Groups flood HCFA with Medicare+Choice input

Many say program needs modifications

Ever since HCFA published its interim final rule establishing the Medicare+Choice Program on June 26, various provider organizations have been preparing and filing their comments and recommended changes in anticipation of the program’s official Jan. 1 launch.

Provider groups such as the Washington, DC-based American College of Physicians - American Society of Internal Medicine (ACP-ASIM), while generally supportive of the rules implementing the Medicare+Choice program, also are wary of the potential "hassle factor of too much paperwork and bureaucratic red tape the rules could inflict on physicians, other health care professionals, and managed care organizations," says the group’s president, Harold C. Sox, MD.

Key areas of concern include:

1. Beneficiary information. One ACP-ASIM member recently complained to the organization that a plan was consistently providing inaccurate physician panel information to patients seeking to enroll with the plan. "When patients asked if the doctor in question was in the plan, the plan responded that they had a doctor with the same last name," says John Moulin, director of managed care and regulatory affairs for ACP-ASIM. After looking into the situation, ACP-ASIM discovered that not only was there a different physician with the same last name, but the physician was located in a different city as well.

"Physician directories are out of date almost from the instant they are printed; for this reason, patients must be able to access more current physician directory information though telephone contact with the managed care plan and through the Medicare Compare Internet Web site," says Moulin.

Physicians: Tell us when patients switch plans

To avoid problems, ACP-ASIM recommends that HCFA make sure each patient knows that his or her current physician may not participate with a Medicare+Choice plan before the patient makes a change to a new Medicare+Choice plan. In addition, ACP-ASIM contends, the primary care physician treating the patient must be notified of the patient’s decision to switch to a new plan when the patient informs the plan. Whenever possible, the specialty care physicians currently treating the same patient also should be informed of the change.

"Often, the physician is not informed or is informed only after the patient has been seen several times after changing to a different plan of which the physician is not a member," says Sox. "At this point, the patient is liable for the cost of care, and it is often very difficult to collect for services provided once that happens."

2. Beneficiary protections. ACP-ASIM supports the requirements for Medicare+Choice organizations to assume financial liability for emergency services; urgently needed services; renal dialysis services; post-stabilization care services; and services denied by the Medicare+ Choice organization for which enrollees are found upon appeal to have been temporarily eligible while outside the plan’s service area.

ACP-ASIM also supports the requirement that upon enrollment, Medicare+Choice organizations must disclose to each enrollee clear, accurate, and standardized information on various procedures and coverage including information about the plan’s service area, benefits, access, out-of-area coverage, emergency coverage, supplemental benefits, prior authorization rules, grievance and appeals procedures, disenrollment rights and responsibilities, and information about the organization’s quality assurance program. Also, ACP-ASIM supports the requirement that upon request, Medicare+Choice organizations must provide additional information on utilization control procedures, the financial condition of the organization, and a summary of physician compensation arrangements. Medicare+Choice organizations also should be required to disclose their plan procedures for the termination of physicians and other plan health care professionals, ACP-ASIM stated in its response to HCFA.

However, the group says the termination notification requirement for physicians is inconsistent and needs to be standardized. For instance, under the proposed rule, when a contracted primary care physician is terminated, Medicare+Choice organizations must make a good-faith effort to give all enrollees who regularly see the physician written notice of that physician’s termination within 15 days of that provider’s receipt or issuance of a termination notice.

The requirement for specialty physicians is stronger. Under ACP-ASIM’s preferred approach, Medicare+Choice organizations must inform beneficiaries at the time of termination of their right to maintain access to specialists, and provide the names of other Medicare+Choice plans in the area that contract with specialists of the beneficiary’s choice, as well as an explanation of the process the beneficiary would need to follow should he or she decide to return to regular Medicare.

3. Quality. ACP-ASIM is concerned that because Medicare+Choice’s Quality Improvement System for Managed Care (QISMC) regulations have not yet been issued, this will make it especially difficult to achieve the program’s quality goals. "We also understand that managed care organizations are concerned that the implementation rate of two new performance improvement projects each year is overwhelming." says Sox. "We are concerned that the rapid rate of implementation will overrun physician offices with data collection requests for information that is not central to patient care." As such, ACP-ASIM does not feel it is right for HCFA to institute a quality process that has unrealistic expectations, which could lead to faulty implementation and create new hassles for physicians and other health care professionals, Sox says.

The group also says the provision requiring plans to maintain a health information system that collects, analyzes, and reports data also is unrealistic, especially for non-network Medicare+ Choice Medical Spending Account plans and Medicare+ Choice private fee-for-service plans. "This requirement will create an inordinate burden for plans and their associated physicians, who will be responsible for data collection and reporting to plans," says Moulin. "Furthermore, Medicare+ Choice plans are unprepared to deal with the potential volume of data they would be required to collect, analyze, and report."

4. Limitations on provider indemnification. ACP-ASIM supports HCFA’s proposal prohibiting Medicare+Choice organizations from requiring physicians and other health care professionals to indemnify the Medicare+Choice plan against any civil liability for damage caused to an enrollee as a result of "denial of medically necessary care."

"This prohibition recognizes that a managed care plan’s refusal to authorize treatment sometimes results in harm to patients," says Sox. Also, provider groups want HCFA to expand this provision to recognize that harm to a patient can sometimes result from a physician simply following the Medicare+Choice plan utilization protocol, which can look like failure to deliver medically necessary care after the fact.

In its comments to HCFA, the Health Insurance Association of America (HIAA) said that scheduled 1998 payment increases to providers could "disappear" because the funding will be diverted to pay for the beneficiary education program in the form of "user fees" on participating health plans. Instead, the Administration should seek the authority to finance this program from the Medicare trust fund, says HIAA.

HIAA also opposes the 2% limit on payment increases to plans. "Simply stated, organizations cannot sustain such arbitrary limits on capitation rate increases," the association says.

The capitated rate was set in the Balanced Budget Act of 1997 and implemented in the interim final rule. "HIAA is urging Congress to reconsider these artificial and arbitrary limits on capitation rate increases," the organization says. Without reconsideration, Medicare+Choice organizations may withdraw from the program or increase health plan premiums, leaving the program "only a shadow of what it has the potential to become," the association remarks.

Addressing concerns that HMOs would choose not to participate in Medicare+Choice, HIAA President-elect Chip Kahn said at a Sept. 17 press briefing that it will take three or four years to judge whether the program has been successful in attracting providers. He explained that the program would evolve, and noted he had spoken to "a number of companies" looking at various kinds of Medicare+Choice products.

Addressing a separate provision requiring plans to use encounter data for purposes of risk adjustment, HIAA requests that the agency seek a "less burdensome basis for [formulating] risk adjustment data," such as a survey-based approach. "Such requirements would create a significant hurdle for new entrants wishing to serve as Medicare contractors and might well deter participation," the association asserts. "We encourage HCFA to continue exploring alternative methodologies for risk adjustment."

After considering these and other comments, HCFA hopes to unveil any changes it feels are appropriate around the end of the year.