Future of Medicare Package Remains Unclear

Abstract

For those who like suspense, intrigue, and uncertainty, the final months of the first session of the 110th Congress can only be described as riveting. For those who prefer an orderly process and foreseeable outcomes, the congressional activities of November and December were maddening. Last November 2007, the Senate Finance Committee began meetings of its members in an effort to reach agreement on a Medicare package that would include changes in the current end-stage renal disease (ESRD) program. These discussions lasted until the Thanksgiving recess and then resumed when Congress returned in early December. With no agreement in sight, Finance Committee chairman Max Baucus (D-Mont.) announced on December 6, 2007, that he was terminating the process of trying to reach committee agreement and that he would begin direct negotiations with the House on what he assumed was the committee position. Based on numerous meetings with senators and staff, the kidney care community believed significant progress was being made as the Senate Finance Committee members discussed the ESRD program with the House. Led by Senator Kent Conrad (D-N.D.), a group of Finance Committee members insisted on improvements in the provisions that passed the House last August. It appeared likely that the Finance Committee package of Medicare reforms would be more equitable to dialysis providers and contain positive provisions concerning chronic kidney disease education, demonstration projects, technician certification, and other sections in the House-passed bill. The Finance Committee package was believed to have contained a bundling provision but with a better reimbursement system. The House-approved bundling provision directed the Centers for Medicare and Medicaid Services to create a bundled payment system for dialysis services at a payment rate of 96% of total estimated payments for all ESRD services as if there were no bundled system. By only delaying for six months the reduction in physician reimbursement, Congress essentially guaranteed that another Medicare bill will be considered this spring. The current ESRD program will again be debated in Congress this year and major reform may be only a few months away. A vote on the Medicare package was to take place later in the day. However, House leaders announced that the Medicare vote would be delayed for two days until a new House package would be added to a bill providing relief from the Alternative Minimum Tax (AMT). But when the morning of December 12 arrived, the Medicare package was no longer a part of the AMT bill. It then appeared that the House would consider its own version of Medicare reform as a freestanding bill and that the measure would be brought to the House floor for a vote on Wednesday, December 13. Then, Wednesday night, the House leadership announced that a vote on the Medicare package would take place the week of December 17, the last week that Congress was in session before recessing for the holidays and for the end of the first session. On December 13 Speaker Nancy Pelosi (D-Calif.) said, “The House will not be originating a Medicare bill.” This left it up the Senate to go first. Where are we now in the legislative process? The ESRD provisions in the House-passed Children's Health and Medicare Protection Act (CHAMP) were not included in the Medicare package that was ultimately approved by the Senate and House and signed into law by the president. Nor did the legislation include an update in the composite rate for this year. What Congress did do was delay the scheduled 10% reduction in physician reimbursement until June 30 of this year and extend a number of other primarily rural-based provisions for the same period. It also reauthorized the Children's Health Insurance Program through March 2009 and provided it with additional funding. By only delaying for six months the reduction in physician reimbursement, Congress essentially guaranteed that another Medicare bill will be considered this spring. Democratic leaders in the House are taking the position that the Medicare package that was passed last summer as part of the CHAMP Act is still pending, leaving it up to the Senate to produce a Medicare bill. The bottom line is that the current ESRD program will again be debated in Congress this year and that major reform may be only a few months away.