NOVEMBER 9, 2005 -- The American Medical Association (AMA) is urging the Centers for Medicare and Medicaid Services not to implement a voluntary reporting program that would measure quality care starting in January.

In a Nov. 3 letter to CMS Administrator Mark B. McClellan, the powerful physician group's Board of Trustees said the program would impose "excessive administrative requirements" on physicians and "negate any intended quality improvement."

The AMA's letter comes after another physician group, the Medical Group Management Association, also urged CMS to postpone implementing the voluntary reporting program.

CMS announced the voluntary program, which would ask physicians to submit data on 36 quality measures, last month. Collecting such data—for now on a voluntary basis—is part of CMS' overall plan to move forward on "pay for performance" programs for Medicare providers. "Linking a portion of Medicare payments to valid measures of quality...would support better health care," McClellan wrote to Congress in June.

A CMS spokesman stressed Wednesday that the reporting program was voluntary and physicians are not required to participate.

The AMA's letter said that under the CMS program, a primary care specialist treating a 70-year-old woman with common conditions would have to report about a dozen measures.

"Physicians practicing in the inpatient setting face the significant problem of not being able to attribute care delivered within a hospital system back to the individual physician level for accurate and reliable performance measurement," the letter said.

The AMA said a scheduled 4.4 percent cut in Medicare physician payments demonstrates that the administration has "failed to meet its obligations to ensure...access to quality care" by refusing to adjust the reimbursement to physicians. As part of the budget reconciliation process, the Senate would boost physician payments by 1 percent. But the House reconciliation measure would leave the scheduled cuts in place.

NOVEMBER 7, 2005 -- Medicare beneficiaries trying to find their way through the new Medicare drug benefit may find the task a bit easier after the Centers for Medicare and Medicaid Services (CMS) unveiled new features Monday on an agency Web site.

The "Medicare Prescription Plan Drug Finder" now allows beneficiaries to compare drug plan features, such as a plan's annual cost, deductibles, premiums, and copayments, for a specific list of drugs. Such a direct, "apples-to-apples" comparison had not been available before Monday.

CMS Administrator Mark B. McClellan said the Medicare drug plan finder's new features would allow beneficiaries to have detailed, personalized information to help them determine what drug plan choices are available to them. "There are some very good deals here with substantial savings," he told reporters. The plan finder is located on www.medicare.gov, the government's official Web site for information on the Medicare drug benefit (PL 108-173), which begins next Jan. 1.
CMS has been under fire from some consumer and seniors groups who said that an earlier version of the Web tool did not help seniors find out what drugs were covered by a particular plan or how much seniors would be expected to pay. Last month, Medicare Rights Center President Robert M. Hayes called the tool "misleading at worst, useless at best."

But even with the new features, the consumer groups worry that seniors may become confused and frustrated by so many choices is likely to remain.

During a demonstration for reporters, CMS created a fictional beneficiary in traditional fee-for-service Medicare who has diabetes, was on three different medications, and had no other drug coverage. The beneficiary would have 55 plans available, a number many advocates for the elderly say will be daunting for Medicare beneficiaries to wade through, no matter how much counseling they receive.

McClellan praised the number of choices available to beneficiaries. "The advantage of having this range of choices is you can focus on the kind of coverage you want," he said, adding that the plan finder can narrow the number of choice available.

Information on the plan finder will be updated weekly, he said, and plans may lower prices they charge based on what their competitors do, McClellan said. While plans could also change the drugs they cover "we don't expect to see that very often," McClellan said.

Ron Pollack, executive director of the consumers group Families USA, said that even with the improvements, searching Medicare drug plan options remains "a very arduous, time-consuming, and confusing process," especially for seniors who are not familiar with computers.

"This is not a realistic way for them to have confidence that they are in a good position" to pick a plan, Pollack said.

NOVEMBER 10, 2005 -- After a fruitless day of arm-twisting, GOP leaders late Thursday gave up at least temporarily on their effort to push a $50 billion, five-year budget savings bill (HR 4241) through the House.

Although the leaders last night expressed confidence that they had made enough changes to bring their moderates on board and pass the bill, they clearly miscalculated. Steps taken to appease the moderates angered other Republicans, and not all moderates were won over in any case.

The leaders said they would probably try again next week, although it was not clear whether they would have any more success then.

At a hastily arranged press conference, Majority Leader Roy Blunt, R-Mo., said that "a handful" of Republicans still had issues with the bill, but he declined to specify what those issues were. Blunt said that he hoped to bring the bill to the floor next week, but he would not go beyond saying it was "possible" that he would do so.

