Washington Watch: Hello and Goodbye: Facing Impasse, Congress Exited in September and Punted to November
On September 10th, the House of Representatives and the Senate returned to Washington after a five-week recess that included the two national party conventions. They were in session for only 13 working days, before leaving town again to campaign on September 21.
This Congress, with a House of Representatives run by Republicans and a Senate run by Democrats, has drawn record low approval ratings and has been called a “do nothing” Congress. Both parties blame each other for the lack of major bills that have passed in the last two years--despite the fact that they have been in session in 2012 for the same number of days as is usual in election years. But, more than the lack of productivity and passage of specific legislation, this Congress has been marred by pervasive dysfunction.
With the exception of a “must-pass” stopgap spending bill (a continuing appropriations resolution) to keep the Federal Government operating for the first six months of the new fiscal year--which began on October 1--very little else was accomplished in this brief session before Election Day. Despite some last-minute gamesmanship, passage of the six-month continuing appropriations bill didn’t entail any threat of government shutdown, because neither party wanted to be blamed for that possibility just prior to Election Day. So, that one bit of mandatory business has been “managed” for at least a few months. However, most legislative activities were put aside as they were overshadowed by the presidential and congressional elections. While it has always been this way as an election approaches--the degree of legislative avoidance was greater this year as partisanship remained extraordinarily high. The Senate is so averse to trying to legislate through difficult issues, that for the first time in more than a decade fewer than half of that chamber’s votes have divided the two parties. The House, on the other hand, is exactly the opposite--where approximately 77 percent of all votes taken in that chamber have resulted in “party line” votes--the highest percentage ever recorded since the Congressional Quarterly has recorded that statistic.
The list of unfinished legislative business is long, including whether and how to stop the automatic budget sequester and whether and how much to extend the expiring George W. Bush-era tax cuts. Action is also anticipated on farm policy, several defense and national security issues, and the approaching 27 percent cut in reimbursement rates to physicians with Medicare patients.
The 112th Congress has been completely hamstrung by ideology and politics. This may or may not change now that the election is over. Prior to Election Day, governing waited while priority was given to campaigning.
CBO: Maintaining Medicare Pay for Physicians to Cost $245 Billion Over Decade
Allowing Medicare payments for physicians to stay at current rates through the next ten years would cost $245 billion more than if a required cut were allowed to take effect, according to a budget and economic forecasting report released on August 22 by the Congressional Budget Office (CBO).
In addition, CBO’s report looked at other Federal health care expenditures, including Medicaid and the health insurance subsidies under the health care reform law. It found that Medicaid spending will be lower than a previous estimate due to the impact of the U.S. Supreme Court’s decision on the health reform law.
Under the Medicare sustainable growth rate (SGR) formula, physician fees are scheduled to be cut by 27 percent as of January 1, 2013. However, if Congress overrides the scheduled reductions, as it has done every year since 2003, spending on Medicare would be $10 billion higher in 2013, increasing incrementally every year to $40 billion higher in 2022, according to the report entitled An Update to the Budget and Economic Outlook: Fiscal Years 2012 to 2022.
“If payment rates for physicians through 2022 stay as they are now, outlays for Medicare (net of premiums) would be $10 billion higher in 2013 and about $245 billion (or about 3 percent) higher between 2013 and 2022 than they are in the current law baseline,” the report said.
CBO’s update is issued each summer with economic and budget projections for the next decade freshened since the agency’s previous report. Overall, CBO said that outlays for Social Security, Medicare, and Medicaid are projected to grow from 10.5 percent of gross domestic product in 2013 to 12.2 percent in 2022, accounting for about 55 percent of all Federal spending by the end of that period.
CBO also said that another factor contributing to the anticipated growth in mandatory spending is the provision of subsidies for the purchase of health insurance, which will become available under the Patient Protection and Affordable Care Act starting in 2014 for those meeting income and other criteria.
MedPAC Considers Recommending Ending Adjustment Pay for Doctor Pay Based On Locality
On September 6, members of the Medicare Payment Advisory Commission (MedPAC) began debating whether to recommend to Congress that doctors continue receiving higher Medicare reimbursements for their work based on costs of their geographic location.
