The doctor-vs.-doctor battle over Medicare reimbursement for practice expenses won't go away.
Despite opposition from primary-care groups and on Capitol Hill, a coalition of specialty groups late last month said they will try to change a provision in the recently passed federal balanced-budget law that would shift $390 million in practice-expense payments to primary-care office visits in 1998 from specialty procedures.
Meanwhile, in the wake of a legislative loss that will cost their members as much as $175 million in 1998, four of the six lobbyists for the American Academy of Ophthalmology are leaving. The organization is one of the medical specialty trade groups fighting the shift in Medicare payment policy. But academy executives said those departures had nothing to do with the budget agreement.
The Practice Expense Coalition, which represents numerous specialty and surgical groups, wants to alter the way in which the balanced-budget law will divert money from specialty procedures to primary-care office visits in 1998.
Primary-care groups won that provision in the balanced-budget law in return for accepting a delay in a change to "resource-based" practice-expense compensation. That change would be worth about $4 billion a year to primary-care doctors.
Thus, the 1998 shift of money to primary-care office visits has come to be called the down payment on the eventual shift of $4 billion under resource-based practice-expense reimbursement. Under the budget law, HCFA will begin phasing in resource-based practice-expense compensation in 1999.
The down payment comes from trimming the compensation for procedures in which the practice-expense portion of a physician's Medicare payment exceeds 110% of the professional-work portion of the physician's fees.
Practice-expense reimbursement covers such costs as physicians' equipment, supplies and staff time used in the treatment of Medicare beneficiaries. It accounts for about 40% of the $30.7 billion that Medicare will pay physicians in fiscal 1997.
As an alternative to the budget's current formula for diverting practice-expense payments, the Practice Expense Coalition proposes HCFA insert a one-year adjustment factor to be applied to the fee calculation of procedures and surgeries done outside physicians' offices.
Specialty groups justify the change because the current down-payment formula will concentrate reductions in such specialties as ophthalmology and cataract, orthopedic and thoracic surgery.
In addition, they said the down-payment formula will affect procedural and surgical fees for more than one year. And they add that because private-sector payers use Medicare fees as a benchmark, the down-payment formula will result in payment reductions when specialists treat privately covered patients.
A one-year adjustment to procedural and surgical billings, on the other hand, would spread the pain more evenly among specialties and would have a much smaller effect on future Medicare reimbursement and private-sector fees. Specialty groups also said their plan would not affect the sum that would be diverted to primary-care office visits.
But such a change demands congressional action, either as part of a bill making technical adjustments to the Medicare program or an even larger bill.
"I think people want to sense if there's any enthusiasm out there (for the coalition proposal), and if there is, we'll press harder," said Michael Maves, M.D., treasurer of the Practice Expense Coalition and executive vice president of the American Academy of Otolaryngology.
As for the shift to primary-care office visits, Maves said, "It's budget-neutral. They will get their money."
Added William L. Rich III, M.D., federal affairs secretary for the American Academy of Ophthalmology: "I think you have to get primary care to buy into it. If they don't, then I think it's a dead issue."
The American Medical Association also has raised the possibility of technical correction to the down-payment provision, although lobbyists were skeptical about the likelihood of passing another Medicare-related bill.
Primary-care groups already are seething at what they saw as a sneak attack on the down-payment provision late in the balanced-budget negotiations. They don't appear ready to budge.
In fact, they threaten to try to move up the implementation of resource-based practice-expense compensation if the down-payment provision is altered.
"If one part of the practice-expense package is open, then all of it is. We're willing to stand behind the existing package as a reasonable tradeoff where everybody got something," said Robert Doherty, vice president for governmental affairs and public policy with the American Society of Internal Medicine. "This clearly is not a technical issue. This is a controversial policy issue."
But Rich responded, "When the rhetoric cools down, I hope we can talk to them in a rational fashion."
A senior Senate aide, however, agreed with Doherty's assessment that the specialists' proposed change fails the test of a technical amendment. "A technical (change) is not something you're unhappy with," the aide said.
The aide added that because there are virtually no other proposed changes to the Medicare provisions of the budget law, it is unlikely there will be a technical amendment bill.
Ophthalmologists, meanwhile, who are already smarting from the loss of up to $175 million in 1998 as a result of the existing down-payment provision, now must also contend with an emptier Washington lobbying office for the time being.
Gone are Michael Roberts, the federal affairs director who will continue advising the group; lobbyist Manuel Bonilla, who has gone to the American Society of Anesthesiologists; Wayne Powell, the academy's assistant director for federal reimbursement policy, who is going to work for the American Osteopathic Association; and lobbyist Gloria Moser Romanelli, who is moving for family reasons to Phoenix.
Group officials said the loss of two-thirds of the academy's lobbying stable was not a post-budget house-cleaning but rather the result of the lobbyists' personal decisions made well before the congressional action on the practice-expense issue.
Rich said, for instance, that Bonilla and Powell chose higher-ranking jobs in their new organizations.
He added, however, that Roberts' departure will give them an opportunity to redefine the federal affairs director's post and hire somebody with a broad understanding of health economics, policy, legislation and regulation.