The 105th Congress -- Alive and Doing Very Well:

Patrick DeLeon, Ph.D., J.D.

We have come to appreciate that it is during the Congressional deliberations on the Budget Reconciliation legislation that the most significant modifications to Medicare and Medicaid are to be expected. The final Senate vote to balance the federal budget by the year 2002 was a bipartisan 73 to 27. The projected reduction in the growth of Medicare expenditures (i.e., the "savings") is $115-$118 billion.

Admittedly, it is still too early to be able to predict with any certainty what provisions will ultimately become public law -- either as part of the Budget Reconciliation Act or perhaps as non controversial "technicals" during the closing hours of the Congress. Nevertheless, during the Senate deliberations some very interesting public policy recommendations were made.

For many senior citizens, raising the Medicare eligibility age from 65 to 67 and establishing a means test for Medicare premiums, will be of considerable concern. The Senate-passed bill provided $16 billion to provide 5 million additional children with health insurance by the year 2002. 10 million children in our nation do not possess health insurance; almost 60 percent living in families with a full time worker. These new funds may be used to expand Medicaid or to fund grants to states -- highly contested public policy options. The D'Amato-Harkin proposal to improve health care quality and reduce health care costs by establishing a National Fund for Health Research fell to a non-germaneness point of order. Portions of the controversial Hatch-Kennedy cigarette tax proposal were adopted. The chiropractors were successful in obtaining a demonstration project on expanded coverage of their services.

The Wellstone-Domenici Child Mental Health Parity amendment was adopted. Senator Domenici: "Mr. President. I obviously would be remiss if I did not thank Senator Wellstone for his diligence in this regard. I think the time is now upon us, with the overwhelming passage of an amendment last year which I sponsored along with my friend Senator Wellstone, which essentially said for the private sector, if you are going to cover people that have mental illness, you have to create some parity for the mentally ill; that is, you cannot say they have less coverage per year or less coverage for the life of the policy. That set a very big wave of movement in the country to try to establish non-discrimination..."

"Today we offer an amendment very similar. It says the coverage that is going to be afforded to children under this bill, if mental illness is covered, it shall be covered with the same kind of coverage that you provide for the physical illness. There is an escape clause of a sort that has to do with making sure we are not impeding the formation of HMOs and managed care.

"Nonetheless, I believe the time is right to try this one on in the country. We are moving step by step, leading to a point where mental and physical ailments will be treated the same in terms of coverage."

Also included in the Senate proposal is a new Medicare Choice program -- allowing HMOs to enter into risk contracts with the Health Care Financing Administration (HCFA), providing Medicare beneficiaries with the option of choosing from a variety of private health plans. Professional nursing did quite well. Authority for their Community Nursing Organization demonstration projects (prepaid capitated, nurse-managed systems of care) was extended for 2 additional years, and perhaps even more significantly, the current geographic limitations (i.e., in rural America) on direct reimbursement for Advanced Practice Nursing (APNs) was eliminated -- providing Medicare beneficiaries with increased access to quality nursing services. Their statutory reimbursement rate was increased from 65% to 80% of physician reimbursement. The Senate also included a provision directing Medicare reimbursement for telehealth services in rural areas, and a new $27 million demonstration project to improve patient access to primary and specialty care, develop a curriculum to train and develop standards for required credentials and licensure of health professionals in the use of medical informatics and telecommunications, and develop standards in the application of telemedicine and medical informatics.

Significant modifications have also been proposed to the Medicare Graduate Medical Education (GME) program, with Congressman Ted Strickland being successful in the House "mark-up" in directing a formal study of the possibility of psychology being eventually included in this important program -- in our judgment, the key to our training institutions' future. The Washington Post noted: "Legislators Get Tough on Managed Care"; one House-passed provision would "...strike at managed care's jugular by requiring Medicare HMOs to defer to doctors on key decisions about coverage. For example, the bill would give the doctor final say over the length of a covered hospital stay...." The Senate included a proposal to study the effectiveness of managed care in meeting the needs of individuals with special health care needs. Without question, the forthcoming House-Senate conference deliberations should indeed be quite interesting. [www.senate.gov/~finance].

The Implementation Process:

The Health Care Financing Administration (HCFA) recently requested public comment on their proposed rule to establish a Medicare Clinical Psychologist Fee Schedule. Until 1997 the fee schedule for clinical psychologist services was a locality-based fee schedule developed by the individual Medicare carriers. The statute (OBRA 1987) first provided for direct payment for services furnished in a community mental health center. The payment was to be based at 80 percent of the lower of the actual charge or a fee schedule. HCFA's initial guidance was to set the fee schedule for therapeutic services at 80 percent of the adjusted prevailing charge for participating psychiatrists, and for diagnostic services at 90 percent of the adjusted prevailing charge for participating psychologists in a locality. An annual CPI-U index was proposed for updates.

