The Visiting Nurse Associations of America thought it needed to take action.
The group contends that the federal balanced-budget law approved by Congress last year contains Medicare payment cuts so severe its member agencies would be put out of business.
But because of its not-for-profit tax status, the VNAA can do only limited lobbying. Undeterred, the group formed a new organization whose tax status allows lobbying. The new group, called the Committee to Protect VNAs and Other Cost Efficient Agencies, might not have a lyrical name, but it serves its purpose. Through the committee, VNAs can fight provisions in the balanced-budget law they claim are excessive.
And the VNAs are by no means alone.
Demonstrating that in Washington, it's never over even when it's over, special-interest groups of every shape and size are working on all branches of the government to change what they don't like about last year's balanced-budget bill. They also are trying to preserve the parts they support.
While every budget enacted is followed by a flurry of lobbying, this year's war is being fought harder than most because of the sweeping nature of last year's budget law.
When the Balanced Budget Act passed last summer, most provider groups followed a time-honored lobbying tradition and gave it a mixed review. For example, American Hospital Association Executive Vice President Richard Pollack said, "There are a lot of good things in the bill that we can support." But Pollack foreshadowed the AHA's strategy when he added, "We're concerned that (Congress) relied on the old system of ratcheting down on providers' payments rather than structural reforms."
Karen Ignagni, president of the American Association of Health Plans, which represents the managed-care industry, was slightly more enthusiastic. "Overall, this agreement appears to be fair and balanced," she said.
But both groups' nonconfrontational comments masks a longer-term strategy: Never stand in front of a moving train, and never say anything that isn't ambiguous enough to be reinterpreted if political circumstances change. No one wants to aggravate the lawmakers hammering out the deal, many of whom will be needed in future battles. However, provider groups and other special interests want to keep their options open to fight any offensive provisions later on.
"This is typical of what happens after every budget: Anyone who loses wants to make changes, but there is a lot more of it this time than in the past because the bill was so big and a lot of the changes were fairly extreme," says James Scott, president of the Premier Institute in Washington, which represents not-for-profit hospitals.
According to Pollack, not only are there more issues this year, but their scope and potential impact also are greater.
"Typically in the past, there have always been technical types of changes -- small things," Pollack says. "But this time around, there are real substantive issues because of areas where the bill overreaches. Billions (of dollars) are at stake."
The AHA has its own list of items it wants reversed. Chief among them is a provision that will reduce hospitals' Medicare reimbursement for transfers of patients from hospitals to post-acute-care facilities. The change originally would have covered a transfer to any post-acute facility for any diagnosis. However, under pressure from hospital groups, it now applies to only 10 diagnoses and does not take effect until Oct. 1 of this year. HCFA has yet to announce the 10 diagnoses.
But hospitals want to kill the reimbursement reduction. To that end, they are supporting a bill introduced by Rep. Jim Nussle (R-Iowa), which has nearly 70 co-sponsors.
Physician groups have their own agenda. Like a professional wrestling match that has spilled out of the ring into the stands, specialists and generalists continue to fight over $4 billion. During the budget debate last year, specialists and surgeons successfully lobbied Congress to order HCFA to redo a proposed rule changing the way Medicare pays physicians for practice expenses like rent, supplies and office staff time. They also won a delay and phase-in of the new payment schedule for practice expenses.
Now, generalists and specialists are urging Congress to pay attention to HCFA's new rule, which was due May 1. If the new proposed rule includes any unacceptable provisions, both sides plan to ask Congress to pressure HCFA for more changes.
"The main thing is to keep the pressure on HCFA," says Robert Doherty, vice president for governmental affairs and public policy with the American Society of Internal Medicine, which has fought for the interests of primary-care doctors.
"We are preparing our friends to ask (HCFA) intelligent questions," says Randolph Fenninger, co-chairman of the Practice Expense Coalition, which is representing specialists and surgeons in the ongoing battle.
But by a wide margin, the most aggressive attackers of last year's budget law have been home health agencies (See story, p. 33). Of all healthcare industry sectors, home health was among the hardest hit. The most drastic change moves Medicare reimbursements for home health from a cost-based system to a prospective payment system beginning Oct. 1, 1999.
As a first step, the budget calls for implementation of an "interim payment system," or IPS.
The IPS pays home health agencies based on their historic costs. However, that locks in high payments for inefficient providers while penalizing cost-efficient agencies, according to low-cost home health providers.
Opponents of the law's home health changes want either of two things: a change in the IPS formula to equalize payments between agencies or replacement of the IPS with prospective payment.
A bill to change the IPS formula already has been introduced in the House, sponsored by Rep. Michael Pappas (R-N.J.), and a similar bill was introduced in the Senate last week by Sen. Susan Collins (R-Maine). Neither bill would incur extra costs for Medicare.
Congress isn't seeing all the action. The National Association for Home Care is planning to file two lawsuits against the IPS. And other home-care groups are planning lawsuits related to other budget changes.
Those are just the first course in the movable feast that is last year's balanced-budget law. Nursing homes want to change the way their soon-to-be-implemented PPS system works. The American Health Sciences Education Consortium, which represents hospital-based colleges of nursing and allied health, wants about $100 million cut from Medicare reimbursements for HMOs and redirected to its members. Managed-care groups don't want that, but they do want other alterations in the way Medicare reimburses HMOs. The National Association for Medical Equipment Services called the reversal of some Medicare reimbursement cuts for home oxygen equipment "a greater priority than continuing to increase spending for transportation or defense."
"Sometimes it seems like someone wants to reopen every part of the whole damn law," remarks one Senate aide who asked not to be identified.
But what are the chances that any of these changes will be implemented?
As with so many things, the problems are time and money.
Satisfying the AHA on the hospital transfer provision would cost Medicare $1.4 billion over the next five years. To abolish the IPS and placate the home health industry would cost more than $2 billion over the same time frame. Other changes, like the one sought by the American Health Sciences Education Consortium, don't cost the Medicare program a penny, but they gore one special interest's ox to feed another.
While individually none of these provisions would break the bank, each must be funded by cuts to other programs, under budget rules.
But what about the budget surplus being projected for next year?
Much of that already has been spoken for in the form of tax cuts, highways and bridges, education initiatives, and other pet lawmaker proj-ects. However, the projected surplus does offer cause for optimism to special interests seeking changes in the balanced-budget law.
"Money is an issue, but I don't view it as that big a problem," Pollack says.
The second obstacle common to all groups seeking changes this year is the calendar. Congress has less than two months' worth of working days remaining this year. And because this is an election year, the conventional wisdom is lawmakers will go home to campaign as early as possible.
"It is an uphill battle this year to find a vehicle to accommodate the kind of changes people want . . . with the truncated legislative calender," says Frederick Graefe, a healthcare lawyer with Baker & Hostetler in Washington.
Lawmakers also are somewhat reluctant to reopen the budget law lest they be overrun with special interests.
"If we gave everyone everything they wanted, there would be nothing left of the original (budget) agreement," one Senate aide comments. "We worked for months on the compromise, and if we open it back up, all hell could break loose."