"We have run out of time today in terms of our members who really wanted to leave or in some cases just leaving," Blunt said. "But also we have not quite gotten there yet. We were not quite where we needed to be to go to the floor."

He said the leaders have asked House Budget Chairman Jim Nussle, R-Iowa, and his panel "to look at this one more time before we make our effort on the floor next week."

Democrats Crowing
Democrats and labor groups were jubilant. House Minority Whip Steny H. Hoyer, D-Md., said the failure to bring the bill to a vote "shows just how bad this legislation is. And it shows a Republican majority in disarray....They know that they cannot, with a straight face, go back home and tell their constituents that they support cutting Medicaid, student loans, food stamps, and other key programs, while turning right around the next week and passing tax cuts for the wealthiest people in America—all the while driving us deeper into debt."

Hoyer contended Republicans were running scared after setbacks in Tuesday's elections—a claim echoed by Gerald W. McEntee, president of the American Federation of State, County and Municipal Employees.

"By putting off the House budget vote, the GOP leadership is horse-trading in hopes of getting moderates to support the Republican-led slaughter of public services," McEntee said. "But moderates have clearly seen the writing on the wall—uncompassionate conservatism just doesn't sell—and they're thinking about their own political future."

The ANWR Dilemma
Last night, the leadership dropped provisions to allow oil drilling in Alaska's Arctic National Wildlife Refuge (ANWR) and in areas offshore, and slightly softened planned cuts to food stamps for legal immigrants.

Blunt said members who had concerns over ANWR and offshore drilling agreed to back the bill last night after the two provisions were removed from the bill, but the count still came up short.

House leaders were hopeful that removing ANWR drilling from the bill would collect the last of the GOP votes they would need to pass the budget-cutting package. No Democrats are expected to support the measure.

But leaders may have conceded too much to the moderates, and in doing so lost the votes of some ardent ANWR supporters.

Energy and Commerce Chairman Joe L. Barton, R-Texas, had said that he would not vote for the measure unless ANWR drilling is included, and House Resources Chairman Richard W. Pombo, R-Calif., also opposed removing the provision.

At mid-afternoon, Pombo called an emergency meeting of his committee's Republicans to discuss the state of play. Afterward, he said, "Nobody is really sure what we do from here. We all decided we want to stick together."

Pombo said that advocates of ANWR drilling had an overriding demand: "The one thing everybody wants is they want to do ANWR in the final bill coming back from conference. That is the priority."

Pombo added, "People are upset. This is an issue we have been working on for a long time....If you don't do energy, I don't know what's the use of doing a bill."

But moderates have already warned that they do not want to see the drilling language in a final bill, and will not vote for any legislation that contains it, creating the makings of an impasse.

Moderates headed into a meeting with House Speaker J. Dennis Hastert, R-Ill., shortly after the vote was postponed Thursday afternoon.

While some of them, such as Charles Bass of New Hampshire, indicated that they would vote for the bill once ANWR drilling was removed, others, including Michael N. Castle of Delaware and Sherwood Boehlert of New York, were pressing for more significant concessions that would mitigate the cuts in programs serving the poor, including Medicaid, food stamps, and other programs.

Castle said he hadn't committed to the bill yet. "I wasn't against it. But I had not made a decision," he said. "They wanted to cut more than $50 billion. That's a big number."

Another Try?
Conservatives were still hoping that the bill could be salvaged. "I still think we can get it done," said Steve Chabot, R-Ind. "But it's going to take more time."

John Shadegg, R-Ariz., another conservative, agreed. "The good thing about the legislative process is, unlike a football or basketball game, the clock doesn't run out." Hastert, he noted, can bring the bill the floor whenever he believes he has the votes. "The good thing about this game is that the Speaker gets to set the calendar."

Meanwhile, the impact on the looming $70 billion tax reconciliation package, which Ways and Means Chairman Bill Thomas, R-Calif., had hoped to move next week, is unclear. Blunt said that he would have to talk to Thomas about the timing.

The floor schedule will also be extremely busy next week, with as many as four appropriations conference reports and a stopgap spending measure to address.

House leaders had met throughout the day with individual lawmakers as they continued to try and line up votes. House Rules Committee Chairman David Dreier, R-Calif., put a safety valve in the rule for considering the legislation by allowing leadership to postpone the vote.

