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Review News Ophthalmology Seeks a Voice in the Elecetion, and MoreSenate Joins Debate on Glaucoma Screening Bill HCFA
Expands AMD Reimbursement Catherine Cohen, the AAO’s vice president of federal affairs, says the Academy maintained an active presence at the Republican and Democratic national conventions. Although it will not be endorsing a presidential candidate, Ms. Cohen says the AAO is making its voice heard. “It’s all about advancing ophthalmology’s legislative agenda,” she says, adding that the AAO is working with the American Medical Association to make health care, specifically patients’ rights, a major election issue. The AAO was part of a health-care community group that sponsored an event for House members at the GOP convention in Philadelphia, in part thanking them for their vote on the Quality Health Care Coalition Act of 2000. The “Campbell Bill” puts physicians a step closer to negotiating contracts with managed care companies. The main focus, however, was the Patients’ Bill of Rights. That bill passed comfortably through the House but was a battle in the Senate, where it became a much narrower version on its way to a presidential signature. It’s now in the hands of the Patient Protection Conference Committee, with its members charged with merging the House and Senate versions. The AAO has joined the Patient Access Coalition (PAC), comprising 129 medical societies, in its concern that the bill passed by the Senate is limited to only those 48 million Americans covered by self-insured plans. The House measure would cover all of the approximately 160 million Americans with private health coverage. “The Senate version is a far cry from the true patient protections that all Americans deserve,” says Ms. Cohen. “To be a true patient protections bill, the reforms must be available to all patients in managed care.” The Academy maintains that any patient protection bill must contain a point-of-service option at the time of enrollment that allows patients to seek care outside the plan; a ban on financial incentives that result in the withholding of care or denial of referrals; adequate in-network access to specialists; a consumer information checklist, including performance measures for health plans; a timely appeals process and a ban on gag clauses. The House and Senate bills are also far apart on the right to sue. The House bill calls for a lift of federal bans on lawsuits for those in managed care plans. Injured patients can sue a health care-provider in state or federal courts for unlimited damages. The Senate bill gives no new right to sue. While the measure is being considered (at a snail’s pace, according to the AAO), the PAC has been putting pressure on Senate Republicans up for re-election to pass comprehensive patient protection legislation. Four Republican senators have recently sided with patients, leaving the Senate just one vote away from endorsing the same fundamental patients’ rights the House passed when it approved the Norwood-Dingell bill by an overwhelming bipartisan majority. The PAC’s focus is swaying legislators; the presidential candidates appear to be in line with the basics of the bill. “Clinton/Gore have been strong on patient protection, and Gov. Bush, on the state level, let it become law,” says Ms. Cohen. The AMA took its patients’ rights campaign to the GOP convention floor by conveying a message on a giant electronic billboard. The message, “Good enough for Bush. Good for America’s patients. Senate GOP: Pass a real patients’ bill of rights,” flashed across 32 television screens every five minutes for 19 hours each day. The AAO joined a coalition of patient and doctor groups that ran ads in August in 37 U.S. newspapers, calling on voters to demand “a real patients’ bill of rights and not another HMO protection act,” like the Senate bill. With the budget surplus in mind, Cohen said the AAO is looking for relief from the 1997 budget cuts. “The hospitals got relief last year, along with the nursing homes, and there’s sympathy in Congress that physicians are still receiving cuts—and is that really fair in such a surplus environment?” says Ms. Cohen. “Some of our key sight-saving surgical procedures, cataract surgery and corneal transplants, still have scheduled cuts in the next two years, so we want those halted.” Two physicians had the opportunity to share the AAO’s views with policy makers at the conventions. David Pao, MD, an ophthalmologist with three offices in suburban Philadelphia, was as an alternate delegate at the Republican convention. He said his mission was to supply GOP policymakers with input they rarely hear: a medical doctor’s prescription for improving health care. “The thing that I got was, ‘Hey, you are the first physician we have seen here,’ ” he says. “I got a chance to meet some of my local legislators first hand, and now I have more access to them.” Dr. Pao believes most physicians are Republicans because they realize that what the Democrats want or promise can never be given. “It would leave too much bureaucracy and debt,” he claims. “I’m a Republican because of the bureaucracy I want to reduce. I want to get government out of our lives as much as we can, and I want reduced taxes.” While attending a dozen endorsement meetings, Dr. Pao echoed the AAO’s view that managed care often sacrifices patient care for profits. He also stated to legislators that he opposes the practice of health insurance firms rewarding doctors for withholding