The View From Capitol Hill

1
The View From Capitol Hill
Electricity or Drugs?

• Todd Ketch and Mark Boesen
• Directors of Government Affairs
• AHQA Annual Session
• Kansas City, MO

• Todd Ketch and Mark Boesen
• AHQA Annual Session
• Kansas City, MO

Disclaimer This is not an actual image of the
Blackout of 2003. This image is provided for
illustrative purposed only.
2
The Legislative Environment

• Current congressional lineup
• House of Representatives
• 230 Republicans,
• 204 Democrats,
• 1 Independent
• Senate
• 51 Republicans,
• 48 Democrats,
• 1 Independent

3
The Political Landscape

• Senate Forced to Be More Bipartisan Due to Close
  Margin
• House More Ideological and Votes are Close
• Medicare reform passed by one vote
• Republican Leadership Under Pressure
• Downside to controlling both ends of Penn. Ave.
• Election Year Rapidly Approaching
• Which party gets credit for action/ blame for
  inaction?
• Will Democrats really help Bush succeed in areas
  that yield biggest election issues?

4
Major Health Care Issues Tracked by AHQA This Year

• Medicare Reform
• Bills include
• New Benefit Structure Private Plan Options
• Coverage of Outpatient Prescription Drugs
• Contractor, Regulatory and Appeals Reform,
  including EMTALA Reform
• Patient Safety/Medical Errors
• Electronic Health Records

5
Other Health Care Issues

• Drug Re-importation
• House passed bill in July Senate rolled into
  Medicare Rx
• Very different approaches conferees will
  discuss
• Provider Payments (included in both Medicare
  bills)
• About 25 million for rural 5-7 million for
  physicians
• Could be divided amongst various providers
• Medical Liability Reform
• House passed HR 5 Senate no Motion to Proceed
• Rumor of limited bill for obstetrics and rural
  providers
• HHS Appropriations (all discretionary for 2004)
• House passed Senate to consider

6
Medicare Name That Year

• President outlines a first step toward
  addressing a growing problem
• I will order a comprehensive study by the
  Department of Health, Education, and Welfare of
  the problem of including the cost of prescription
  drugs under Medicare.

7
Answer

• 1967
• From President Lyndon B. Johnsons State of Union
  Address delivered January 10, 1967.

8
New Medicare Benefit Structure

• H.R.1 and S.1 passed in June
• Currently in conference committee
• Both create new private plan options for seniors
• HR1 FFS, Enhanced FFS (PPO), Medicare Advantage
  (formerly MC), Medicare Savings Accounts,
• S1 FFS, MedicareAdvantage (PPO and MC)
• Biggest disagreement Level of competition
  between options to be included in the system.

9
Medicare Outpatient Prescription Drugs Name
That Year

• In what year was the following forwarded by a
  candidate for President of the USA
• We willstrengthenMedicare, and help finance
  prescription drugs under Medicare.

10
Was it

• 2003
• 1991
• 1975
• 1968

11
Answer

• 1968, Presidential Candidate Hubert H. Humphrey
• Source Humphrey-Muskie Campaign Brochure

12
Outpatient Prescription Drug Coverage

• House (H.R. 1) and Senate (S. 1)
• Create new voluntary FFS drug benefit options
  starting in 2006 administered by a new DHHS
  agency.
• Govt. contracts with private risk-bearing
  entities known as PBMs to provide drug coverage.
• Interim prescription drug discount card in
  2004-2005 with, perhaps, a federal subsidy for
  low-income seniors.
• Allow PBMs to use their own formularies, but
  beneficiaries can appeal for non-formulary
  drugs.
• Bills differ in beneficiary deductible, copays
  and catastrophic limits.

13
Outpatient Prescription Drugs

• Differences between H.R. 1 and S. 1
• FFS Drug Premium H.R. 135.50, S. 134.00
• Deductible H.R. 1250, S. 1275
• Beneficiary Out-of-Pocket
• H.R. 1 20 up to 2000, 100 from 2001-3500,
  then 0 after 3500
• S. 1 50 up to 4500, 100 from 4501-7400, 10
  after 7401

14
AHQA Provisions in Drug Bills

• Senate (S. 1)
• QIO role described in statutory language.
• Section 225. Expanding the work of Medicare
  Quality Improvement Organizations to include
  Parts C and D.
• Adds new authority for QIOs to work with new
  private plans/PBMs.
• Directs QIOs to offer QI assistance pertaining to
  Rx drug therapy to plans/PBMs, providers and
  practitioners.
• House (H.R. 1)
• QIO role described in report language.
• Energy and Commerce Committee Report 108-178 Pt1
• Ways and Means Committee Report 108-178 Pt 2
• AHQA working to assure new plans/PBMs share
  appropriate data for QIO work.

15
AHQA Provisions in House Reports

• Ways and Means (excerpt)
• the Committee believes the existing experience
  of the Medicare Quality Improvement Organizations
  (QIOs) would be employed to offer assistance to
  beneficiaries, providers and plans operating in
  Parts C, D and E, particularly as it relates to
  quality improvement
• Energy and Commerce (excerpt)
• The Committee believes that expanding the QIOs
  work to include the new entities and benefits
  created in this legislation will help improve the
  quality of care for all Medicare beneficiaries
  across the entire continuum of the care.