Medicaid, Food Stamps, Education
Some members were demanding changes in the section of the bill that would cut Medicaid spending by $12 billion over five years.

Vernon J. Ehlers, R-Mich., said he wanted changes to protect the most vulnerable, including deletion of provisions in the bill that would increase copayments charged to patients covered by the joint federal-state health insurance program for the poor.

Lincoln Diaz-Balart, R-Fla, said that food stamp changes adopted by the Rules Committee Wednesday night amounted to a "grandfathering" of legal immigrants who are current food stamp recipients, as long as they are 60 or older, disabled, or have applied for U.S. citizenship by the date of the bill's enactment.

"The overwhelming majority of food stamp beneficiaries are elderly; they are over 60," Diaz-Balart said. "When you include that with the protection for the disabled, that in my experience would cover the overwhelming majority."

But the Congressional Budget Office scored the change at just $20 million out of the $275 million cut planned for food stamps for immigrants, bringing the $844 million total food stamp cut to $824 million.

That brought fresh criticism from the Center for Budget and Policy Priorities, which argued that the change was minor compared with the overall cut and would translate to effectively no difference after two years. The food stamp provision would have automatically prohibited immigrants from receiving food stamps for seven years instead of the five years in current law.

Interest groups had claimed such a move would cut 300,000 individuals, including 70,000 legal immigrants, from the program. Lawmakers said they were unsure how many of those people would remain on the rolls with the new food stamp provision.

Education and the Workforce Chairman John A. Boehner, R-Ohio, said he was disappointed that House leaders did not include his $2.5 billion proposal to provide those displaced from Hurricane Katrina with accounts for tuition at public or private schools.

The Boehner measure would have provided displaced parents with up to $6,700 per student for their child to attend a public, private, or religious school for one year. But it faced opposition from moderates who contended it was a school voucher plan that would siphon off money that should go to public schools and blur the lines between church and state.

Boehner's own panel rejected the measure Oct. 27 by a 21–26 vote, with four Republicans crossing party lines to oppose it.

NOVEMBER 10, 2005 -- Just days before seniors can begin to enroll in the Medicare drug benefit, a survey released Thursday found that many beneficiaries do not understand the benefit and do not know whether they will sign up for the coverage, which begins Jan. 1.

The survey, conducted by the Kaiser Family Foundation and the Harvard School of Public Health, found that more than six in 10 seniors either do not understand the drug benefit at all or feel they do not know it very well. More than a third of seniors surveyed said they do not plan to enroll in the Medicare drug benefit, while 43 percent have not yet decided. Twenty percent said they would sign up for the coverage.

"It does raise the big question: Will beneficiaries jump in the pool or sit on the sidelines?" said Drew E. Altman, the foundation's president and chief executive officer. The enrollment period for the Medicare drug benefit begins Nov. 15 and ends May 15.

Kaiser's nationally representative sample of 802 respondents age 65 or older was conducted Oct. 13–31 and has a margin of error of plus or minus 3.5 percentage points.

Department of Health and Human Services Secretary Michael O. Leavitt said it was no surprise that seniors may not yet have a high comfort level with the drug benefit. "There is no reason to believe that the average American would have experience with this. It's new....By the time we get to May, people will have experience with this and they will have a much deeper understanding," Leavitt said during a conference call with reporters.

Centers for Medicare and Medicaid Services Administrator Mark B. McClellan said that other recently released surveys have shown a greater awareness among seniors about the benefit and higher numbers that plan to enroll. McClellan also noted that 60 percent of Medicare beneficiaries in the Kaiser survey who said they were either not going to enroll or were not sure whether they would enroll said they already have prescription coverage from another source, such as a retiree health plan.

The Kaiser survey also found that 46 percent of those who were either not going to enroll or were not sure whether they would said they did not know enough about the benefit to decide and 45 percent said they did not believe the drug benefit would save them money. Thirty-seven percent they were staying away because the benefit was too complicated to understand.

The Kaiser report also found that nearly three-quarters of seniors found that the array of choices for coverage—most beneficiaries will have at least 40 choices—"makes it confusing and difficult to pick the best plan." McClellan praised the number of choices, saying that seniors can pick the coverage that's best for their particular circumstances.

Leavitt and McClellan said they have visited 90 cities since June to explain the benefit to seniors. "The feedback we're hearing on the road has been extremely positive," Leavitt said.

