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Independent Practitioners under Medicare (1968)

CHAPTER II:
ISSUES INVOLVED IN CONSIDERATION
OF CHANGES IN COVERAGE

Health and Safety of Beneficiaries

The health and safety of its elderly beneficiaries is the focus of the Medicare program. Primary concern when any change in Medicare is contemplated is whether or not the change will improve, or contribute toward improvement of, the health status of geriatric patients, with adequate safeguards for their safety and well-being. The views and advice of the various health professions are an invaluable asset in assessing the adequacy with which Medicare meets the needs of geriatric patients, particularly when changes or extensions in coverage are considered. However, if in these considerations the interests of Medicare beneficiaries appear to come into conflict with the interests of any health profession or group of practitioners -- or with precedents set either in or outside Medicare related to the health professions -- reconciliation of the conflict must be accomplished within the framework of the focus of the program.

Effects of Changes in Coverage

Medicare is still in its early formative years; contemplated changes should be seen in terms of their effects -- short-term and long-term -- on the total program, for provisions instituted now will have lasting effects. If revisions of Medicare coverage might bring about changes in prevailing patterns of care, then the results must be demonstrably in the best interest of the total population, not just of Medicare beneficiaries. Sound planning, therefore, is an essential element of Medicare's responsibilities to its beneficiaries and to the total public.

Patient Entrance into Health Care System

Another over-all consideration for the professions studied is whether the practitioners' services are (1) adjunctive to or supportive of the services of the primary sources of care, the physician; or (2) offered in a manner that substitutes the practitioners' services for those of the physician.

This distinction is of crucial importance in determining provisions necessary under Medicare to assure quality and appropriateness of services and the safety of the patients, and to determine the effects of coverage on the Medicare program and on the total health care system. Related to this distinction, and to determining appropriate conditions of coverage, is whether practitioners provide their services in private, independent practice or in some type of organized or institutional setting. Both "supportive" and "point of entry" services can be offered in either type of setting, but the former are more likely to be in organized settings, the latter in independent practice.

Within the context of these overall considerations, the following issues were examined for the specific practitioner groups in this study.

Needs of Medicare Beneficiaries

Geriatric patients are likely to suffer from multiple symptoms and various interrelated disabilities, with underlying pathology that is complex and that requires a range of diagnostic and therapeutic services. Their medical conditions are often further complicated by social, psychological, and economic instability, requiring various non-medical consultative services as well. There is little doubt. therefore, that Medicare beneficiaries need coverage for the services of most of those practitioners included in this study.

However, the needs of beneficiaries, for these or any other services, are not automatically met by providing coverage for them. In the maze of the complicated systems and Subsystems of medical and related specialties and subspecialties, any patient is apt to be perplexed in choosing the practitioner best equipped to provide the type and quality of services he needs. The geriatric patient, frequently with multiple diagnoses and complex conditions, in particular may experience difficulty in assessing his needs and seeking out the resources to meet them. Fragmentation of care appears inherent in increasing specialization of the health professions and the resulting multiplicity of practitioners, and this fragmentation is undeniably exacerbated when the practitioners are in independent practice.

Hence, a critical need of the Medicare beneficiary (perhaps even the greatest need in relation to the practitioners in this study) is for a mechanism to bring the patient and the service together, to coordinate and guide him to the various services available to him -- in short, for management of his care. A related need is for assurance of the safety and quality of the services to which he has access.

In evaluating needs of beneficiaries for each of the services considered in this report, three questions should he answered. within the context of: (1) whether the service is provided as supportive to or a substitute for the physician's service; and (2) whether it is provided in an organized setting or by an independent practitioner:

  1. What is the prevalence of need for the service among the aged?
  2. How can this service be coordinated with patient's total health care management?
  3. How can Medicare provisions for coverage of services of each practitioner group assure the safety of the patient and the quality and appropriateness oi care?

