Extending Medicare Coverage for Preventive and Other Services (2000) / Chapter Skim
Currently Skimming:
1 Introduction
1 Introduction
Pages 13-25
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From page 13... ...
With growth in Medicare spending and health care costs having far exceeded 1960s' estimates, the increased cost of additional services has generally discouraged coverage expansions. Moreover, Congress has set budget rules for itself requiring that decisions to increase most types of federal spending must be accompanied by explicit decisions to reduce spending elsewhere or to raise taxes.
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From page 14... ...
These services were screening for skin cancer; medically necessary dental services; elimination of time restrictions on coverage for immunosuppressive drugs for transplant recipients; nutrition therapy; and routine patient care for beneficiaries enrolled in approved clinical trials. This request from Congress reflects two significant developments since Medicare's beginnings: an accelerating pace of technological innovation and partly as a consequence a greater than anticipated escalation of program expenditures and overall health care costs.
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From page 15... ...
, it was responding to the growing availability of effective medical services and the difficulty faced by older people in either paying for these services directly or obtaining private health insurance.2 At the same time, Congress also created the federal-state Medicaid program (Title XIX of the SSA) , which provided health insurance for certain categories of lowincome individuals (primely low-income mothers and children and low-income aged, blind, or disabled people)
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From page 16... ...
. When Medicare was created, hospitalization and other major expenses related to care for acute illnesses fit the model; expenses for most preventive services, outpatient prescription drugs, and dental care did not.
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From page 17... ...
Medicare beneficiaries covered by health maintenance organizations (HMOs) may be eligible for additional preventive and other services, sometimes by paying an additional premium, but HMOs vary greatly in the extent to which they offer benefits not required by Medicare (Kaiser Family Foundation, 1998~.
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From page 18... ...
As mentioned earlier, congressional budget rules require that certain decisions to increase federal government spending in one area be offset with actions to reduce spending in other areas or to increase taxes or other revenues. For example, higher estimated net spending for covering new preventive or dental services or outpatient drugs would usually have to be matched by increased taxes or reduced spending either elsewhere in the Medicare program (e.g., through lower payment rates for health care providers)
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From page 19... ...
Health Care Financing Administration Within the broad coverage categories established by Congress, more specif~c determinations about what services are or are not covered are the responsibility of the Health Care Financing Administration (Bagley and McVearry, 1998~. HCFA also provides detailed guidance to Medicare contractors regarding the application of its coverage rules and the development of local contractor medical policies for situations not dealt with by such rules.
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From page 20... ...
6In establishing specific coverage policies, HCFA does not necessarily restrict coverage to the so-called labeled indications. For decisions about off-label uses, HCFA provides that its administrative contractors may consider authoritative medical literature and "accepted standards of medical practice" (Carriers Manual, section 2049.4 tHCFA, 1999b]
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From page 21... ...
which generates nearly all coverage questions, they are known as "carriers." HMOs and other private health plans approved by Medicare to serve beneficiaries must follow intermediary and carrier policies, but they also must make their own coverage determinations in the absence of such .
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From page 22... ...
In addition to revising procedures for national coverage decisionmaking and clarifying the role of local organizations in the coverage process, HCFA has a contractor examining variation in local medical policies. COVERAGE, ACCESS TO CARE, AND OUTCOMES Rationales for Extending Medicare Coverage The conditions and services examined in this report illustrate the range of arguments which may or may not be supported by evidence for altering statutory coverage exclusions.
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From page 23... ...
Research also suggests that lack of financial access is not the only barrier to the provision or use of preventive and other services (e.g., see CDC, 1997; Chan et al., 1999; Lave et al., 1996; Lieu et al., 1994; Schauffler and Rodriguez, 1993; Weese and Krauss, 19954. Other barriers may include lower levels of education or information, rural or inner city residence, language difficulties, physical or cognitive disabilities, transportation difficulties, and health care organizational or system problems.
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From page 24... ...
Screening presents questions about the political saliency of different health problems and the importance of scientific evidence in decisions about which preventive services Medicare should cover. Proposals to extend the coverage of immunosuppressive drugs raise questions of why one disease or organ gets differential priority (i.e., immediate Medicare coverage of dialysis or kidney transplants for persons with renal failure)
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From page 25... ...
More specific information about methods is provided in the chapters and appendixes examining specific coverage topics. Chapters 3, 4, and 5 focus, respectively, on screening for skin cancer, medically necessary dental services, and immunosuppressive drugs for transplant patients.
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