Cheryl Matheis, director of health strategies integration for AARP, said that she has also seen other studies that contradict Kaiser findings. She also said that when AARP conducts educational sessions about the new benefit, "people are very interested in finding out about it. That's the message we're getting."

Consumer groups that have been critical of the Medicare drug law said the Kaiser findings underscore problems with the benefit. Families USA Executive Director Ron Pollack said the Kaiser survey revealed "flaws" in the Medicare drug law that "are producing bewilderment and confusion among seniors."

Robert M. Hayes, president of the Medicare Rights Center, said the Kaiser findings "reflect every consumer call we get....Virtually everyone is in a state of upheaval and our frustration, and it's extremely difficult for the best experts to provide meaningful help."

NOVEMBER 8, 2005 -- Some of the neediest and sickest people in Medicare already have prescription drug coverage—though Medicaid. So one of the big challenges facing federal officials in implementing the new Medicare drug benefit is to ensure the six million "dual eligibles" don't fall between the cracks when they switch from Medicaid to Medicare drug coverage on Jan. 1.

In a speech Tuesday to state Medicaid directors, Centers for Medicare and Medicaid Services Administrator Mark B. McClellan announced new steps officials are taking to lessen the odds of that happening. But not everyone is satisfied that the changeover will work well.

How might the "duals" fall between the cracks? One concern is that a dual will show up at the pharmacy on New Year's Day with no prescription drug card in hand. The main thing CMS is doing to keep that from happening is "auto-enrolling" the duals in a plan, which means duals will still be able to get prescriptions filled even if they don't choose a plan for themselves.

McClellan expressed pride in the job his agency has done identifying duals for purpose of automatically switching them into a drug plan. McClellan said there is a very close match—"way over 99 percent"—between CMS estimates of how many duals there are and the number revealed through state records.

CMS has identified 6,130,120 duals and has assigned 5,498,604 of them to randomly chosen Medicare prescription drug plans. Letters informing them of their plans were sent last week. The letters note that beneficiaries can switch to other plans if they prefer.

(Of the remaining 631,516 duals, 626,214 will get drug coverage through a Medicare managed care plan in which they are already enrolled. The rest are in jail or live outside the United States.)

But even with auto enrollment and the notification letters, officials expect some duals to fall through the cracks, because many of them are cognitively or visually impaired or suffer from low literacy, Medicaid analysts note.

If that happens, CMS said pharmacists can file an eligibility inquiry with a contractor to find the plan to which the dual belongs.
CMS announced plans Tuesday to deal with another type of dual—one who hasn't been automatically enrolled in a drug plan but who shows up at the pharmacy with cards showing they are enrolled in both Medicaid and Medicare. Under this new "point of sale mechanism" being developed by CMS the beneficiary will be able to get a prescription filled while a CMS contractor immediately confirms the dual's eligibility and arranges for his or her enrollment in a Medicare prescription drug plan, McClellan said.

The mechanism will ensure Medicare drug coverage if there is a lag between the time a person becomes a dual and when that person is actually assigned to a plan. That gap could occur when a person first becomes a dual or when the person switches in and out of dual eligibility.

David Parella, Medicaid director for the state of Connecticut, praised the new point of sale mechanism. "This is a very key issue for people," he said. Connecticut has 67,000 duals but two or three thousand are "on and off" in their eligibility. "Magnifying that across the country" generates a significant number of people who otherwise could have problems getting prescriptions filled, he suggested.

Advocates for duals also worry that the switch to Medicare coverage will require recipients to change their medications because the drugs they had been taking might not be covered on the formulary of the new plan. Medicare is dealing with that problem by requiring drug plans to have an "effective" proposal for dealing with changes in medication. One of the plans for dealing with changes in medication may be to give the beneficiary a 30-day supply of the old drug while the plan works with his or her doctor to switch to a drug on the formulary of the new plan.

But patient advocates say switches even within the same therapeutic category can be dangerous for conditions such as mental illness. McClellan said Tuesday that Medicare plans will cover all drugs for serious mental illness under a Medicare policy requiring coverage for "all or substantially" all drugs in certain therapeutic categories.

But an official with Forest Laboratories insisted otherwise. He said the company's depression medication Lexapro is taken by 40 percent of long-term care residents but that there is no mandate by CMS that Medicare prescription drug plans cover the drug.

CMS officials said that Lexepro users would be able to continue on the drug. Medicare drug plans must allow continued access to medications for a limited period of time. Doctors would have to file for an exception during that time to allow the patient to stay on the drug if it were not on the plan's formulary.