treatment. “I think that the Democrats have a better emotional feel on universal health care, and the Republicans have a better physical or responsive feel, but they don’t show it,” says Dr. Pao. Dr. Pao agrees with the House version of the patients’ rights bill, particularly the passage stating independent, qualified medical professionals, not health plan administrators, should make medical decisions. The Senate plan requires that external reviewers use the health plan’s definition of “medical necessity” when making coverage determinations. “I stressed to legislators that medical decisions should be made by physicians,” he says. “Also, you have to define what medical doctors are, not by Medicare’s definition of physicians.” Dr. Pao says the physician—someone who is licensed to practice medicine as a medical doctor—must make the decision. Donald Schwartz, MD, an ophthalmologist with a private practice in Long Beach, Calif., attended evening events at the Democratic convention in Los Angeles. He was able to rub elbows with delegates and legislators at a healthcare-sponsored event honoring House/Senate health-care champions. Although Dr. Schwartz says it was difficult getting the undivided attention of legislators during the less business-like night festivities, he looks forward to building their support on such topics as the new glaucoma detection initiative that “would allow patients of the appropriate age and risk group a screening examination.” The Medicare Glaucoma Detection Act would provide coverage of a glaucoma detection eye examination for Medicare beneficiaries at a higher risk of developing glaucoma. With the budget surplus in mind, the AAO has been pushing to have this provision included in any Medicare bill considered by Congress. One other area that Dr. Schwartz would like to pursue with legislators is appropriate care and medical savings accounts (MSA), which he “believes strongly in on a personal basis outside of ophthalmology. I think that should be expanded.” An MSA allows individuals to fund health care. It is a tax-deferred bank or savings account set up for individuals and families to pay for their health-care expenses and medical insurance, and to allow them to accumulate savings to pay for future medical expenses and for more general uses after retirement. A former active member of OPHTHPAC, he was marking a 40th anniversary of sorts. In 1960, he shook hands with nominees John Kennedy and Lyndon Johnson on the convention floor when he attended the Democratic convention in Los Angeles, courtesy of a high school press pass. “I don’t think the candidates are as clearly defined as they were in the past on medical issues-it’s more of an issues type of vote than a partisan vote,” says Dr. Schwartz. Senate Joins Debate on Glaucoma Screening Bill The AAO is one step closer to achieving its goal of getting the first blindness prevention benefit included under Medicare. Last month, Senators Chuck Robb (D-Va.) and Lincoln Chafee (R-R.I.) introduced S. 3024, “The Medicare Glaucoma Detection Act of 2000,” a bill containing language developed by the Academy that calls for a Medicare-covered glaucoma detection exam every two years for individuals at high-risk of developing the disease. Its companion bill, H.R. 2620, the “Medicare Glaucoma Detection Act of 1999” was introduced in the House last July by Rep. Mark Foley (R-Fla.), and it continues to gain cosponsors. The benefit would consist of a dilated eye exam with an intraocular pressure measurement, and direct ophthalmoscopy or slit-lamp biomicroscopic exam. The Academy and the bills’ cosponsors continue to fight for the provisions to be included in any Medicare reform packages to be considered in both chambers later this year. In July, the Academy sent an alert to its members urging them to contact their Congressional representatives about cosponsoring H.R. 2620. A sample letter can be found at www.eyenet.org/member/ comm/federal_affairs/glaucoma_letter.html. As Congress considers repealing cuts mandated in the “Balanced Budget Act of 1997,” the AAO has called on its members to make the detection exam the first blindness prevention benefit under Medicare. Ken Tuck, MD, president of the Academy, says these bills are the first step to help seniors get the preventive exams they need in a fiscally responsible way. “ The language we provided for both bills will fill a shameful void that exists under Medicare,” he says. “Glaucoma afflicts more than three million Americans, half of whom are unaware that they have the disease, and an estimated 120,000 are legally blind because of it.” HCFA Expands AMD Reimbursement Iridex Corp. reported that the Health Care Financing Administration (HCFA) issued an updated Program Memorandum, Change Request 1278, that changes the coverage policy for Medicare reimbursement of many age-related macular degeneration (AMD) procedures. AMD procedures that use the company’s Iris Medical OcuLight infrared laser, such as transpupillary thermotherapy (TTT), destruction of macular drusen, and feeder vessel technique, can now be submitted to Medicare for reimbursement. Change Request 1278, implemented September 4, 2000 and effective July 18, 2000, instructs local medical carriers that, “Both coverage and payment for these procedures are carrier determined.” Previous policy, outlined in Change Request 1214 and implemented July 1, 2000, had instructed local medical carriers to “deny such claims as experimental.”
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