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An Update on
the Medicare Prescription Drug Benefit Bill by Russ Newman, PhD,
JD, APA Executive Director for Professional Practice
This message provides information related to the Practice Directorate's
work to secure Medicare funding for psychology internship training,
as well as information regarding the Medicare prescription drug
benefit included in the legislation recently passed by Congress.
Medicare Funding for Psychology Training The Practice Directorate,
with the help of the Education Directorate, has been engaged in
efforts since 1997 to gain Medicare funding for hospital-based psychology
internship and postdoctoral training programs. This has been a long
and extremely difficult fight, although we have made significant
progress along the way. In January 2001, we were successful in persuading
the Department of Health and Human Services (HHS) to interpret current
law to include Medicare funding of postdoctoral training programs.
Key members of Congress, especially Ted Strickland and former Florida
Congresswoman Karen Thurman, had helped us to put pressure on HHS
for inclusion of psychology. The interpretation of current law to
include funding for postdoctoral training was a partial win in response
to these efforts. Inclusion of psychology internship programs has
proven to be a much more difficult road. HHS has made it clear to
us that we would need to get an express authorization from Congress
before they would be able to finalize an implementation rule to
make internships eligible for funding.
Senator Breaux Champions Our Cause The first viable opportunity
to get an authorization from Congress was when it began this year
to work seriously on a Medicare prescription drug bill. Although
not being able to predict at that time what direction such legislation
might take, we did not believe that there would likely be another
vehicle of this type for more than a year given next year's anticipated
presidential politics and its typical impact on Congressional activity.
A good friend of psychology and well-respected moderate Louisiana
Democrat, Senator John Breaux, agreed to carry our provision during
the Medicare prescription drug benefit legislative debate. Thanks
to Senator Breaux's efforts, our psychology provision was one of
only a very few provider-specific provisions to be included when
the Senate passed its prescription drug bill in late June. The House
passed its version of a prescription drug bill at the same time
but did not include our provision. We then had our work cut out
for us to keep the provision in the legislation, as a few Representatives
and Senators attempted to work out the differences between the two
bills in a conference committee in August. While we were very fortunate
that Senator Breaux was part of the conference committee, Representative
Bill Thomas, the powerful chairman of the House Ways and Means Committee
was appointed to head the committee. Representative Thomas was,
in general, opposed to the provider-specific provisions in the Senate
version of the bill.
Bipartisan Support in Conference Committee This scenario
has led us into an intense months-long fight to keep our psychology
provision in the Medicare bill. Thanks to amazing grassroots work
by psychologists across the country and stepped-up political giving
by our members, we were able to create good bipartisan support on
the conference committee. Senators Charles Grassley (R-Iowa), Orrin
Hatch (R-Utah) and Max Baucus (D-Montana) all actively supported
our provision. We also were able to make substantial inroads with
House conferee Representative Nancy Johnson (R-Connecticut). In
addition, we had support from influential House Republicans who
were not on the conference committee--Representatives Jim McCrery
(Louisiana), Clay Shaw (Florida) and Deborah Price (Ohio).
Provision Stripped Out in Final Hours Unfortunately, as
the conferees worked toward the final version of the legislation
last week, our psychology provision was one of the very last provisions
to be stripped out of the bill. Needless to say we are extremely
disappointed, particularly after having come closer to succeeding
than any time previously. I want to thank the many psychologists
across the country, including those of you on Council, and my staff
who worked so hard on this. Although we did not get psychology included
in the Medicare funding program at this time, I do believe we have
furthered the awareness of our cause and developed new supporters
that will help us on our next attempt to get this done.
Private Competition in Medicare Of course, in the bigger
scheme of things our psychology provision has been overshadowed
by the debates related to the prescription drug benefit and other
changes being proposed to the structure of Medicare, some proposed
changes potentially useful to healthcare for Medicare beneficiaries
and some not. The most controversial portions of the legislation
have been provisions related to private competition, which were
not originally included in the Senate bill to which our psychology
funding provision was attached, but which were part of the House
bill. Much of the "deal making" that has gone on in the last few
weeks has focused on the degree to which private competition would
be further encouraged by the legislation. By "private competition",
I am referring to provisions that would allow private managed care
health plans to compete with traditional Medicare to provide services
to Medicare beneficiaries. The Bush Administration and many Republicans
in Congress have argued that private competition is a necessary
method to control costs in an entitlement program as huge as Medicare.
Other Members of Congress, such as Senator Ted Kennedy, argue that
allowing private plans to compete with Medicare will undermine the
program, both by improperly rationing care through managed care
and by enabling private plans to "cherry pick"" the youngest and
healthiest beneficiaries. This then would lead to the older, sicker
patients being left in the traditional Medicare plan with higher
premiums the result.
Prior Attempt to Privatize Medicare + Choice This is not
the first time efforts have been made to increase the degree of
privatization in Medicare. In 1997, during the first years of new
Republican control, Congress included the Medicare+Choice program
in a bill signed into law by then-President Clinton. In Medicare+Choice,
beneficiaries could choose between a traditional Medicare plan and
private managed health plans. Although still in existence, Medicare+Choice
has not been successful. Most beneficiaries chose not to leave traditional
Medicare, and beneficiaries who did, found themselves without a
plan as private plans pulled out due to what they believed to be
insufficient profits. The current legislation attempts to address
this by including provisions to rework Medicare+Choice to encourage
private plans to cover beneficiaries through improved reimbursement
and subsidies beginning in 2006, although the details concerning
this proposed attempt remain unclear. Some in the current Medicare
debate believe that Medicare beneficiaries will continue to refuse
to choose any new private plans as a result of the prior experience
with Medicare+Choice.
