In March I called Barbara Lee's office to get an appointment to discuss the serious devolution of Medicare. I was told there was a crisis going on and the staff memeber in charge would have to call me back. She never did.
Dot, dot, dot...
At the end of my post, I went websurfing and found out the White House had issued a new executive order in March for OMB (office of managenment and budget) giving OMB power to review, deny, and write reimbursement schedules and other guidelines for CMS and FDA. The importance of this EO is that it completely by-passes the rule and regulatory system of Congress, charged with oversight and review of these executive branch agencies.
Congressional committees can review and pass, not pass, and hold hearings on these kinds of executive branch guidelines. Congress can also direct the executive branch agencies to perform this guideline review. This depends on how the original legislation was written.
This was most likely the crisis Lee's local office staff member was probably trying to sort out when I called in March. She probably just forgot to return the call. This WH crap was a big deal.
The reason March was so critical was that there was a building political pressure across the healthcare industries over proposed guidelines and fee schedule changes. Likely as not Congress was getting heat. The EO by the WH complete cut off any possibility of changes in these rules under the normal rule making process through Congress. OMB simply reviewed the guidelines and scheludes it liked, tossed the ones it didn't, wrote others as OMB saw fit, and directed CMS and the FDA to follow them. (CMS, Centers for Medicare and Medicaid Services)
CMS is currently under temporary appointment of Leslie Norwalk, since the last appointee quit after a year and a half. He had an MD and a PhD and probably went nuts.
Here is a recent letter Henry Waxman sent to The Honorable Leslie Norwark:
``This morning the Committee is holding a hearing on the response of the Department of Health and Human Services to the nation's emergency care crisis. Last Thursday, June 14, the Committee invited you to provide testimony on actions taken by CMS to address this crisis. Your staff has informed us, however, that you are unable to attend or send a representative on your agency's behalf.
The programs administered by CMS play a major role in the financing of the nation's emergency and trauma care system. Of the 115 million emergency room visits in 2005, over 40% were covered by Medicare, Medicaid, or SCHIP. Obviously, an understanding of your agency's views is essential to an assessment of the Department's response to the emergency care crisis. I therefore request that you supply answers to the following questions:
l) What actions, if any, has CMS taken to address the boarding of admitted patients in emergency rooms at hospitals receiving Medicare or Medicaid funds? If CMS has taken no action to address this issue, please supply your rationale for such inaction.
2) What actions, if any, has CMS taken to address the diversion of ambulances from emergency rooms at hospitals receiving Medicare or Medicaid funds? If CMS has taken no action to address this issue, please supply your rationale for such inaction.
3) What actions, if any, has CMS taken to address the decrease in coverage by on-call specialists at hospitals receiving Medicare or Medicaid funds? If CMS has taken no action to address this issue, please supply your rationale for such inaction.
4) What actions, if any, has CMS taken to address the adverse health consequences of emergency room crowding, the boarding of admitted patients in ERs, and the diversion of ambulances on Medicare and Medicaid beneficiaries? If CMS has taken no action to address this issue, please supply your rationale for such inaction.
5) CMS has issued a final rule that would limit Medicaid payments to government providers, including safety net hospitals that furnish emergency care and level 1 trauma services. (72 Fed. Reg. 297 48 (May 29, 2007)). In developing this proposal, did CMS seek the opinion, formal or informal, of the Office of the Assistant Secretary for Preparedness and Response (OASPR) as to whether the proposed rule would have an adverse effect on the nation's disaster preparedness? If not, please explain why CMS did not seek the OASPR's opinion on this matter. If so, please provide a copy of any document received from the OASPR relating to its opinion on this matter.
6) CMS has issued a proposed rule to eliminate federal Medicaid matching payments for the costs of Graduate Medical Education (GME), including the costs of residents who staff emergency rooms and trauma centers. (72Fed. Reg. 28931 (May 23,2007)). In developing this proposal, did CMS seek the opinion, formal or informal, of OASPR as to whether the proposed rule would have an adverse effect on the nation's disaster preparedness? If not, please explain why CMS did not seek the OASPR's opinion on this matter. If so, please provide a copy of any document received from the OASPR relating to its opinion on this matter.
7) In its June 2006 report, The Future of Emergency Care, the Institute of Medicine (IOM) recomended that "CMS should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring and enforcement of these standards." What actions, if any, has CMS taken to implement this recommendation? If CMS has taken no action to implement this recommendation, please supply your rationale for such inaction.
8) In its June 2006 report, IOM recommended that CMS "remove the current restrictions on the medical conditions that are eligible for separate clinical decision unit (CDU) payment." What actions, if any, has CMS taken to implement this recommendation? If CMS has taken no action to implement this recoÍrmendation, please supply your rationale for such inaction.
9) A recent GAO study concludes that Medicare payments for EMS services are 60% below the average cost of an ambulance transport, and l7% below cost in super-rural areas. (U.S. Government Accountability Office, Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly (May 2007) (GAO-07-383). What actions, if any, does CMS intend to take to address the GAO findings? Please submit your responses by Friday, June 29, 2007. If you have any questions regarding this inquiry, please contact Art Kellermann at 225-5056.''
So what did the ad hoc appointed, temporary Leslie Norwalk say for herself? She wrote or had written a long letter (too long to post) that was a flat out stonewall---but of the verbose variety. When Waxman asked what actions had been taken, Norwalk described existing projects, many of which had little direct bearing on the issue at hand. Those on-going projects that did have relevance, were simply described from their guidelines, as if Norwark was carrying out the project, when in fact, the question was why hasn't the project been carried out. Answers to other questions amounted to saying, we are taking that question under advisement, or we have some group studying the matter.
For those interested in seeing the kind of high handed bullshit coming out of the executive branch functionaries, go to Waxman's site and download the June 29, 2007 file, `CMS Response to Chairman Waxman's Inquiry.'
None of this kind of absurdity gets on the news. That's why information is still a radical thing to do. You just have to dig it out and put it together, and then write easy to understand summaries with referrence back to source---so those who want to pursue it can.
And what's the latest word on the temporary, ad hoc Leslie Norwalk? Here you go. Read it and laugh:
``Daily Health Policy Report Administration News | CMS Officials Norwalk, Kocot To Leave Agency on July 20 [Jul 16, 2007]
Acting CMS Administrator Leslie Norwalk in an e-mail sent on Thursday told agency employees that she will leave the agency on July 20, CQ HealthBeat reports.
CMS employees "administer some of the most important programs in the world -- the number of lives we touch, the importance of the health care services we cover and the amount of taxpayer dollars we spend mean that all the world watches us," Norwalk, who served at the agency for six years, wrote in the e-mail. She added, "People often ask me about my greatest achievement at CMS. Some will imagine that it's the implementation of the drug benefit, the Medicare quality initiatives or revamping the Medicaid program. But those aren't even close. I'm most proud of the team that will lead CMS through its next phase of growth."
The Senate Finance Committee has scheduled a July 18 hearing to consider the nomination of Kerry Weems to serve as CMS administrator. Norwalk previously withdrew herself from consideration for the nomination.
Separately, S. Lawrence Kocot, senior adviser to the CMS administrator, on Friday said that he also will leave the agency on July 20 "to pursue some of my professional and personal goals and interest in the private sector." Kocot said that he decided to leave CMS "after much reflection" with his family and that his tenure at the agency "has been the most fascinating and rewarding experiences of my...''
So long Leslie, so long Larry.
CG