Quality of Care

Assurance of the provider's capacity to give professionally acceptable care is a responsibility of the Medicare program. The full participation and advice of professional groups and accrediting bodies must be obtained in setting standards and devising methods of surveillance, but Medicare cannot delegate its ultimate accountability. The one statutory exception is that hospitals accredited by the Joint Commission on Accreditation of Hospitals are deemed to meet all Medicare requirements except utilization review.

The need of geriatric patients for guidance in obtaining health services with respect both to type and quality has been mentioned. In the absence of any other mechanism' they look to Medicare itself for guidance, the fact of Medicare coverage being accepted as assurance that the services covered may safely be used.

Medicare has placed major reliance on direct supervision by physicians and provision of services through approved providers to assure a reasonable quality of services given by health personnel. General mechanisms exist for surveillance of care given and assurance of the capacity to give acceptable care in organized, institutional provider settings under Part A. These include the initial approval of the facility for participation (and the required periodic reapproval), combined with ongoing, continuous surveillance through peer review committees.

Performance standards for nonphysician practitioners providing their services in independent practice Would need to he more stringent, in statement and application, than for such practitioners in organized settings. In organized settings peer groups can formally and informally review patient care. In such settings consultation either by fellow practitioners or by practitioners of other disciplines is more readily available; and there is an element of the employment relationship to assure some surveillance of quality of care and the screening of practitioners for their qualifications. Also, the organized setting (clinic, agency, or center) would have met standards for eligibility to participate in the Medicare program.

The most rigorous standards are needed for those nonphysician practitioners who want to serve as the point of entry for the patient into the health care system. Since the patient will not have had a referral diagnosis by a physician, the practitioner himself must evaluate the patientÕs need for his services. For these professions, the quality and content of the educational programs must be examined carefully in terms of adequacy of training and clinical experience of the practitioners to prepare them to make this initial evaluation. They must be able not only to recognize and evaluate the patient's need for their own services, hut also to recognize signs and symptoms of other pathology that might contraindicate their services or indicate that the patient should be referred to a physician.

If a profession wants coverage for services only on referral from a physician, the patient will already have undergone differential diagnosis and his need for services determined. For such practitioners, the educational program should be examined in terms of the practitioner's preparation to provide specialized health services to patients, including geriatric patients. However, he should be able not only to provide services of high quality. but also to recognize general signs, symptoms, and behavior patterns in geriatric patients that indicate the need to refer the patient back to the physician.

Impact on Medicare Program

The preceding section discussed the most important aspect of any proposed changes within the primary focus of the program -- the effects on quality of care in relation to the safety and well-being of the beneficiaries. Other aspects, however, must also be considered, since they also have impact on the effectiveness with which Medicare fulfills its goals.

When Part B coverage was added to Medicare, the assumption was made that, since the coverage conformed with the present mode of practice of physicians, controls through administrative mechanisms could safely be minimal. And as long as Part B covers principally doctors of medicine and osteopathy, the safety of the patient is, with few exceptions, not seriously threatened, With inclusion of other practitioners, however, the lack of quality control procedures -- and lack of recourse in cases of abuse -- present problems, and establishing effective review of patient care and cost controls would be difficult with respect to practitioners in independent practice.

In considering these issues, the distinction between supportive and point of entry services. and between organized settings and independent practice, is important for each of the professions. Physician referral for supportive services, for example, partly solves the problem of determining medical necessity. And, as was mentioned previously, in the organized settings there are procedures to accomplish surveillance of quality, appropriateness of services, and costs. If there is extension of coverage for additional nonphysician services provided by independent practitioners. it will be necessary to devise means to accomplish the following:

  1. Determination of medical necessity for each of the services covered;
  2. Maintenance of standards in the delivery of each of the services, in several of the disciplines personnel and education standards are now in developmental stages; in others there appears a lack of consensus within the profession itself regarding standards.
  3. Detection and handling of professionally unacceptable practices or financial abuses -- as well as a means, with "due cause," to exclude the services of the practitioner from the program;
  4. Determination of "usual and customary" fees. For those disciplines in which there is little independent practice at present, data are nonexistent in some localities, inadequate in others: for those disciplines in which there is some degree of independent practice, profiles to use as the basis for determining charges are difficult to derive: even establishing -- "prevailing-range" screens is difficult. In organized settings, with reimbursement based on costs, this problem does not arise.

