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Legislation

Congress studies long-term health care, assistants at surgery, physician payment system

Although Congress repealed the catastrophic health care legislation, long-term care remains a major issue. A report by the Pepper Commission, which studies health care issues, is due to Congress this month. The Commission is focusing on how to provide access to health care, which encom- passes both the problem with the uninsured and long-term care issues.

Sen John D. Rockefeller IV (D-WVa), chairman of the Pepper Commission, is expected to convert the Commission’s recommendations into a legislative package and introduce it later this session.

One Commission proposal would require employers to provide insurance that covers specified services or to pay a tax, according to the Dec 25, 1989, issue of American Hospital Association News. If an employer opts to pay the tax, those employees without insurance coverage would receive benefits through a federal program, or they could purchase private insurance.

In addition, the plan would establish cost- containment mechanisms that could significantly affect provider payments because hospital and physician payments would be attached to Medicare rates. Private insurers would have the option to use publicly determined rates. Providers would have to accept those payment rates as a condition of participation in Medicare and the new public program.

The second major initiative that the Commis- sion is considering would create a limited long- term care program for people who are severely impaired. It would combine the use of home- and community-based care with nursing home care.

In addition, the Commission will consider a government program for long-term home health care, Medicaid-funding expansions for long-term care, and tax incentives to encourage the growth of private long-term care insurance.

Congress has asked that the issue of Medicare payments for assistants at surgery be studied further, according to the Nov 21, 1989, issue of the Congressional Record-House. The measure was approved as part of the $14.7 billion Omnibus Budget Reconciliation Act of 1989 that Congress passed at the end of December. President Bush signed the measure.

A study conducted by the Physician Payment Review Commission (PPRC) will examine whether it is necessary and appropriate to use an assistant at surgery as well as the use of physicians and nonphysicians at surgery. Another aspect of the study is to assess how Medicare reimbursement of physician assistants who act as first assistants has affected the employment of RNs as assistants in surgery. A report is due to Congress by April 1, 1991.

Since 1987, AORN has been lobbying Congress to pass legislation that would allow RNs who assist at surgery to receive indirect reimbursement through Medicare. On previous occasions, the measure has been stripped out of other must-pass legislation (ie, budget reconciliation act, technical tax legislation). This is the first time that Congress has decided to study the reimbursement issue.

Several other nursing related provisions are included in the Omnibus Budget Reconciliation Act of 1989, according to a press release from

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The new pay schedule is expected to reduce payments for surgery while increasing fees for

medical evaluations and case management.

the American Nurses’ Association (ANA). It authorizes nurse practitioners and clinical nurse specialists, working in collaboration with physicians, to certify and recertify the need for skilled nursing facility care under Medicare, authorizes indirect Medicare reimbursement for services of nurse practitioners performed in a nursing home, and requires states to provide Medicaid coverage for services of certified pediatric or family nurse practitioners practicing within the scope of state law, regardless of whether they are under the supervision of, or associated with, physicians.

The Omnibus Budget Reconciliation Act of 1989 also added a new section to Title XVIII of the Social Security Act that provides a comprehensive package of Medicare physician payment reform, according to the Dec 29, 1989, issue of the Federal Register. The new section, 1848, includes three major provisions.

One provision is effective immediately. It regulates the allowable rate of increase in physician payments. This provision addresses the problem of unacceptably high annual rates of increase in Medicare expenditures for physician services. Each year, the Secretary of the Department of Health and Human Services (HHS) will recommend to Congress acceptable rates of increase. For example, the rate of increase for FY 1990 is 9.1%. The rate will vary each year depending on factors such as the increase of actual expenditures, inflation, changes in technology, access to necessary physician services, and changes in the number and age of Medicare enrollees under Medicare Part B.