Adjustments to Medicare physician payments based on geography are intended to account for regional variations in wages, rents, and other costs. They are divided into three components: work, practice expenses, and practice liability insurance. The adjustments are made by indices, known as the Geographic Practice Code Indices (GPCI), which reflect how each geographic area compares with the national average.
The work GPCI, which is being discussed by MedPAC, adjusts payments for physicians and other providers who are reimbursed under Medicare Part B for such elements as cost-of-living in a locality and amenities. The commissioners began their discussions on the work component in advance of a report due to Congress on June 15, 2013.
In February of this year, Congress passed the Middle Class Tax Relief and Job Creation Act of 2012, which required MedPAC to study whether Medicare should continue geographically adjusting the work-related payments.
The Medicare and Prescription Drug Improvement and Modernization Act of 2003 established that for three years there would be a “floor” of 1.0 on the “work” component of the formula used to determine physician payments. In other words, physician payments would not be reduced in a geographic area because the relative cost of physician work in that area fell below the national average. Congress has extended the work GPCI floor several times, with the Middle Class Tax Relief and Job Creation Act of 2012 providing an extension through 2012. Since the floor expires on December 31 of this year, MedPAC wanted to address the topic early in its report cycle so that Congress would have the Commission’s idea and analyses before the end of the year. It is anticipated that recommendations on the work GPCI will be put forth for the MedPAC commissioners’ consideration in November.
SAMHSA Announces New CMHS Director
On August 9, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced that Paolo del Vecchio, MSW, has been selected to serve as the next director of SAMHSA’s Center for Mental Health Services (CMHS).
Over the course of his 17 years at CMHS, del Vecchio served as the acting director, the associate director for consumer affairs, and the acting director for the Office of External Liaison. He was also the first consumer affairs specialist hired by SAMHSA.
Prior to joining SAMHSA, del Vecchio worked for the Philadelphia Office of Mental Health in the areas of policy formation and the planning of a comprehensive system of community-based mental health services addressing homelessness, HIV/AIDS, and a number of other issues. He has been involved in behavioral health for over 40 years.
CMS Final Rule Delays ICD-10 Compliance
On August 24, the Centers for Medicare and Medicaid Services (CMS) released a final rule confirming a one-year delay in compliance for the ICD-10 code set, moving the date from October 1, 2013 to October 1, 2014.
The final rule, which was published in the September 5 Federal Register, also adopted a standard for a national unique health plan identifier (HPID) for all health plans and other organizations performing health plan functions, including third-party administrators and clearing-houses. All health plans and organizations, with the exception of small plans, will be required to obtain an HPID by November 5, 2014, while small plans will have until November 7, 2015. Covered entities will have to begin using the HPIDs in transactions beginning on November 7, 2016.
The HPIDs are required by Section 1104(c) (1) of the Patient Protection and Affordable Care Act. The unique 10-digit HPIDs are designed to end confusion in the health care industry stemming from the multiple identifiers currently being used by health plans, according to the final rule.
The one-year ICD-10 compliance delay was prompted by concerns that many health care providers and plans were behind in their implementation efforts, and the final rule said “we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing.” In addition, the final rule said that the one-year delay would result in $3.6 billion to approximately $8 billion in savings from “the avoidance of costs that would occur as a consequence of significant numbers of providers being unprepared for the transition to ICD-10.”
ICD-10 is intended to be used for classifying health care diagnoses and procedures and entails moving from the 13,000 codes of ICD-9 to roughly 68,000 codes. The expanded code set will allow for the inclusion of new conditions and treatments as well as more data collection.
Obama Orders Improvements in Mental Health Care for Veterans
On August 31, President Obama signed an Executive Order aimed at reducing the rate of suicide and mental health disorders in veterans and troops by improving access to behavioral health care.
The Executive Order, entitled Improving Access to Mental Health Services for Veterans, Service Members and Military Families, includes actions to improve access to mental health services for service members and veterans, including enhanced partnerships with community providers and increased VA staffing, and mental health research. In addition, the Executive Order directs the Veterans Administration (VA) to work with the Department of Health and Human Services (HHS) to establish a pilot program that leverages community mental health resources to reduce the waiting times that veterans often face when seeking mental health services.