outside advice. Non-governmental input into federal policy making is an integral part of our democratic process. We strongly recommend that HIBAC be continued and assigned a meaningful advisory function. SECTION 41-AMBULANCE SERVICE This section would provide Medicare coverage for ambulatory service to hospitals other than the nearest hospital if the nearest is not adequately equipped and staffed to provide the necessary treatment. This solves only part of the identified problem with coverage for ambulatory service. While it addresses the obvious need for adequate faciilties, it ignores the desirability of having the patient treated by his personal physician. When treatment is provided by another physician, unnecessary repetition of tests and longer hospital stays often result, increasing the cost of medical care. It is recognized that there are instances which preclude taking a patient to the hospital where his physician has privileges (i.e. when there is an unreasonable distance to travel or when there is an emergency requiring prompt treatment). However, it is often expensive to deny a patient treatment by his personal physician in the absence of such conditions. SECTION 44-DISCLOSURE OF AGGREGATE PAYMENTS TO PHYSICIANS This section would prohibit the release of names of physicians who have been paid large amounts for treating Medicare or Medicaid patients except as required by other laws, i.e. the Freedom of Information Act. We interpret this to mean that the Secretary cannot routinely provide such lists, but still must comply with the request under the Freedom of Information Act. Although we applaud this provision as a step in the right direction, we urge you to extend it to completely prohibit the release of physicians' Medicare program payments. Past experience indicates that little is accomplished by such lists other than unfairly implying wrongdoings by many honest physicians. STATEMENT OF THE AMERICAN SOCIETY OF ORAL SURGEONS The American Society of Oral Surgeons ("ASOS") is the official organization of nearly 3,700 oral surgeons representing all fifty States, the District of Columbia and Puerto Rico. Today all members must complete 3 or more years in an accredited surgical residency in a hospital following completion of 4 years of dental school. Members limit their practice to oral surgery in offices and in hospitals as staff members. ASOS is submitting this statement first to bring to the attention of the subcommittee two important inequities in the reimbursement provisions under present medicare laws. S. 1197 has been introduced by Senator Dole and would correct these two inequities. Correction of the first inequity described below would not expand covered services and thus would not increase the cost of the present medicare program. Accordingly, reform of this matter by amendment to S. 1470 would be consistent with the aim of this bill, and ASOS urges such an amendment. The second inequity herein discussed involves a modest increase in costs and in the judgment of the subcommittee may be more appropriately dealt with as part of other legislation. I. ELIMINATE DISCRIMINATION BETWEEN PHYSICIANS AND ORAL SURGEONS AND OTHER DENTISTS IN THE PROVISION OF COVERED SERVICES Many of the professional services presently provided by both oral surgeons and other dentists and physicians are only reimbursed when they are provided by physicians. The ASOS asks the subcommittee to include in the bill presently being considered provisions that will eliminate this discrimination. The requested correction will not increase the costs of medicare. The professional practice of oral surgeons overlaps with that of physicians to a significant extent. Both groups, for example, often admit their patients to hospitals and perform complicated maxillofacial procedures. Further, both groups often provide diagnostic care and treatment of oral infections. Medicare, however, will pay all benefits for these services if they are performed by a physician, but the Medicare Intermediary will routinely reject the payment request if the diagnostic care or treatment of oral infection was performed by an oral surgeon. Under present law, medicare only covers the services of dentists when they constitute so-called "physicians' services." It is necessary, therefore, to look at the definition of "physician" in deciding whether a specific service is covered. "Physician" is defined to include a doctor of dental or oral surgery licensed by his State "but only with respect to" (1) surgery related to the jaw or any contiguous structure or (2) reduction (that is, the alignment) of fractures of the jaw or any facial bone. As existing medicare law is interpreted by the Social Security Administration, a dentist only functions as a "physician," and his services are only covered, when he is involved in the actual performance of surgery or reduction. Thus the law seriously discriminates against oral surgeons by excluding important nonsurgical functions (such as the management of salivary gland infections) which are covered only if performed by a physician. None of these functions involves routine dental care, which is separately excluded under existing law whether performed by an oral surgeon or physician. No logical reason exists to support this unfair treatment. Both disciplines are professionally trained and