Primary-care physicians and specialists each won a partial victory in recent Capitol Hill maneuvering over Medicare compensation for doctors. But the bruising battle left neither side totally happy.
Now the focus of the two groups will shift from the legislative arena to regulation as efforts intensify to influence HCFA's creation of rules covering the distribution of future practice-expense payments.
In August, specialists were unsuccessful in an 11th-hour effort to stop a plan that would shift money from them to primary-care physicians. But they won a one-year delay in implementation and a phase-in of the plan, which threatened double-digit losses in their Medicare revenue.
Primary-care physicians were able to increase their Medicare practice-expense compensation for next year, but the hike is a fraction of the $4 billion they were expecting.
Medicare currently pays physicians based on historical charges for such overhead expenses as rent, office staff and equipment related to serving Medicare beneficiaries. A 1994 law requires Medicare practice-expense payments in 1998 to be based on the actual resources required to deliver service.
But specialty groups and surgeons protested that flawed data was used by HCFA to develop a regulation on resource-based expenses.
In response, Congress gave HCFA until May 1, 1998, to publish a new proposed rule for implementation on Jan. 1, 1999. Aug. 18 was the deadline for comments on HCFA's first effort at a rule, and between now and next May the agency needs to decide what revisions in data and methodology to make in its proposed rule.
"There's going to be a real tug of war between the specialties, the AMA and others about how far HCFA needs to go in terms of developing an alternative methodology," says Robert Doherty, vice president of governmental affairs at the American Society of Internal Medicine.
Although Doherty thinks improvements are needed, he says, "We don't believe that HCFA needs to start from scratch. . . . It's appropriate to supplement that data with additional data."
A coalition representing specialists has requested a meeting with HCFA in September to discuss its proposal to establish a "public-private partnership" to help assure that HCFA's information about physician costs is valid.
The delay and transition period established by Congress "has created a period of time to get this done right," says Randolph Fenninger, co-chairman of the Practice Expense Coalition, which represents specialty groups.
HCFA is expected to give physicians another shot at formal input before developing its new rule, but Fenninger points out that there are "a lot of ways for the agency to get information and (groups') views without going through the formality of a notice and comment period."
The appointment of a new HCFA administrator also will determine how some of the issues get worked out, he noted.
Primary-care groups say they will fight efforts to go back to "square one" on the payment issues. The groups refer to the $390 million in additional compensation they will receive for 1998 as a "down payment" on improved compensation for primary-care expenses.
"We think what Congress did was beneficial and long overdue. . . . We don't want any mucking around with the language," Doherty said.
Practice-expense payments represent about 40% of the $30.7 billion Medicare will spend on physician payments in fiscal 1997.