It sounds so easy. Just get rid of the fraud in Medicare and we could save as much as 10 percent of the massive program's annual spending, auditors say. But in practice, it always seems to get messy.
A case in point is the fix Congress now finds itself in over Medicare's home health benefit. Long near the top of the Medicare fraud and abuse rogues' gallery, Congress took tough steps in the 1997 Balanced Budget Act to bring home health spending back in line.
But cracking down on the bad guys always seems to hurt good guys, too. For example, Congress originally required home health agencies to post "surety bonds" to prevent fly-by-night agencies from setting up shop, collecting a lot of money and skipping town. But almost immediately agencies began complaining that the bonds were too expensive or too difficult to obtain. Congress and the Health Care Financing Administration quickly backed down on the surety bond requirement.
Now the problem is the new payment system the 1997 act imposed. What was supposed to be a temporary system, to be replaced with a "prospective payment" system similar to how Medicare pays hospitals, now may have to stay in place longer, thanks to HCFA's year 2000 computer problems. But the "Interim Payment System," which bases payment on 1994 spending, penalizes those who acted efficiently back then, particularly if they are now serving sicker patients.
There is significant dispute over just how bad the situation is, whether only a few hundred agencies have closed their doors, or 1,200 as the industry's trade group, the National Association for Home Care contends. But home care has indisputably become a political problem. Most members of both the House and Senate have cosponsored at least one of more than a dozen bills to alter the payment system, and last week a demonstration on the Capitol's West Front featured a 2 1/2-mile long petition urging the payment system be fixed.
The bipartisan members who wrote the health section of the BBA have tried, unsuccessfully, to head off changes that would again encourage open-ended spending on home health care. The same day as the demonstration, they issued a CBO estimate that going back to the old payment system would cost more than $20 billion over five years. But on Tuesday, those same members of the Ways and Means Health Subcommittee unanimously approved a bill that would add back at least $1.4 billion in home health payments. And given that it is an election year with a key element of a popular program in peril, that may just represent an opening offer.
The rift between the American Medical Association and the congressional GOP leadership continues to widen. Formerly among Republicans' most loyal and generous backers, the AMA has of late been in an ugly war of words with the joint Republican leadership over physicians' endorsement of the Democratic- backed "Patients' Bill of Rights."
Now, organized medicine for the second time this year is opposing a bill being pushed by Republicans at the behest of social conservatives. Back in February, medical groups, the AMA among them, helped block legislation to ban the cloning of humans. The problem with that bill was not its intent, virtually the entire medical community opposes the idea of cloning a human, at least at this point, but rather its potential for "collateral" damage; i.e., inadvertently banning more than cloning.
That is the situation with the Lethal Drug Abuse Prevention Act. The bill, which could reach the House floor as early as today, would make it illegal for physicians to prescribe drugs on the federal government's list of controlled substances for the purpose of assisting in a suicide. Intended at the moment to override Oregon's landmark "Death With Dignity Act," the measure is also an effort by groups opposing assisted suicide to nip the legalization movement in the bud.
But physician groups, led by the AMA, that oppose assisted suicide also oppose the bill. One problem, they say, is that legal controlled substances, including barbiturates and opiate painkillers, are not the only way to assist in a suicide. Assisted suicide physician Jack Kevorkian, for example, has used carbon monoxide, not even a drug, much less a controlled one.
But the heart of the medical community's opposition is survey after survey has shown that many terminal patients die in needless pain because doctors are loathe to prescribe adequate medication. They say the specter of an investigation by the Drug Enforcement Administration is not going to make physicians more likely to use appropriate means to control pain, and could, ironically, make assisted suicide more attractive to the terminally ill.
"We fear the 'real world' consequences of the bill would be to discourage the kind of appropriate aggressive palliative care that can dissuade patients in pain from seeking just such an early death," AMA President-elect Thomas Reardon told the House Judiciary Committee this summer. If the bill is passed, he said, "Recent promising advancements in the care of people at the end of life could be set back dramatically, to the detriment of patient care."
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