licensed by state law to perform these procedures. This problem has serious consequences for the patient, and is important to the professional life of the dentist. If the patient is aware of the discrimination, his freedom of choice of provider between a physician and a dentist will be prejudiced. If he is not aware of this legal pitfall when he is treated by an oral surgeon, he will be deprived of reimbursement for what surely must appear to him a completely arbitrary distinction. To put this problem into concrete terms of actual cases as illustrations, the Social Security Administration's interpretation of present medicare law: -denied payment to a patient for the services of an oral surgeon who had been called to the emergency room by the patient's physician to locate a bullet in the patient's tongue; -forced a 73-year-old woman to find her own means of paying for an oral surgeon's evaluation of oral and maxillofacial injuries suffered in an automobile accident; -denied reimbursement to an elderly man who was treated by an oral surgeon for temporomandibular (jaw) joint arthritis; -denied payment for drug injections administered by an oral surgeon to a facial nerve of a patient suffering from tic douloureux, the most painful and debilitating of all facial pains; and -denied payment to a patient for treatment by his oral surgeon of an obstruction and swelling of a salivary gland.1 These are not isolated examples. The files of our Society contain numerous similar cases. The problem is serious and it needs prompt correction. The solution provided in S. 1197 will not increase the scope of covered services. The existing exclusion of coverage of routine dental care found in § 1862 (a) (12) would not be changed. Those services that fall into this category would still not be covered. The solution of this problem will merely assure that patients will not be denied reimbursement for otherwise covered services solely because of the academic degree of the provider. II. COVER INPATIENT HOSPITAL SERVICE FOR ALL DENTAL PROCEDURES THAT REQUIRE HOSPITALIZATION The second area of concern in medicare which the ASOS would like to bring to the attention of the subcommittee concerns reimbursement for hospitalization required by the severity of a patient's dental condition. To correct this problem will increase benefits and thereby the cost of the program by a relatively modest amount. The subcommittee, therefore, may want to deal with this matter in other legislation. Existing medicare law differentiates between cases in which the dental procedure itself is a covered service (and thus the dentist's fee is reimbursable) and cases involving noncovered procedures. If the procedure is covered, the inpatient hospital expenses are also covered. However, the present Medicare statute as interpreted by the Social Security Administration restricts the payment of inpatient hospital expenses in the case of a noncovered dental procedure 1 The ASOS has compiled a binder of documented examples of cases where this serious inequity has created problems for patients. This binder is available for the review of the Subcommittee and its staff. to circumstances in which the patient's underlying medical condition, and not solely his dental condition, requires hospitalization. The only example of a medical condition justifying the hospitalization of a patient for a noncovered dental service given in the Social Security Administration's "Intermediary Manual" is "a patient who has a history of repeated heart attacks who must have all of his teeth extracted." The effect of existing law is to preclude hospitalization coverage where, in the judgment of the patient's dentist, the severity of his dental condition alone requires hospitalization for the safe performance of a noncovered dental procedure. In these cases the patient must find his own means of payment for the hospital expenses. Sample medicare rejections when contrasted with the example in the S.S.A. manual starkly demonstrate the problem under present law. For example: -an 81-year-old woman in Florida who was hospitalized by her oral surgeon for the removal of six maxillary teeth had her claim rejected because the medicare intermediary found that she was treated for a purely dental condition; -a 93-year-old man in Illinois who was hospitalized by his oral surgeon for the extraction of eleven seriously diseased teeth had his claim denied ; and -in Missouri a medicare patient had to pay his own hospital bill because he was hospitalized by his oral surgeon for preparation of the lower jaw for dentures using a skin graft. These are only three of the examples regularly received by our Society every year but they graphically illustrate the problem.2 ASOS urges and S. 1197 provides that medicare should cover inpatient hospital expenses if in the judgment of his dentist the severity of a patient's dental condition requires him to be hospitalized for performance of a dental procedure notwithstanding that the procedure itself is not a covered health service. This will not increase the coverage of dental fees. It will only increase hospital coverage and aid the patient. The Social Security Administration in 1973 estimated the additional first-year Federal costs of coverage of medicare patients in such instances to be $4 million. STATEMENT OF THE AMERICAN SPEECH AND