment allows medical residents to postpone
repayment of their student loans using up to three annual deferments
without the additional interest penalties of forbearance. Despite
the statutory elimination of the 20/220 pathway for economic hardship
under the CCRAA, the Department used the Secretary's authority to
continue the pathway for economic hardship in its November 2007
regulations. However, citing a $1.1 billion cost over 10 years,
the Department March 4, 2008 announced it will not accept applications
beyond July 1, 2009, with the start of the income-based repayment
program. [see Washington Highlights,
March 7]
The income-based repayment program will be available for all residents,
regardless of income or debt. The new program will require a minimum
student loan payment capped at 15 percent of the borrower's monthly
income that exceeds 150 percent of the applicable poverty line.
The calculation for married borrowers' repayments will include spousal
income.
A new loan forgiveness program will absolve Direct student loans
for borrower's who work 10 years in certain public service jobs
and make loan payments during that time. Residents with other federal
student loans will be able to consolidate under the Direct loan
program to participate in the loan forgiveness program. Public service
will include all 501(c)(3) employers.
Carrie Steere-Salazar, chair of the AAMC Committee on Student Financial
Assistance (COSFA) and director of students services at UCLA, San
Francisco, represented the AAMC and the graduate/professional education
community on the committee. The Department is expected to publish
a notice of proposed rulemaking for public comment.
Information:
Matthew Shick, Senior Legislative Analyst
AAMC Government Relations
mshick@aamc.org
(202) 862-6116
HHS Names First BARDA Director
The Department of Health and Human Services (HHS) April 14 named
Robin Robinson, Ph.D., as the first director of the Biomedical Advanced
Research Development Authority (BARDA) under the auspices of the
HHS Office of the Assistant Secretary for Preparedness and Response
(ASPR). Since joining HHS in May 2004, Dr. Robinson has served as
Deputy Director of BARDA's Influenza and Emerging Disease Program
where he has led the development, procurement and stockpiling of
the world's first H5N1 influenza vaccine approved for human use.
BARDA, established in 2007, is tasked with coordinating interagency
research, development, and procurement of public health medical
emergency countermeasures, including management of Project BioShield.
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