A second provision would replace the current charge-based physician payment system with a resource-based relative value system under which every physician would receive the same fee for

a given treatment based on the time and effort the physician exerts to perform those services. The new pay schedule is expected to reduce payments for surgery while increasing fees for medical evaluations and management of cases, according to the Dec 8, 1989, issue of the American Medical News. Thirty-six surgical procedures have been targeted for reduced payments including breast surgery, knee arthroscopy, coronary artery bypass, appendectomy, and hysterectomy.

Several steps are involved in making the transition from a charge-based system to a resource-based system. It will be phased in over a five-year period, beginning Jan 1, 1992, according to the American Medical News. Until the new plan is initiated in 1992, the HHS will continue current payment for certain areas and make geographic adjustments that reflect practice costs and a portion of area earnings differences.

A third provision specifies that as of April 1, 1990, all physicians must accept assignment on claims of Medicare patients whose copayments and premiums are picked up by Medicaid. Also, on Sept 1, 1990, all physicians must file all Medicare patients’ claims-including those for nonassigned services.

Eight billion dollars would be cut from Medicare, according to a proposed budget for fscal year 1991. The Office of Management and Budget has suggested that cutbacks be made in federal funds for medical education and capital improvements for urban hospitals, and in a lower rate of reimbursement to hospitals, according to the Dec 8, 1989, issue of Capital Update.

If Medicare payments to hospitals are reduced, nurses’ salaries could be jeopardized because the cost of providing nursing services is factored into the payment hospitals receive under the Medicare program, according to the article.

Several members of Congress and the HHS Secretary oppose the proposed budget.

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Under a program by the Health Care Financing Administration (HCFA), five hospitals are participating in a new five-year demonstration program that provides reimbursement for the clinical education of graduate student nurses, according to the Nov 22, 1989, issue of Capital Update.

These hospitals are eligible to receive Medicare Part A reimbursement. They are reimbursed for instructors’ and supervisors’ salaries, student and supervisor transportation to work, classroom costs, and student stipends. The amount is not exceed $200,000 during a cost-reporting period. Iniated July 1989, the program will be effective through July 1994.

The hospitals are Grady Memorial Hospital, Atlanta; Presbyterian-University Hospital, Pitts- burgh; Vanderbilt University Hospital, Nashville, Tenn; Hermann Hospital, Houston; and Fairfax Hospital, Falls Church, Va.

Legislation that will help recruit and retain military nurses is expected to be introduced this session. These provisions were stripped from the Veterans’ Benefits Amendments of 1989 that Congress passed in the first session, according to Kathy Michaels, RN, JD, senior staff specialist, congressional and agency relations, ANA.

Not included in the bill were provisions that addressed collective bargaining rights of Depart- ment of Veterans’ Affairs (DVA) nurses, nursing pay raises, locality pay, and bonuses to help recruit and retain nurses. The bill would

ensure that retired military nurses keep their military pensions if employed by the DVA, allow the DVA to exceed salary limitations for physicians in difficult to recruit situations, and extend for five years a leave-sharing program for medical emergencies.

A trauma care bill passed the House of Representatives that would establish state-run emergency medical services systems, according to the Nov 22, 1989, issue of Capital Update.

It also would develop comprehensive plans for providing varying levels of trauma care services. In addition, a central data reporting center would

be established to coordinate various states’ trauma services with one another. Because of the large number of trauma that occur in rural areas, 10% of the funds are designated for use in rural communities, Its companion bill in the Senate (S 15) has not been considered yet.

A memorial dedicated women who served in Vietnam will be placed in the vicinity of the existing Vietnam Veterans’ Memorial in Washing- ton, DC. The Vietnam Women’s Memorial Project first received authorization to establish a memorial during the 100th Congress; however, additional legislation was needed to allow placement of the memorial, according to a press release from The Vietnam Women’s Memorial Project, Inc. Congress passed a resolution last session, and President Bush has signed it.

Congress has passed the Immigration Nursing Relief Act of 1989, according to the Oct 21, 1989, issue of Capital Update. It provides amnesty to working RNs and their spouses and children who currently hold H-1 visas, who as of Dec 3 1, 1989, are residing in the United States, and who have worked for the past three years as RNs. In addition, the legislation places new conditions on hospital administrators who apply for H-1 visas for foreign nurses in the future. These conditions will prevent hospitals from bringing foreign nurses to the United States to avoid paying competitive wages. President Bush signed this bill.

