When HHS Secretary Tommy Thompson convenes the first meeting of his Advisory Committee on Regulatory Reform this week in Washington, he is expected to highlight the bane of hospitals' existence with a visual aid: a 4-foot-high stack of documents constituting one critical-access hospital's three-month Medicare cost report.
While it is hospitals' favorite regulatory whipping boy, the report is only one example of what executives say they hope the new committee will target: a blizzard of federal healthcare paperwork that diverts nurses and other practitioners from patient care.
Thompson and his administrator of the Centers for Medicare and Medicaid Services, Thomas Scully, have made regulatory reform one of HHS' chief goals during President Bush's tenure. The creation of the committee represents the latest stage in the paperwork-relief battle. It is the first time providers will be able to formally voice complaints about such issues as the Medicare cost report in a forum that could result in official recommendations to Thompson and other lawmakers.
"We need to focus on those things that are detrimental to the care of patients," said Douglas Wood, a Mayo Clinic cardiologist whom Thompson named as the committee's chairman.
But before the committee had even begun its work, it faced scrutiny last week from some beneficiary groups that fear it may be tilted too far toward the interests of providers and insurers and would make recommendations that would conflict with the intent of the Medicare program. Of the 27 committee members, 25 represent providers, insurers, suppliers or government officials, with only two being representatives from beneficiary groups (See chart, p. 5). Of the four government officials named to the committee, three are Republicans. One of the Republicans, Gary Mendoza, a former HMO regulator under former California Gov. Pete Wilson, is a GOP candidate to be California's insurance commissioner.
"Regulatory reform sounds good," said Robert Hayes, president of the Medicare Rights Center, a New York-based seniors' advocacy group. "Obviously you need some breadth of experiences to create sound recommendations. The current makeup of this committee sorely lacks consumer representation. Experience suggests that a committee like this could take aim at regulatory responsibilities that require accountability and patient protection."
Thompson selected the committee members from nominations he received from interest groups and other parties, an HHS spokesman said.
Wood highlighted Medicare's guidelines on how to properly document the services provided in office visits as an example of regulations the committee plans to target. "To the extent that physicians concentrate on how the note is written, the focus isn't on (the patient) in front of them," he said.
Congress also in the game
In addition to HHS' and the CMS' efforts to trim regulations, Congress is continuing its focus, begun last year, on changing Medicare law to ease the regulatory burden. The House has passed legislation that would allow the CMS to choose Medicare carriers and intermediaries through competitive bidding, as well as ease some oversight activities of the CMS and the HHS inspector general's office (Nov. 12, 2001, p. 4).
The new committee, however, is focusing on regulatory changes that could occur without changes in the laws enforced by the CMS and other HHS agencies such as the Food and Drug Administration.
For hospitals, simplifying the cost report will be one chief goal (Nov. 19, p. 30) as well as streamlining patient-dumping regulations and promoting a formal procedure for clarifying gray areas in certain regulations. Under that procedure, which the American Hospital Association calls the "model practices" process, hospital groups and other provider organizations could write the CMS to communicate their understanding of an unclear regulation and ask whether they are correct. The CMS could either concur with the interpretation or provide further clarification.
For Tony Fay, a committee member and vice president of government affairs at Brentwood, Tenn.-based Province Healthcare Co., a for-profit chain of 19 hospitals, clarity and predictability are key.
"What I would strongly suggest is that Medicare get to the point where it can publish a Medicare manual once a year and resist the efforts to twist and tinker with it until next year's edition," he said.
In announcing the creation of the new committee, Thompson framed regulatory reform as a healthcare quality issue.
"When we flood doctors and hospitals with excessive paperwork, patients suffer the consequences," he said in a written release. "It is important that doctors spend more time with patients and less on paperwork."
But some consumer advocates warned that patients shouldn't be forgotten in the committee's quest to ease regulatory burdens on healthcare businesses.
"I don't think any of us are sitting there saying that regulation and paperwork should get in the way of care," said Charles Inlander, president of the People's Medical Society, a healthcare advocacy group based in Allentown, Pa. "(Provider representatives on the committee) are not people who are sitting there with their first obligation and their first choice (being) protecting the public, which is why regulations exist. There needs to be far more consumer input from consumer advocates."
But panel members reject that complaint, saying they also are looking out for the beneficiary.
"To me it's a false dichotomy to say either it's a provider issue or it's a beneficiary issue, because more often than not they're joined," said Bruce Cummings, chief executive officer of 14-bed Blue Hill (Maine) Memorial Hospital and a member of the committee.
For example, he said home health nurses must complete a lengthy 40-page home health quality reporting form, called the Outcome Assessment and Information Set, before they can begin treating a beneficiary on an initial visit.
"Technically, the home health aide is not allowed to lay a hand on a patient, no matter how uncomfortable this frail elderly person is, until that OASIS form is completed," he said.
Recommendations coming this fall
The committee itself is on a tight time frame. After this week's organizational meeting at Providence Hospital in Washington, it is scheduled to meet only twice more in Washington and hold regional sessions between February and May. It is scheduled to deliver final recommendations to Thompson in September or October.
Wood hopes to keep it on an even tighter schedule. He said at each meeting he wants the committee to present Thompson with a set of regulatory reforms that could be implemented immediately.
"I'm sure the committee will be able to present several," he said.
Though HHS is looking for advice from providers, some issues are off the table. The committee will not discuss payment adequacy or formulas, for example, nor make any new policy recommendations or assess what would happen to the regulatory burden if any Medicare laws were changed. Instead, it will focus on ways to simplify regulations and paperwork in a way that is consistent with the intent of Medicare law.
Thompson, however, has the ultimate authority to decide whether the panel's recommendations are consistent with Medicare law and whether or not to carry them out.