Effective January 1, 1997, the fee schedule for psychologist services was linked to the physician fee schedule in the same manner as most other health care practitioner services.

HCFA's proposed changes: There are two types of services billed directly to Medicare Part B by psychologists: diagnostic services and therapeutic services. A variety of health care practitioners under Medicare have payment levels that are tied, by law, to the physician fee schedule. These practitioners include nurse practitioners, nurse midwives, and physician assistants. HCFA believes that it is also appropriate to establish a psychologist fee schedule that is linked to the physician fee schedule. The implementation of 24 new billing codes for psychotherapy services effective January 1, 1997 required establishing relative values under the physician fee schedule for each code. Since this was done, HCFA has now proposed the clinical psychologist fee schedule for all services be at 100 percent of the physician fee schedule amount for the corresponding service.

HCFA had previously considered setting the clinical psychologist fee schedule at the level established under the physician fee schedule for similar services. However, at that time, the CPT descriptors for individual psychotherapy services included the term "[with] continuing medical diagnostic evaluation, and drug management, when indicated." These are medical aspects of a psychotherapeutic service that are outside the scope of clinical psychologist licensure. Therefore, HCFA was concerned that it would be inappropriate to set the psychologist fee schedule amounts at the same level as the physician fee schedule when clinical psychologists were unable to perform the full service described in the codes. During 1996 HCFA concluded that the CPT code descriptors for individual psychotherapy needed to be changed to define the services more clearly, recognize the variations in work associated with different types of psychotherapy as well as the settings in which the types of psychotherapy are furnished. One of the effects of the coding system changes for psychiatric services is that now there are codes for reporting psychotherapy both with and without medical evaluation and management services. " As a result, it (seems) both reasonable and equitable to pay clinical psychologists the same amount as physicians for equivalent services [Federal Register, June 18, 1997]."

The Prescription Privilege Evolution - Continuing Progress:

We are increasingly impressed by the extent to which there is growing grass roots support for the prescription privilege agenda. Mike Schwarzchild reports: "Yesterday marked the end of the Connecticut Psychological Association's four session course in Basic Psychopharmacology, the first such program in the country to be based on the APA curriculum. The instructor, Joe Pachman (a psychologist-physician), concluded this rigorous undertaking with an examination that he designed to be, in his words, 'credible'. I found it to be quite credible. In any event, a significant amount of information was passed on to the psychologists who completed the training. Formal and informal discussions of the national and Connecticut prescription privilege initiatives were included, resulting in five new members for our Psychopharmacology Committee. Participants provided a good deal of feedback about the course, which will be incorporated in future iterations. Forward!"

David Miller: "We are starting a psychopharmacology training program here in the Kansas City area this Fall. It is sponsored by one of our local colleges and by an APA-approved continuing education sponsor. The classes of 15-25 licensed, doctoral-level psychologists will be meeting across from a local hospital. We are following the APA guidelines leading to Level I and Level II certification in psychopharmacology, and certificates will be provided."

The prescription agenda is still fundamentally an educational initiative, being advanced primarily by the practice community. Accordingly, I have been particularly pleased by its increasing acceptance within our educational leadership. APA Board of Directors member Janet Matthews provided this insight: "I wanted to share with you a comment from a local psychologist colleague at a recent dinner party because it illustrates the impact we can have with undergraduates. My colleague noted that he really had previously had no opinion on prescriptive authority for psychologists but was probably leaning against it. He was supervising one of my senior field placement students and the topic arose in one of their supervision sessions. He said she really 'jumped all over me' about it. She then proceeded to give him a point for point explanation about why he SHOULD be in favor of it even if he did not want to pursue such training for himself. He said she raised issues he had never considered and now is a strong supporter. We had discussed this topic in the mandatory seminar I conduct with this course and they had readings, both pro and con, as well as writing a short paper on whether or not psychologists should be able to prescribe. For this student, who will begin doctoral studies in clinical in the Fall, apparently the material not only stuck but was very meaningful. She was articulate and persuasive. Needless to say, I felt good about what I am doing in this course as well."

The AMA News reports that their House of Delegates was to consider more than 180 resolutions at their recent annual meeting. Resolution #204, from the American Academy of Child and Adolescent Psychiatry: "Asks the AMA to work with psychiatric groups to oppose legislation that allows prescribing by psychologists". One might conclude that we must be having an impact!

Jeff McKee
Saturday, April 25, 1998