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Summarization The New England Journal of Medicine dated October 19, 2000, includes a "sounding board" of the presidential candidates' views on health care issues. I will summarize and comment on a number of their proposals. Both candidates focus on
the national embarrassment of uninsured children. The most vulnerable
group remains those children in families not eligible for Medicaid and
too poor for private insurance (11,000,000 children). Currently, the
State Children's Health Insurance Program (SCHIP) is a federal program
providing state block grants to expand affordable care. Governor Bush
would allow the states greater flexibility in using the money to expand
coverage, but does not espouse enlarging the expenditures to this
program. The proposed coverage for the parents of children on the SCHIP program, and for all adults in general, is incremental. Governor Bush offers a "Family health Credit", a voucher of up to $2000 per year, to any family making less than $30,000 per year. This credit is alleged to cover 90% of the purchase cost of a health insurance policy. Many disagree that the dollar value of this voucher is adequate. For individuals not eligible for this program, based on their income, he will promote expansion of employee-based insurance programs for small businesses. These businesses will be encouraged to conglomerate into purchasing groups to obtain better rates for coverage. Governor Bush will support the expansion of medical savings accounts as an alternative approach. The Vice President would expand SCHIP to cover adults at or below the 250% poverty level. Above this income bracket, he proposes a 25% tax credit to individuals and to employers offering health coverage. The Vice President desires expansion of Medicare allowing individuals aged 55-65 to buy into the program. The Vice President does not offer a view on the perpetuation of medical savings accounts as an alternative approach to coverage.
Prescription drug coverage for Medicare patients remains a critical election issue. Governor Bush's program is entitled "MedicaRXes" (Medicare choice and Access to Prescription Drugs for Every Senior.) It covers all prescriptions for drugs at the 135% poverty level and pays 25% for all drugs above the 175% poverty level. He would limit the out of pocket expenses of seniors to $6,000 per year. The Vice President would limit all out of pocket expenses for prescriptions to $4000 and cover 50% of the prescription cost to $5000. Unlike his opponent, Vice President Gore would segregate Medicare funds into a "locked box" sequestering this portion of the Medicare surplus for future expenditures. Both candidates favor the patient bill of rights and improvements in the quality of care and reduction of medical errors (apple pie and motherhood). Whoever sits in the Oval Office after Election Day will have difficult choices regarding the future of medical care to address. For now, incremental expansion of insurance coverage but not universal coverage is the goal. Medicare recipients can expect subsidies but not a free ride on prescription coverage. And as for physicians, what's ahead? The Medicare surplus grows larger, as a consequence of our hard work. The funds may end up in a "locked box" if Vice President Gore is the winner, but we don't have the key. David Eskreis, MD
The New York State Department of Insurance (SID) has taken two distinct actions in response to the June 9, 2000 Supreme Court decision by Justice Gangel-Jacobs which declared the new no-fault regulations null and void on the grounds that the regulations were issued without a Regulatory Impact Statement and were in violation of the State Administrative Procedure Act.
The SID has taken the following actions:
The MSSNY is a plaintiff in the original litigation opposing these shortened notification periods and has also issued a statement in opposition to this new identical regulation promulgated by the SID. Physicians should be aware that until the Insurance Department wins its appeal or the Supreme Court rules in favor of the new regulation, the original 90/180 day notification periods remain in effect. The Society will keep its members apprised of any new events in this matter.
The current fines by company are:
The companies listed have paid fines imposed by the Department. They also acknowledge that they failed to pay claims promptly and agree to put corrective measures in place to avoid future violations. In addition to paying the fines, the law also requires the HMO's and insurance companies pay interest on late claims at the greater of 12 percent per year, or the corporate tax rate as set by the Commissioner of Taxation and Finance. The stipulation also mandates that all claims requiring the payment of interest be reported to the Department. Since the law went into effect in January, 1998, the Department has received over 67,500 prompt pay complaints. To register a prompt pay complaint, you can call the Department's toll-free hot line at 1-800-358-9260.
Brown and Williamson Tobacco Corp. last week filed suit in federal court against the state of New York over a new law that bans mail-order, telephone and Internet sales of cigarettes. The New York law was passed earlier this year and is set to go into effect next month.
Joseph Conway, spokesman for Governor Pataki, said, "The law is an important public health measure that will help save lives by preventing young people from obtaining cigarettes illegally. We're confident that the law is constitutional and that the lawsuit will be unsuccessful. "
Health insurers have generally agreed to cover the newly approved RU-486 abortion pill, according to a survey of leading managed care plans. Heavyweights Aetna, United HealthCare and Cigna, will cover the abortion pill as a standard benefit.
NEWS FROM
NASSAU COUNTY DEPARTMENT OF HEALTH You must give your patients current vaccine information statements under the new law. Before a health care provider vaccinates a child or an adult with a dose of DtaP, DTP, Td, MMR, varicella, polio, Hib or hepatitis B vaccine, the provider is required by the National Childhood Vaccine Injury Act (NCVIA) to provide a copy of the Vaccine Information Statement (VIS) to either the adult vaccinee or to the child's parent/legal guardian. The use of the VIS has been required since 1994.
