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Reading....and reading....and reading - HR 3200 (Pages 255-304) - Lots of Questions on this part!

This post is #6 in an ongoing series of posts as I read through the entire proposed health care legislation, HR 3200.  You can visit my new blog site to see all of them in one place:

I am about 30% of the way through the bill at this point, having taken a break over the weekend.  As I expected, I have seen some very interesting stuff during my reading, most of which I haven't seen covered by the traditional media on either side.  This particular section revealed a pretty big error in need of correction.

Without further ado, please see my notes on pages 255-304 below.






Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 1395iii(b)(1)(A)) is amended to read as follows:

`(A) the period beginning with fiscal year 2011 and ending with fiscal year 2019, $8,000,000,000; and'.

MY NOTE: I looked at this section of the Social Security Act for a long time to make sure I wasn't getting loopy.  There IS no section (A) there at all under (1) for the Act, so it's not easy to figure out what is intended here. 

They may be adding $8 billion to the Medicare Improvement Fund, which runs counter to all of the other budget cuts made to Medicare earlier in the bill, or they could be replacing the $19.9 billion figure listed there currently with $8 billion, which would represent a $12 billion savings. 

Since there is a typo, the bill is not clear at all on this point, in my opinion.  My sense is that they are trying to cut the improvement fund to a more reasonable level, but this definitely needs to be more clearly written.  Here is the section of the Social Security Act as listed on the Social Security Administration website, if you're interested in seeing it for yourself:


(a) (C) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER PRESUMED UTILIZATION- In computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)), the Secretary shall adjust such number of units so it reflects a 75 percent (rather than 50 percent) presumed rate of utilization of imaging equipment.'

MY NOTE: This is one of the first places that I have found where actual medical services could be affected adversely, or lead to unnecessary rationing of care.  By increasing the utilization rate, the payment for each service is reduced significantly.  They were originally seeking to raise the utilization rate from 50% to 95%, but in an apparent concilatory gesture, reduced this to 75% in the bill. 

According to EVERY source I read on this topic, this increase in the utilization rate for imaging equipment would amount to a deep and arbitrary reimbursement cut for diagnostic imaging services.  If this happens, it could definitely limit access to life-saving services to detect cancer, etc. 

I found a letter that was written to the President and Congress urging them not to increase this rate.  The thirteen groups that signed the letter are: American Brain Tumor Association; American Pain Foundation; Black Women's Health Imperative; Brain Injury Association of America; Breast Cancer Network of Strength; Colon Cancer Alliance; Colorectal Cancer Coalition; Kidney Cancer Association; Lung Cancer Alliance; Men's Health Network; National Ovarian Cancer Coalition; Society for Women's Health Research; and Us TOO International Prostate Cancer Education & Support Network. 

Clearly, this is something that should be debated and studied more.  I must admit that I spent over an hour trying to understand the formula and the math behind this problem, but I couldn't quite get there.  


(d)(2)(C) applying a payment reduction for physicians who treat the patient during the initial admission that results in a readmission

MY NOTE: This is a very long section overall, and it deals with exactly what you would think.  Namely, they are looking for ways to adjust payments under Medicare both to hospitals and to physicians when patients are later re-admitted. 

It seems as though the assumption is that the facility and/or the doctor didn't get the job done the first time around.  I have mixed emotions about this one.  If the doctor did all that was in his/her power to heal the patient, should they be punished if that person gets sick again soon thereafter, necessitating another admission?  I don't know the answer - I just wanted to throw it out there as a point of conversation for all of us. 

(EDITED: After one of the comments I got on this post from Facebook, I thought it was pertinent to include here - my friend Joy Hilscher remarked, "Wouldn't doctors want to keep patients in the hospital longer than necessary just to make sure and avoid these fines? Seems to me that it would increase cost."  I must wholeheartedly agree.)

(e) Funding- For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services for the Center for Medicare & Medicaid Services Program Management Account $25,000,000 for each fiscal year beginning with 2010. Amounts appropriated under this subsection for a fiscal year shall be available until expended.

MY NOTE: As with the assessment of medical codes that I mentioned in my last post, this seems like a lot of money to budget every single year for this function.  I can understand a one-time expense, but allotting so much on an ongoing basis seems potentially wasteful.  I would prefer to see a mechanism for evaluating this each year.  If the money is provided, I have a tough time imagining that it won't be spent somehow, right?


MY NOTE: This section charges the Secretary of Health and Human services with developing a program to determine if acute care services can be bundled.  It also mentions taking into account gainsharing (doctors and hospitals both profit), anti-referral, anti-kickback, and anti-trust laws. In order to implement this portion of the bill, the Secretary is given $45,000,000 over a three-year period.  Yikes! 

(2) EXPEDITED DATA COLLECTION- Chapter 35 of title 44, United States Code shall not apply to this section.

MY NOTE: My first question upon reading this line was, "What is Chapter 35 of title 44 of the USC?"  Thankfully, it was easy to find the answer.

Here's a link to the "Purposes" section of title 44 if you want to see it for yourself:  As you can see, this code is intended to make reporting for federal agencies more streamlined and more transparent.  Why would this portion of the bill be exempt from that code?  In fairness, the next section calls for "public reports", but only "as the Secretary deems necessary".  What if he/she never deems public reports to be necessary?

As you can see, the pages I covered here are all dealing with Medicare in one way or another.  During my last post, I was encouraged by some of the ideas to trim costs and waste.  This portion, however, seems to involve a lot of spending, unless the aforementioned $8 billion is a reduction from the previously-approved $19.9 billion. 

I welcome your input!



Please see my note above about Section 1146 - this badly needs to be clarified.  As it is currently written, it's not possible to tell if this is calling for a new $8 billion expenditure, or a $12 billion savings. 



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