As Yogi Berra once said, "It ain't over 'til it's over." The same could be said for limits on Medicare fees this year as providers lobby furiously to reverse policies enacted in 1997.
Provider groups want Congress to repeal Medicare-savings provisions ranging from payment reductions when hospitals transfer patients to skilled-nursing facilities to a cap on physician expenditure growth, which is almost sure to lead to reduced fees in 2000.
The federal government enacted those policies under the Balanced Budget Act of 1997, which aimed to save $115 billion between 1998 and 2002. But because the law squeezed payments slowly, many providers are only now starting to feel the pain, sending their lobbyists scurrying back to Capitol Hill.
And they may have an opportunity to secure some changes. Unlike in 1998, when Congress passed only a one-year spending package without changing ongoing entitlement programs like Medicare, lawmakers this year are more likely to draft and pass a comprehensive budget bill as they seek to cut taxes and pass long-term reforms for Social Security -- and possibly Medicare.
Whether Congress wants to reopen the budget law, however, is a different matter. Members of Congress usually fear repealing a single Medicare cut on behalf of one provider group because they know it will only encourage others to plead for relief.
One GOP congressional aide with responsibility for healthcare predicted that Congress would "hold tight" on the current provisions affecting providers.
In addition, many of the changes providers want will increase Medicare costs. Federal budget rules could require Congress to impose spending cuts elsewhere to offset the increased costs of the provider-sought changes.
But when making their pitch to Congress, provider groups also are emboldened this year by the projected $117.3 billion federal budget surplus in 2000 and are pushing the following wish list:
Hospitals. Surprisingly, hospital groups aren't pleading with Congress to boost inpatient payments, which received a 0.5% update this year, 1.9 percentage points below the hospital inpatient inflation rate. That policy was expected to save about $14 billion over five years, the biggest hit on hospitals and one of the biggest Medicare savings items in the budget law.
Instead, hospital groups want Congress to reverse the transfer policy, which aimed to prevent hospitals from "double-dipping" by discharging Medicare beneficiaries from their inpatient beds early and moving them to hospital-owned skilled-nursing beds.
The 1997 budget law cracked down on that practice by designating as "transfers" all discharges to post-acute facilities of Medicare beneficiaries admitted under 10 DRGs. For transfers, inpatient payments are reduced.
The Congressional Budget Office originally projected the policy would save $1.3 billion over five years. But the CBO now says the policy will save $3 billion.
Hospital groups also want to give some relief to hospitals most affected by the change of outpatient department reimbursement to a prospective payment system.
Academic hospitals, too, want to repeal cuts to Medicare's reimbursement for their indirect medical education costs.
"IME is dropping 29% (from $5 billion in fiscal 1997) over the lifetime of the (balanced-budget law)," said Robert Dickler, the group's senior vice president. "That's having a significant negative impact."
Physicians. The hottest button for physicians is the sustainable growth rate, a measure designed to police physician fees based primarily on changes in the gross domestic product and fee-for-service enrollment.
The CBO estimated the rate, as implemented by the 1997 budget act, would cut physician payments by 11% between 1998 and 2002.
"No other health group has been asked to absorb this sort of across-the-board decrease in payments," the American Medical Association said in written testimony to the House Ways and Means health subcommittee March 2.
Robert Doherty, a top lobbyist of the American College of Physicians-American Society of Internal Medicine, said part of the problem is that HCFA claims the law prohibits it from refining its rate projections during the course of a year, no matter how far off they are.
"Because HCFA is using obsolete data (to compute the rate), physicians are held to a much tighter limit on increases than is appropriate," Doherty said.
Nursing homes. The assisted-living industry wants Congress to repeal a $1,500-per-year therapy cap for Medicare Part B services.
"It's unfair because a person can go to a hospital outpatient clinic and get the same services without the $1,500 cap," said Robert Greenwood, a spokesman for the American Association of Homes and Services for the Aging. "In a nursing home, you can't do that. We have some residents who are refusing therapy because they don't want to use up (their allowance under the cap) too quickly."
Nursing homes also want an "outlier" policy in place so Medicare will pay them extra for cases of unusually high acuity, a payment currently made only to hospitals.
Medicare+Choice plans. Managed-care plans are angered by HCFA's proposal to adjust capitation payments to Medicare HMOs based on enrollees' risk of illness, because it cuts an additional $11 billion from managed-care reimbursement over five years.
They argue that the balanced-budget law intended for the risk-adjustment formula to offset any cuts in fees for low-risk enrollees with increases in fees for high-risk enrollees.
Managed-care plans also said they are concerned about a growing gap between Medicare+Choice capitation payments and Medicare's total costs for treating beneficiaries in the fee-for-service sector.
The plans also said Congress needs to change the Medicare+Choice payment formula to ensure equity in Medicare expenditures between Medicare managed-care enrollees and beneficiaries still in the fee-for-service sector.
Home health agencies. Perhaps the group most adversely affected by the 1997 law, and the group fighting most fiercely for change, is the home health industry.
The system limits reimbursement to the average cost of providing services, or about $4,000 per patient in 1998. Citing HCFA data, industry officials said that led to a 17% drop in payments to home health agencies between 1997 and 1998.
"When Congress passed the Balanced Budget Act, members believed they were voting for a modest reduction in the rate of growth of home care, not slashing the benefit itself," Val Halamandaris, president of the National Association for Home Care, said in a written statement. "This CBO analysis demonstrates that the changes enacted by Congress in 1997 have had a serious, unintended result of severely reducing access to the Medicare home health benefit."