HEARING ASSOCIATION On behalf of the 27,000 speech pathologists and audiologists who comprise its membership, the American Speech and Hearing Association is pleased to offer its support for S. 1470, the Medicare-Medicaid Administrative and Reimbursement Reform Act. The need to streamline the administration of the medicare and medicaid programs in an effort to stem the tide of a federally supported health care costs under these seemingly insatiable budget monsters is apparent. We further applaud your effort to meet the fiscal crisis created by rapidly escalating health care costs by focusing on cost effectiveness rather than curtailment of essential health services. Our statement will address three concerns directly related to the fiscal constraint objective of the legislation: (1) the need for a technical modification of title XVIII, endorsed by the Senate Finance Committee in 1973 but never passed into law, clarifying the physician-speech pathologist relationship; (2) the dilemma created by the application of Medicare standards to all patients served by outpatient facilities; and (3) the ballooning of medicare outlays spawned by the need to provide speech and hearing services "under arrangements." Physician-speech pathologist relationship Since the initiation of the medicare program, speech pathologists have experienced frustration in their efforts to serve the needs of the communicativelyimpaired elderly. The law requires that speech pathology services be provided according to a patient plan of care formulated by a physician, and reviewed by that physician at 30-day intervals. This restriction on speech pathology services represents a precedent-shattering disregard for the traditional physician-speech 2 As in the case of the first inequity discussed in this statement the ASOS has compiled documented examples of this problem. These are also available for the use of the subcommittee and its staff. pathologist relationship long accepted by both professions, and inevitably impacts adversely upon communicatively-impaired Americans. The speech pathologist is the only health care provider qualified by training and experience to evaluate a speech impairment and formulate a plan of therapy specifically designed to remediate that impairment. In the absence of a medical specialty in speech, the physician-prescription requirement merely necessitates a cumbersome and expensive rubber-stamp procedure that results in the wasteful, nonproductive expenditure of Federal health care dollars. The prevailing requirement for a physician's prescription and review of medicare speech pathology services is the product of a legislative mishap. In 1972, Congress most appropriately extended medicare coverage of speech pathology to those services rendered in such outpatient facilities as clinics, rehabilitation centers, and public health agencies. But, in end-of-session haste to pass the legislation which became Public Law 92-603, bill drafters analogized the provision of speech pathology to physical therapy services in Section 1861 (p) of the Social Security Act. The unfortunate-and unintended-result is that the law now contains an inappropriate provision requiring that a physician prescribe a plan of treatment and recertify the need for speech pathology services every 30 days. Not only does this requirement for Federal reimbursement abrogate the traditional physician-speech pathologist relationship long accepted by both professions, but it costs the communicatively handicapped, medicare, and, ultimately, the American taxpayer countless thousands of dollars in unnecessary physicians' fees. In 1973 the Senate Finance Committee sought to correct this legislative oversight in its report on H.R. 3153: The provision in Public Law 92-603 unintentionally penalized the speech pathologist. By incorporating through reference certain requirements applicable to physical therapy, the provision seemed to require that there must be not only a physician's referral but also a specific physician's plan detailing the amount, duration and scope of services to be provided by the speech pathologist. Since speech pathology involves highly specialized knowledge and training, physicians generally do not go into this type of detail when referring a patient for these services. [See attachment, S. Rept. 93-553, pages 66-67.] Unfortunately, the committee's effort to clarify congressional intent came to naught when, with only hours remaining in the 1973 session, House-Senate conferees agreed to put H.R. 3153 aside and report a skeleton compromise bill (H.R. 11333) providing an increase in social security benefits. We sincerely hope that in its report on this legislation the Finance Committee will seize the opportunity to reassert the recommendation made in 1973, using S. 1470 as the bridge from affirmation to implementation. Outpatient rehabilitation agency dilemma Another critical problem stemming from overutilization of the physician as the sole entry to health care services surfaced this year when outpatient speech and hearing clinics began applying for medicare certification as rehabilitation agencies. Clinic directors were informed by medicare surveyors that, under the June 1976 regulations promulgated by the Bureau of Health Insurance to implement Public Law 92-603, speech and hearing clinics must maintain records