According to the law, before administering the vaccine, you must give the patient or parent/guardian a copy of the most current VIS available for that vaccine. The patient should have time to read the VIS prior to administration of the vaccine. You must also record in the patient's chart the date that the VIS was given as well as the publication date of the VIS as appears on the bottom of the VIS. VIS forms are available from the following: The CDC web site at http://www.cdc.gov/nip/publications/
or from the Nassau County Department of Health Immunization Action
Program at 571-1680.
The Medical Society has developed a CME program on this topic which will be presented at the NCMS on December 13, from 6-9PM. Use the registration form on page 8 to register for this important program.
According to new guidelines issued by the US Dept. of Health and Human Services, effective immediately, physicians who accept reimbursement by Medicare and Medicaid qualify as recipient/covered entities and are obligated to provide foreign language interpreters for all their Limited English Proficiency (LEP) patients.
The OCR has assured the Society that, although this matter is rarely pursued, should a complaint be received, the matter will first be discussed and technical assistance provided before any legal action would be taken.
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The Vice President would expand the program to cover all
children in families up to 250% of the poverty level, and give a 25% tax
credit to all families for insurance coverage above this income group.
Neither candidate has a plan providing universal coverage to children
under any proposal.
Universal coverage for
adults is avoided by both candidates. Governor Bush is hopeful that
insurance buying conglomerates for small businesses and MSAs may fill
part of the gap for the uninsured. The Vice President is including
younger patients on Medicare but leaves a gap for many adults younger
than age 55 that are above the 250% poverty level. Universal coverage
remains too complex and politically risky for any candidate to approach.
The new no-fault
regulations would shorten the time period for an automobile accident
victim to notify the no-fault carrier of an accident from 90 days to 30
days. In addition, the shortened time period for a covered person, or a
physician assigned the no-fault benefits, to submit proof of a claim for
medical services would be 45 days instead of the original 180 days.
Superintendent of Insurance Neil D. Levin
announced on October 18, that the Dept. of Insurance has once again
levied fines against 21 health insurers and HMOs totaling $575,000 for
violations of the state's Prompt Pay Law. The fines paid in this, the
fifth round of prompt pay fines, exceed the total fines paid in all of
the previous four rounds. This is in keeping with the warning given by
superintendent Levin to the industry earlier this year. In an earlier
press release and Circular Letter number 6, both issued on January 27,
2000, the Superintendent advised that the Insurance Department would be
intensifying its investigation of prompt pay violations and seeking
tougher penalties for the insurers that have repeatedly violated the
statute.
The law bans sales practices that
"make it easier for children to get cigarettes and for smokers to
dodge the sales tax," according to legislators. But Brown and
Williamson said the law "interferes with interstate commerce, and
accuses the state of engaging in 'impermissible economic protectionism
at its most flagrant." David Remes, the tobacco
company's attorney, said the case is "the first of its kind in the
country and has implications beyond" the tobacco industry. Remes
added, "if all 50 states try to dictate their own rules for
e-commerce, it will be difficult for e-commerce to flourish."
A price has not been established by Mifeprex,
although including doctor visits and counseling, it is expected to cost
about the same as a surgical abortion, about $700. The difference
between the abortion pill and other new drugs is that it is only
dispensed directly from a physician's office and not through a pharmacy.
Thus plans such as United have decided to cover the abortion pill as a
standard medical benefit, rather than a drug benefit.
VIS's are also available for influenza,
pneumococcal and hepatitis A vaccines. Their use is recommended but not
required by federal law. They are not required because these additional
vaccines are not routinely recommended for children and, therefore, are
not covered by the NCVIA.
Health and Human Services' Office of Inspector
General has issued final guidance to help physicians in individual and
small group practices design voluntary compliance programs. "The
intent of the guidance is to provide a road map to develop a voluntary
compliance program that best fits the needs of that individual practice.
The guidance itself provides great flexibility as to how a physician
practice could implement compliance efforts in a manner that fits with
the practice's existing operations and resources," IG June Gibbs
Brown said. "We are encouraging physician practices to adopt the
active application of compliance principals in their practice, rather
than implement rigid, costly, formal procedures." Unlike other
comparable OIG guidance, the Compliance Program Guidance for individual
and small group physician practices does not suggest that physician
practices implement all seven standard components of a full-scale
compliance program. Rather, it emphasized a step-by-step approach to
follow in developing and implementing a voluntary compliance program.
Although the Office of Civil Rights
(OCR) will focus compliance review on large entities, such as hospitals,
this does not mean that the small practitioner can neglect his
obligations under Title VI. The OCR will investigate all complaints or
reports alleging possible noncompliance. However, the OCR will make its
assessment of the type of language assistance needed on a case-by-case
basis, focusing on whether the LEP patient and the physician can
communicate effectively. To do this , the OCR will take into
consideration factors such as the size of the medical practice, group v.
solo practitioner, cost of providing the interpreter, and the community
serviced by the physician.
Just a reminder - the new Medicaid fees for
selected E&M services became effective on October 1. The affected
codes are 99201-99205, 99211-99215, 99381-99385, and 99391-99395. All
these codes are payable, by Medicaid, at $30.
HCFA has announced new toll free telephone numbers
effective October 1, 2000.