the necessary changes could not be accomplished overnight and that ultimate success will depend upon the good faith of all parties, the administrative skills of the participants, and a better understanding within and between the executive and legislative branches of government. However, the potential benefits of such an improved relationship are of great importance and the potential payoff tremendous. Some immediate things that can be done are: (1) The Commissioner of Social Security, following the suggestions made at the Belmont Conference on the Administration of Medicare,* should supply the personal leadership to develop a means, formal and informal, for joint government-private sector consideration of contract policy issues, leading to a statement useful as a guideline for the multiplicity of actions and decisions of all parties. This policy cannot be successfully developed or implemented unilaterally. In the carrying out of the means developed, the continuing participation of the Commissioner and his Deputy will be essential if success is to be achieved. (2) A joint review by SSA and the contractors should be made of the organization of Medicare administration to consider the number and jurisdiction of contractors and the systems of communication between them and SSA. (3) A SSA-contractor system of cooperation on proposed legislative changes which bear on contractor relations should be developed. All parties should enter into discussions with the appropriate legislative committees so that the Congress is appraised of what is going on. (4) A joint SSA-contractor study should be undertaken before the next series of contracts are signed, aimed at making recommendations for moving towards the goal of increasingly shared responsibility. (5) Both SSA and the contractors should examine their internal management systems and the interfaces between and among them to see if they are consistent with increased responsibility and public accountability for the contractors. (6) Title XVIII Section 402 of the Social Security Act as amended provides encouragement for a variety of administrative experiments. This congressional direction should be vigorously pursued toward the SSAcontractor goal of a more effective private sector role. * See Summary of the Proceedings of the Belmont Conference on the Administration of the Medicare Program, National Academy of Public Administration, Washington, D.C., 1973. MEDICARE PROJECT PANEL Richard C. Brockway (Co-chairman) The National Health and Welfare Retirement Association Phillip S. Hughes (Co-chairman) John A. Perkins Vice President for Administration Professor William B. Storm James E. Webb STAFF Neil Hollander Project Director Senior Research Associate Robert G. Joyce Sarah Jo Melender Donna Gallia Secretaries CHARTER A Joint Project of the National Academy of Public Administration And the Social Security Administration for the Improvement of Contractor Operations in the Medicare Program I. Background The Medicare Program, now in its fourth year of operation, is administered by the Social Security Administration (SSA) under the provisions of Title XVIII of the Social Security Act, in large part, through contracts with intermediaries and carriers. These organizations, as contractual representatives of SSA, are charged with the responsibility of determining the coverage of services rendered to beneficiaries under the program and the payments due the providers of such health care and the suppliers of such medical services and of making such payments. They are also responsible for performing certain related administrative services such as disseminating program information to providers and auditing their records. The contractual relationship is complex in its service requirements and in its interface with SSA. With regard to Part A of the program, an intermediary, to be selected, must first be nominated by the providers of services and SSA must determine that the selection is administratively sound. With regard to Part B of the Program, no nomination is involved and SSA selects carriers to serve an assigned geographical area. The Social Security Administration is concerned with optimizing the effectiveness of contractor operations, providing effective measures of contractor performance, and improving the relationship between contractors and the Administration. It is SSA's judgment that a concentrated examination of the experience of the past four years and of current issues and problems, and a careful search for innovations or new boundaries can be productive in defining improvement possibilities and accomplishing such improvements. It is the further judgment of the Social Security Administration that a prestigious, disinterested, highly professional third party by reason of its great experience, knowledge, and objectivity could contribute greatly to furthering this effort by bringing an independent point of view to bear on how to achieve optimum effectiveness in the performance of the responsibilities assigned by statute and contract to contractors. At the level of competence and prestige we envisage, such a third party could be extremely helpful also in exploring new dimensions and directions, in developing new channels of exchange and communication, and in acting as an independent agent for the presentation of possible program innovations involving the roles or responsibilities of contracting organizations. With these considerations in mind, the Deputy Commissioner of the Social Security Administration, the Assistant Commissioner for Administration, and the Director of the Bureau of Health Insurance engaged in an exploratory dialogue with the National Academy of Public Administration. The National Academy was represented by George A. Graham, Executive Director and Secretary; James E. Webb, Treasurer; 76-614 O 76 - 8 and Neil Hollander, Research Associate. These exchanges were supplemented by a feasibility survey made over the course of a month by Mr. Hollander, which focused particularly on the administrative