which include a physician's prescription and 30-day review of treatment plan for "All" individuals served by the clinic. Speech and hearing clinics now find themselves caught between a rock and a hard place: (1) a clinic can revamp its operating procedures to accommodate the medicare requirement, or (2) it can decline to accept Medicare patients. Since medicare beneficiaries would represent only a fraction of a clinic's total caseload, and since the expenses that would be incurred in opting for the first choice would be prohibitive--both to the clinic and to its private patients—in point of fact there is no legitimate, feasible option available. Thus the overly restrictive requirement shuts the door on what may well be the only source of services in the face of the elderly speech impaired-the very individuals whom Congress sought to serve by extending the medicare program to cover outpatient speech pathology services! BHI staffers have been sympathetic and diligent in seeking a solution to the dilemma that would not violate medicare's equal treatment standard. A directive has been issued to regional medicare officials exempting from the physician prescription requirement all referrals from "normal sources," defined by BHI as "education institutions, State and local rehabilitation agencies, crippled children's programs, or other education or social organizations of record." But BHI's action offers only a partial solution, leaving unanswered the plight of the private patient who would be required to incur the additional expense of a monthly visit to his physician. In effect, congressional intent has been short-circuited by the regulation which purports to put it into motion. There is a special irony in the fact that a standard intended to assure that medicare beneficiaries receive quality health services, on a par with private patients, actually bars the medicare recipient from receiving the service at all! Wasteful administrative procedures The law presently denies the speech pathologist recognition as a qualified medicare provider, making it necessary for speech pathology services to be rendered "under arrangements" with a certified medicare provider-hospital, extended care facility, or home health agency. The medicare provider bills the fiscal intermediary for the speech pathology service and subsequently reimburses the speech pathologist according to the terms of the contractual arrangement between the provider and the speech pathologist. The paperwork required by such convoluted administrative procedures pads the nation's medicare bill and represents an unjustifiable waste of precious health care dollars. In some instances, institutional middlemen are not only skimming the cream off the top, but taking most of the milk too, charging the medicare program anywhere from 20 to 100 percent for administrative costs. Recognition of the speech pathologist as a qualified medicare provider would put an end to this unnecessary and extravagant drain on the program's resources. In some instances medicare-certified facilities have declined to accommodate the cumbersome administrative procedures involved in providing speech pathology services for medicare patients. Again, as in the case of outpatient clinics, the tragic result is significantly reduced accessibility to speech pathology services for many communicatively-handicapped elderly. Summary Long overdue recognition of the speech pathologist as the health professional best qualified to provide services for communicatively-handicapped individuals would substantially alleviate the three problems outlined above. While this Association readily accepts the physician's status in providing medical services, the physician does not offer and cannot provide necessary therapy for the remediation of speech impairments. The restrictive physician-prescription requirement, in its failure to acknowlede the widely accepted professional independence of the speech pathologist, ignores the many years of highly specialized academic and clinical training required to attain the high standards of the speech pathology profession and imposes on physicians a responsibility for which they are not trained and which, quite naturally, they do not want. The clumsy rubber-stamp procedure that results is wasteful and costly both for the communicatively impaired and the medicare program. STATEMENT OF THE ASSOCIATION OF PATHOLOGY CHAIRMEN, INC. The Association of Pathology Chairmen (APC) strongly supports the efforts of the College of American Pathologists to establish a relative value scale for the professional responsibilites of pathologists as such relate to patient care. Teachers of pathology in academic medical centers often devote significant amounts of time and effort to such responsibilities and a significant fraction of these persons' salaries are thus derived from patient care income. With respect to the autopsy, a relative value scale also is desirable. The professional input involved in autopsy pathology varies greatly depending upon individual circumstances. Reimbursement should reflect such variability. Some categories of autopsies that have been provided include: 1. Stilborn infants. 2. Autopsy limited to select organs or regions of the body by request of the family. 3. Complete autopsy with detailed examination of the central nervous system. |