Former HCFA director William Roper, MD, is leaving his political post with the Bush administration to head the Centers for Disease Control (CDC), Atlanta, according to the Dec 29, 1989, issue of Medicine & Health.

Dr Roper had been White House domestic policy deputy, a job he accepted in early 1989. He had been director of HCFA from 1986 to 1989, and before that, he was a special assistant to then President Reagan on health policy issues. Because of his past position with HCFA, he had been the key voice in the Bush Administration on Medicare/Medicaid policy issues because HCFA did not have a director in 1989.

As director of the CDC, he will manage a staff

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of 5,000 and a budget of $1.1 billion. With a specialty in pediatric and preventive medicine, he is expected to be involved in research and clinical work.

President Bush approved Antonia Novello, MD, to be US Surgeon General, according to the Nov 6 1989, issue of Medicine & Health.

Her primary issues are children’s health care, minority health care, and the acquired immune deficiency syndrome (AIDS). She is expected to push for more testing of promising drugs on children infected with the human immunodefi- ciency virus.

She had been director of the National Institute of Child Health 8z Human Development, Bethesda, Md. As a Public Health Service officer, she worked on a program to develop artificial kidneys and treat chronic uremia and served on AIDS-related commissions and task forces.

Living wills would be required in all states, according to legislation that has been introduced in the Senate. Known as the Patient Self- Determination Act of 1989, the bill requires that staff members at hospitals and skilled nursing facilities inform patients about their right to make their own medical treatment decisions. If they do not, the hospitals and skilled nursing facilities cannot participate in Medicaid or Medicare, according to the Nov 1 1,1989, issue of American Medical News.

The bill (S 1766) is sponsored by Sen John C. Danforth (R-Mo) and Sen Daniel Patrick Moynihan (D-NY). The following describes how hospitals should conduct patient education regarding living wills.

Patients need to be informed about their right to make decisions about their own medical care, including the right to accept or reject treatment, the right to appoint an agent to make health care decisions on their behalf, and the right to provide the institution with written instructions about their treatment choices. Patients should be asked if they have prepared living wills or designated power of attorneys for health care decisions.

The staff must record the treatment wishes of patients, and periodically review such wishes with them. The staff must ensure that legal patient directives are implemented to the extent permissible by state law. The staff must arrange for patients’ transfers when the facility cannot, as a matter of conscience, implement the patients’ wishes.

Anti-smoking legislation has been introduced in the Senate that calls for $185 million to be spent on tobacco products regulation, anti- smoking advertising, and anti-tobacco education programs, according to the Dec 1, 1989, issue of American Medical News.

In addition, a Center for Tobacco Products would be established within the CDC. The new center would have authority to regulate tobacco products in a way that is similar to the way that the Food and Drug Administration regulates other products. It also would coordinate education, research, and prevention efforts. These efforts will be targeted at high-risk groups such as pregnant women and those with the highest prevalence of smoking (eg, minorities and blue-collar workers).

The bill also would replace the current warning label with a new label. It would say, “Surgeon General’s warning: Smoking is addictive. Once you start, you may not be able to stop.”

The proposal also would give state and private organizations more authority in regulating local tobacco advertising and promotion. Currently, they cannot pass tobacco advertising and promotion regulations that are more stringent than federal laws.

The tobacco industry is fighting the proposal; however, the bill’s sponsor, Sen Edward Kennedy (D-Mass), believes that this is the time to pass anti-smoking legislation, according to the article. A bill went into effect earlier this year in which smoking is banned on US domestic flights. In addition, according to a Surgeon General’s report, the percentage of people who smoke has decreased from 40% in 1965 to 29% in 1989.

SUSAN SCHLEPP ASSISTANT EDITOR

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