relationships between the Social Security Administration and the operating contractors. These exchanges and this brief survey generated an agreement on basic principles and approaches, and an expressed interest by the National Academy in participating in an undertaking of this kind. This Charter summarizes the agreement and defines the objectives and approaches of the National Academy and the Social Security Administration. II. Objectives The project, through a series of interacting programs and activities over the course of three or more years, is intended to accomplish the following primary objectives: (1) An exploration and definition of mission objectives and values on the part of SSA and on the part of intermediaries and carriers for the purpose of reconciling such objectives and values in the interest of the most effective accomplishment of program purposes. Essential to this activity is a recognition of the constraints imposed by the statute and the legislative history, the diligent exercise by Congress of its legislative oversight functions, the role of other elements of the Department of Health, Education, and Welfare, such as Office of the General Counsel, Audit Agency, Community Health Service, Social Rehabilitation Service, etc., and the strong concerns and interests of a very great variety of other organizations, such as the American Hospital Association, American Nursing Home Association, American Medical Association, etc. Also the role and concerns of the State certifying agencies and State Welfare Departments. (2) An analysis of the effectiveness of existing arrangements for SSA oversight and surveillance of contractor operations, including the measurement of the effectiveness of contractor operations. (3) An analysis of attitudes, postures, and administrative practices within SSA and within the intermediaries and carriers to determine consistencies or inconsistencies with defined mission objectives and values. (4) Development and conduct of programs designed to make changes and produce attitudes and postures that would contribute more effectively to the cooperative achievement of program objectives. (5) Development of contractual arrangements and the use of contractual terms that would both clarify and improve roles, relationships, responsibilities, and expectations as between the two parties. (6) Identification of administrative devices and approaches found effective in similar settings and their application in some form to the SSA context for the purpose of securing good, mutually productive contractual relationships. (7) The exploration and possible testing, within broad parameters of programs and social considerations, of administrative arrangements in lieu of or to supplement present SSA/contractor administration. III. Organization of National Academy Effort The Academy will establish a five-man panel to plan, organize and conduct the Academy's activities in the project. This panel will include at least three members of the Academy. Panel members, from the Academy or outside of the Academy, will be selected on the basis of individual abilities, general administrative knowledges, and broad social and administrative interests. The panel will include individuals who are experienced and interested in the relationship between the private and public sectors and the use of private contractors in the public service. Specialists in medical care administration will not be included on the premise that representation of specialized interests or points of view would inhibit establishment of the best rapport and work relationships among all parties. Technical specialists will, however, be called on for assigned tasks as the need arises. Panel members will commit a substantial portion of time to the project over the next several years. The panel will function as a working entity rather than a body acting primarily to observe, comment and advise. Meetings of the full panel, for assessment of work status and redirection of efforts, will be held several times during the year and will last for as much as three days each. In addition to panel meetings and structured work assignments with responsible officials and organizational entities in both the public and private sectors, the panel will spend a substantial part of its time in informal work relationships with staff involved in the Medicare program. This will include on-site visits to intermediary and carrier organizations, providers of service, and day-to-day dealings with SSA executives and staff. The purpose of these visits will be to develop an understanding of operational methods and problems, to relate these to successful administrative practice in other endeavors, and to develop information and judgments for fruitful lines of study and for recommended lines of action. Over time, individual members of the panel will be given the responsibility to focus on specific issue areas or functional parts of the project. Thus, by way of example, one of the members may apply himself to the auditing process as it affects incentives to improved contract administration. The panel will be assigned a member of the Academy staff for support activities. He will spend approximately three-fourths of his time on the panel in the preparation of materials, reports, and on a day-to-day basis to facilitate its activities. He will be responsible for administering the activities of the panel and for day-to-day liaison and work with SSA staff assigned to the project. IV. Program of Academy Activities The program contemplated by the Social Security Administration and the National Academy is projected, at this stage, in general terms for a period of three years, beginning in fiscal year 1971. The details of activities will be further specified in initial planning meetings of SSA officials and the Academy panel; these plans will be periodically reviewed and adjusted in other such joint meetings. At the end of three years, the Medicare program situation and the assistance rendered by this project |