Mixed Reactions to Medicare Bill from American Medical Assn and Specialty Groups

Strategic Insights -

The Medicare bill recently passed by the House of Representatives has drawn mixed reactions from the American Medical Association (AMA) and specialty groups. While the bill includes patient-protecting provisions such as quality assurance, appeals and grievances, and disclosure, it fails to include rules governing due process, utilization review, and emergency coverage that the groups had been lobbying for. The AMA's Trustee, Thomas Reardon, MD, notes that the bill is a significant step towards addressing patient and physician rights, but acknowledges that it does not meet all of the AMA's expectations.

Key Takeaways:

  • The Medicare bill includes four pages of patient protection standards, including provisions for annual disclosure of benefits, cost-sharing liability, and prior authorization by MedicarePlus organizations.
  • The bill shields doctors from sole legal responsibility when a managed care plan's coverage rules conflict with clinical decisions, thanks to an amendment by Rep. Greg Ganske, MD (R, Iowa).
  • The bill clarifies when MedicarePlus organizations can limit patient access to providers and sets a maximum out-of-pocket payment level for out-of-network and point-of-service coverage.
  • The bill requires plans to establish an on-going quality-assurance program for health care services, which the AMA has been pushing for.
  • The bill would force HHS to contract with an independent group to resolve appeals of denials of coverage related to urgent or emergency services.
  • Managed care groups welcomed the removal of provisions that had rankled the industry, including one that would have barred MedicarePlus plans from denying participation by health care professionals based solely on licensure and certification.
  • The bill does not include a mandatory point-of-service provision, despite attempts by Reps. Ganske and Coburn to add it.
  • The bill's biggest headache for managed care groups is a provision added by Dr. Ganske that would ban hold-harmless clauses, which do not belong in legislation according to Blue Cross and Blue Shield Assn Executive Director Henry Bachofer.

Statistics:

  • 4 pages of patient protection standards are included in the Medicare bill.
  • 2 out-of-network service provisions are clarified in the bill, one of which sets a maximum out-of-pocket payment level.
  • 1 quality-assurance program is required by the bill for health care services, which must include written protocols for utilization review and provide review by physicians and other health professionals.
  • 90 seconds is the time limit within which the notice of denial of emergency services must be issued under the bill.
  • 24-25 vote was the margin by which an amendment offered by Rep. Sherrod Brown (D, Ohio) passed, protecting non-board-certified physicians from being left out of networks.
  • 30 minutes was the time limit within which an HMO must authorize emergency services, as proposed by Dr. Ganske's amendment, but ultimately not included in the final bill.

Sources:

  • Thomas Reardon, MD, American Medical Association Trustee
  • Rep. Greg Ganske, MD (R, Iowa)
  • Rep. Pete Stark (D, Calif.)
  • Rep. Sherrod Brown (D, Ohio)
  • Julie Goon, Group Health Assn. of America's legislative affairs director
  • Henry Bachofer, Executive Director for Legislative Policy, National Blue Cross and Blue Shield Assn.
  • Energy and Commerce Committee
  • Ways and Means Committee