16
Contractor, Regulatory and Appeals Reform

• Provisions included in H.R. 1 S. 1. Conference
  committee has completed negotiations on this
  section and it could be passed separately if
  other Medicare reforms falter.
• Provisions include
• EMTALA Reform
• Appeals Changes
• Split-up of FI Carrier Functions, creation of
  new Medicare Administrative Contractors and
  reform of contracting process to promote
  competition
• Regulatory Process Changes

17
AHQA Successful in EMTALA Reform

• AHQA Workgroup on EMTALA Policy Recommendations
  Included in Conference Report
• Makes mandatory early QIO review of all EMTALA
  complaints alleged to involve a medical quality
  of care concern.
• Requires CMS to inform providers and
  practitioners about the findings of an EMTALA
  investigation.
• Establishes an EMTALA regulatory reform task
  force to standardize EMTALA enforcement across
  all CMS Regional Offices.

18
AHQA Successful in Appeals Reform Without
Legislation

• CMS published proposed rule for BIPA that
  satisfies all of AHQAs requests (FR, Nov. 14,
  2002)
• CMS plans to implement the new appeals (both for
  fee-for-service- and MC) through the QIOs
  without publishing a final regulation.
• President requested 129 million for implementing
  Medicare appeals changes (including QICs) in the
  FY 2004 Budget.
• QIOs eligible to apply for QIC contracts.

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The Medicare Conference

• Need to Appeal to Middle
• Dueling Visions of Competition
• Effect on the Budget Deficit
• Call for Greater White House Involvement
• Time Could Run Short
• Talk of Ending up with Discount Drug Card plus
  High/Low Income Provisions

20
Patient Safety/Medical Errors Name That Year

• When was the following recommendation made
• Congress should pass legislation to extend peer
  review protections to data related to patient
  safety and quality improvement that are collected
  and analyzed by health care organizations for
  internal use or shared with others solely for
  purposes of improving safety and quality.

21
Answer

• 1999 To Err is Human Building a Safer Health
  System
• Report of the Institute of Medicine Committee on
  Quality of Health Care in America

22
Patient Safety/Medical Errors

• Nearly 4 years since IOM report, To Err is Human
• House bill (H.R. 663) passed in March
• Senate bill (S. 720) passed HELP Committee in
  July
• Both create Patient Safety Organizations (PSOs)
  to collect voluntary reports from providers,
  promote best practices, improve care.
• New federal confidentiality protections apply to
  patient safety data submitted to PSOs.

23
AHQA Influenced Both Patient Safety Bills

• QIOs eligible to be certified as PSOs under both
  bills (AHRQ has acknowledged to AHQA that QIOs
  will be the primary source of PSOs).
• Three year recertification now required for PSOs.
• PSOs can now work with all provider under the PHS
  definition, which includes pharmacists. (Social
  Security Act does not recognize RPhs as health
  care providers.)
• DHHS Sec. now required to create national patient
  safety database for collection of PSO data

24
Electronic Medical Records Name That Year

• When was this goal adopted
• The committee believes that the computerized
  patient record can be well established within a
  decade in the majority of offices of physicians,
  dentists and other health care professionals and
  in clinics, hospitals, and multifacility provider
  institutions. Achieving such widespread use in
  only 10 years is an ambitious goal . . .

25
Answer

• 1991 -- The Computerized Patient Record An
  Essential Technology for Health Care
• Report of the Institute of Medicine Committee on
  Improving the Patient Record.

26
Electronic Health Records

• Efforts are underway in the Administration and
  Congress to enhance the use of quality
  improvement technologies, such as Electronic
  Health Records (EHRs) to improve patient
  safety/reduce medical errors.
• National Health Information Infrastructure (NHII)
  Act of 2003 (H.R. 2915 -- Rep. Nancy Johnson)
  requires DHHS Sec. to adopt interoperability
  standards for health information technology
  systems and appoint a National Health Information
  Officer.
• Senate Majority Leader Frist is developing his
  own NHII bill as well.
• There are several proposals for grant programs to
  encourage providers to implement health care
  informatics systems.

27
AHQA Helping Define QIO Role in EHR

• AHQA participates in policy discussions with CMS,
  organized medicine (AAFP, AMA), and Congress
  about the establishment of a NHII.
• QIOs could
• Support data warehouse needs (regional or
  national)
• Work directly with EHR vendors to promote the
  integration of quality indicators into their
  tools
• Evaluate and educate providers and practitioners
  of the products available and their applications
  to their specific site

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Important Non-Health Care Matters in the
Spotlight
Disclaimer This is not an actual image of the
Blackout of 2003. This image is provided for
illustrative purposed only.
29
Which Grid?
30
Energy Bill

• Debate re-energized by Aug 14th blackout.
• Power reliability provisions were obscure, now
  key.

31
Iraq

• Recent bombings, growing U.S. casualties.
• White House doubles current spending, seeks
  international help.

32
But Dont Worry, Theres Still Hope
33
Homeland Security U.S. Patriots Act

• Department of Homeland Security gets mixed
  reviews
• Emerging civil liberties concerns in Congress
• House refused to fund portion of Patriots Act
• Administration wants to expand it, Congress
  reticent

34
One Humorous Solution
35
The Federal Deficit

• Current deficit projection based on current law,
  which includes 400 B tax cut package (CBO)
• 2003 401 B
• 2004 480 B
• 2013 Surplus of 211 B
• If Medicare enacted (400 B/10yrs) and current
  tax cuts extended
• 2013 Deficit of 324 B
• If new Iraq spending (87 B) approved (OMB)
• In 2004, projected 475 B deficit will reach
  about 562 B or 5 of the GDP

36
Other Important Mattersin the Universe
37
Any Questions?

• Todd Ketch
• 202-331-5790 (ext 310)
• Tketch_at_ahqa.org
• Mark Boesen
• 202-331-5790 (ext 311)
• Mboesen_at_ahqa.org