Impact on Total Health Care System

The magnitude of the Medicare program as a financing mechanism for health care, combined with its impact as a concept of social responsibility, inevitably means that policies and precedents established under it will affect the total health care system. Contemplated changes in coverage should be approached with caution, and with full awareness of the role of Medicare as an agent of change. Hasty changes, made without adequate information and without thorough debate, exploration, and preparation within the health care community, could be damaging not only to Medicare beneficiaries but also to the total population. On the other hand, a too-timid approach, -eared to conformity with the status quo, could inhibit inventive planning and progress in improved methods of organizing and delivering services to adapt to scientific, technological, and social changes.

Changes in coverage may have the effect of weakening our voluntary health system. While those disciplines that are older and have well-developed professional organizations can probably accept partnership responsibility for standard-setting and other control functions necessary in Medicare, other disciplines are still relatively young and are just developing these controls and cannot yet assume even minimal responsibilities. Premature action by Medicare could inhibit the voluntary developments now going on among them. Moreover, for developing health professions, such action could have the effect of freezing functions or making it difficult to change job descriptions within the profession.

Inevitably, inclusion of a service in Medicare, and the provisions of its inclusion, will be interpreted as a stamp of approval and cited as a precedent. For example, in support of their requests for changes of coverage, some professional associations representing the disciplines in this study cited Title XIX (Medicaid) as a precedent since it is frequently associated with Medicare. If this citation is presented as "indicative" of the validity of various claims, precedents set by Medicare will almost certainly be cited as "proof" -- and this will be a difficult argument to refute. Hence, any change in Medicare should be tested against its applicabflity to the total population, to other health practitioner groups, and to other health care programs.

The requested changes in Medicare coverage could have other far-reaching effects on the total health care system. Among the issues that should be considered with respect to each practitioner group are the following:

  1. Will the change in coverage affect present patterns of delivery and use of services? This could happen when the change in coverage is not consistent with the prevailing mode of practice of the profession. In such cases, the effects must be examined in terms of efficiency, economy, availability of services. and quality of care for all patients, not just for Medicare patients.
  2. Will the change affect quality of care? The effects on quality might be in both directions. First. the existence of standards for participation in Medicare of practitioners in various types of settings would have the effect of raising standards of care for all patients. On the other hand, independent practice is vulnerable to the charge that it contributes to fragmentation of care and lessens the effectiveness of both formal and informal peer review mechanisms. which help to insure professionally acceptable care. If the change in coverage caused a proliferation of independent practice, difficulties could be encountered by the increasing number of patients who would have to receive services in this settin2 , but without the protective provisions that might be devised for Medicare beneficiaries. Perhaps a corollary question might be asked: Can a mechanism be found to counteract adverse effects, or should the disadvantage be accepted in order to secure other and more important benefits?
  3. How would the change affect availability of manpower? In the view of some of the professional associations, their requested changes would increase manpower availability and brin2 about a better distribution. However, coverage of services of additional practitioners in independent practice could draw an increased number of health personnel into independent practice, thus setting up increased competition among approved providers for qualified personnel. aggravating shortages that already exist and leading to dilution of the professional component of services in various settings. In the organized settings, on the other hand, tasks and responsibilities can more easily be delegated to nonphysician personnel, thus making maximum use of available manpower. These effects could vary among the professions studied and were kept in mind in evaluating each.
  4. What would be the effects on health care costs? There is speculation that Medicare has been inflationary, and certainly health care costs have risen more rapidly since Medicare than they did before. for physicians' fees as well as for hospital costs. It has not been demonstrated that lack of adequate cost controls in Part B of Medicare is responsible for this increase, but the circumstances lend weight to the supposition. If Part B coverage is to be extended for services of other independent practitioners, the possible mechanisms for cost controls should be examined for each of the disciplines for which services are to be covered.

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