Demonstration Project to Encourage Privatization While the
very concept of increasing private competition in Medicare is problematic,
the specific attempts in the current legislation are limited by
comparison to earlier proposals in this legislative process. Earlier
this year, President Bush proposed that a Medicare beneficiary could
only get the proposed drug benefit if he or she enrolled in a private
managed care plan. Additionally, an earlier version of the House
bill proposed the broad inclusion of private plans to compete with
the traditional Medicare plan, although the beneficiaries could
choose whether to leave the traditional plan for the private plans.
This was ultimately rejected in the final prescription drug bill.
Instead, the final bill contained an effort to include private competition
by way of a six-year demonstration project that would begin in 2010
to be conducted in six yet-to-be-named metropolitan areas where
private plans have at least a 25% market share. To address, in part,
the concern about rising Medicare premiums due to competition with
private plans, the bill includes a cap of 5% per year on any increase
in premiums. One major exception is that beneficiaries with low
incomes would not have their premiums increased at all. As a result
of this demonstration project approach, some supporters of private
competition in Medicare have attacked the bill as too limited and
ineffectual, while those opposing private competition in Medicare
have attacked the bill as moving Medicare in the wrong direction
and threatening its existence as an entitlement program.
We have much work ahead of us to ensure the preservation of Medicare
as an effective entitlement program for all older Americans. As
the details of the proposed demonstration project are developed,
our profession will need to be talking and meeting with relevant
Members of Congress about concerns regarding the private competition
direction of Medicare, and we will need to be working to ensure
that the implementation details do not enhance the scope of the
project or prematurely assume that the results of the demonstration
project are a foregone conclusion. Of course, we will also be continuing
our efforts to see to it that funding for psychology internship
training will occur.
Protecting practitioners'
autonomy
APA stands up to Oxford Health Plans over audits of psychologists'
records -- and gets results. by Jennifer Daw Holloway, APA Monitor
Staff
Talk to some psychologists and they'll tell you their holiday cheer
was dampened by managed care.
But more than just general managed-care doldrums sparked some New
York psychologists' heavy moods.
Last year, Oxford Health Plans-which operates in New York, New
Jersey and Connecticut-began retrospective audits of the records
of some mental health professionals with whom the company has contracted.
For the most part, the audits occurred in New York, where Oxford
has most of its providers.
"The company did this under the guise of looking for fraud-not
an uncommon practice in the field," says Russ Newman, PhD, JD, APA's
executive director for professional practice.
But APA and the New York State Psychological Association (NYSPA)-on
behalf of audited psychologists-stepped in because the company's
methods and justification of these audits seemed far from normal.
The two organizations penned a letter demanding corrective measures
from Oxford in October. Nearly a month later, the company agreed
to stop requiring repayments based on alleged deficiencies in recordkeeping.
APA will continue to monitor the situation to ensure that the company
does indeed follow through on its promise, says Newman.
APA took issue with the audits for two reasons. First, according
to practitioners, Oxford demanded patient records without first
showing that the company had obtained valid patient consent. Some
psychologists felt pressured to turn over their notes-especially
those who receive the bulk of their referrals from Oxford, says
Newman. Then, after performing audits, Oxford demanded repayment
of practitioners' reimbursement for services previously rendered-to
the psychologists' and APA's alarm.
Basically, the company determined that records for particular therapy
sessions were not sufficiently detailed to justify 45-minute sessions,
for example, and unilaterally decided that only payment for 20-minute
sessions was warranted. Thus, providers were asked to pay back a
portion of what they'd already been reimbursed based on what Oxford
deemed inadequate recordkeeping.
According to Newman, the legality of this move is questionable.
In the letter to Oxford's chief executive officer, Charles Berg,
he and NYSPA's executive director Gayle Everitt wrote, "Since, as
we understood it, the stated purpose of the audits was to assure
that 'all billed office visits really took place,' it is at best
unclear how the result can be your company's decision to only pay
for part of a session."
In the same letter, Newman and Everitt pointed out that there is
no support for this practice-- termed "downcoding"-- in either Oxford's
provider manual or New York state law. The latter only mandates
that records accurately reflect the evaluation and treatment of
the patient and makes no reference to individual sessions or specific
note-taking requirements.
"There were no grounds for them to ask for this money back-they
effectively refused to pay for services they contracted for," says
Newman. And, he points out, the provider manual assures that Oxford
will attempt to resolve record-keeping problems through corrective
action.
Furthermore, he notes, the provider contracts require Oxford to
pay psychologists the amount stated as long as the psychologists
have provided medically necessary, covered services, used the proper
billing format and obtained sufficient pre-certification. So Oxford
violated provider contracts and failed to give providers proper
warning, Newman says.
Under pressure from APA and NYSPA, the company publicly announced
that it would stop demanding repayment and would even return money
providers had already paid back.
At press time, APA and NYSPA anticipated ongoing dialogues with
Oxford to continue pressing psychology's concerns.
This article appears in the January 2004 issue of APA's Monitor
on Psychology..
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