American College of Physicians: Internal Medicine — Doctors for Adults ®


A look at ACP's policy agenda for the year ahead

From the February 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Elizabeth Prewitt

As the final session of the 105th Congress gets underway, ACP is aggressively promoting its federal policy agenda in order to accomplish as much as possible before adjournment in October.

Bipartisanship will be difficult to achieve as elections near in the fall; already, the distant presidential election in 2000 is causing battle lines to be drawn within the Democratic party. House Minority Leader Richard Gephardt (D-Mo.) is trying to differentiate himself from the Clinton administration and Vice President Gore, his likely rival for the party's nomination.

Not all of ACP's policy agenda, however, will be achieved through legislation. Regulatory action will be key on a number of issues. HCFA, for example, is developing regulations to implement new statutory authority to fund graduate medical education in ambulatory settings and may modify the new evaluation and management (E/M) documentation guidelines during the "grace period" ending in June. Several high-level commissions dealing with Medicare reform and quality in health care may also provide important forums for advocacy of ACP positions.

A number of broad issues on the College's agenda that are expected to receive consideration include the following:

  • Medicare reform. The deliberations of the newly appointed 17-member National Bipartisan Commission on the Future of Medicare provide a highly visible forum for ACP's Medicare reform recommendations.

    After months of political infighting, Sen. John B. Breaux (D-La.), member of the Finance Committee and ranking member of the Special Committee on Aging was named consensus chairman. Ways and Means Health Subcommittee Chairman Bill Thomas (R-Calif.) will serve as administrative chairman. (The blueprint for ACP's policy agenda for changing Medicare is contained in "Reforming Medicare: Adapting a Successful Program to Meet New Challenges," available in ACP Online's public policy section at

    While we are concerned that 10 of the 16 commissioners are elected officials (four Republicans and five Democrats), it is possible that they will produce politically viable recommendations that have an excellent chance of enactment. The commission's report is due March 1, 1999.

  • Graduate medical education (GME). The College will also advocate proposals to reform GME, including the option of an all-payer system to finance it. New College materials to educate the public and policy-makers about the value of GME are in the works.
  • Tobacco settlement legislation. While enacting tobacco settlement legislation in this Congress will be difficult, members in both houses and parties have expressed their support. Public opinion favors comprehensive tobacco control legislation, but the huge sum being spent by tobacco interests on opposition efforts—an estimated $15.8 million in the first half of 1997—will undoubtedly influence the final outcome.

    The College mobilized ACP policy activists to urge President Clinton to address the tobacco issue forcefully in his State of the Union address and to urge Congress to enact comprehensive tobacco control legislation. To maximize its influence and visibility on this issue, the College has joined the Effective National Action to Control Tobacco (ENACT) coalition, composed of a broad range of medical organizations and other health groups. ACP supports full FDA authority over tobacco, taxes on cigarettes to discourage youth from smoking and penalties if the rate of youth smoking escalates.

  • Health care quality. The President's Commission on Consumer Protection and Quality in the Healthcare Industry has provided a forum to address a number of ACP recommendations designed to improve health care quality. These include facilitating beneficiary choice; developing measures to evaluate quality; implementing quality assurance mechanisms; protecting patient confidentiality; and protecting access to patient data for vital research to advance medical knowledge and improve public health. While a key issue is how to enforce the commission's Bill of Rights, an even bigger challenge will be ensuring that any new requirements do not impose further regulatory burdens on physicians.

    Legislation has already been introduced that incorporates at least some of the Bill of Rights' concepts. Rep. Charles Norwood (R-Ga.) has introduced the Patient Access to Responsible Care Act, which has considerable support from both parties, while Sen. Jim M. Jeffords (D-Vt.) has another bill in development.

    ACP is working with the sponsors of these bills and the commission to have ACP quality recommendations incorporated.

  • Private contracting. The College has raised concerns about the approach by Sen. Jon Kyl (R-Ariz.) and Ways and Means Chair Rep. Bill Archer (R-Texas), to allow service-by-service private contracting under Medicare. The Board of Regents has recommended a number of alternatives to the Kyl bill, including raising limits on balance billing for higher income beneficiaries and patient use of other coverage alternatives. These alternatives address the issue of fair compensation, which is of concern to physicians. Under the Balanced Budget Act of 1997, physicians can privately contract with Medicare patients, but they "opt out" of Medicare and can't bill HCFA for any patients for a period of two years. (For more information on private contracting, see box, below.)
  • Fraud and abuse. Several high-visibility scandals have turned up the legislative and regulatory heat to stamp out fraud and abuse and punish offenders. The College's goal is to promote a system that eliminates fraud and abuse, but one that does not unnecessarily burden physicians with costly bureaucracy and fear of punitive action for inadvertent errors.

    The College will continue to educate physicians and provide individual assistance regarding the new E/M documentation guidelines, which are scheduled to take effect in July. The College will also pursue modifications that may make the new system less onerous before the guidelines are implemented. (See "ACP will work to modify 'punitive' E/M guidelines "

    The College is developing a nuts-and-bolts primer that guides physicians on compliance issues, including areas like coding. The College is monitoring the enforcement of fraud and abuse laws and is working closely with the American Society of Internal Medicine to develop a fraud and abuse legislative package.

    In addition, the College has joined the Physicians at Teaching Hospitals (PATH) lawsuit to stop retroactive enforcement of ambiguous rules related to payment for E/M services.

  • Universal coverage. A new policy paper was approved by the College's Board of Regents in January that provides specific recommendations for expanding access to care incrementally. These recommendations have been used to initiate discussions with congressional staff and other organizations, including the National Coalition on Health Care, on what goals might be politically feasible. ACP is seeking a sponsor or sponsors of legislation incorporating our proposals.

    The College recommends expanding Medicaid to cover everyone living in poverty, as well as subsidies for those earning between 100% to 200% of the poverty level. The College is evaluating President Clinton's proposal to allow certain individuals between the ages of 55 and 64 to purchase Medicare coverage.

  • End-of-life care. ACP's Board of Regents has identified end-of-life care issues for future policy development. In addition, the College is developing educational resources through the Education Committee and the Ethics and Human Rights Committee. Current public policy, which includes ideas in our Medicare position paper, will provide the basis for ACP's advocacy efforts. For example, the College recommends more flexibility in Medicare to provide coordinated care for the terminally ill and believes that Medicare should provide hospice-type services such as palliative care and family counseling outside of hospice environments.

Elizabeth Prewitt is Director of Public Policy in ACP's Washington, D.C., office.

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