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ISSUES BRIEF:

HR 655 - THE MEDICARE SOCIAL WORK EQUITY ACT OF 1999
INTRODUCED BY CONGRESSMAN STARKS

Medicare beneficiaries receiving skilled nursing care or residing in nursing homes are scheduled to lose or have already lost access to critical mental health services provided by clinical social workers ("CSWs") under several new Medicare statutory provisions and regulations. Although the Medicare regulations affecting most such nursing home residents have been delayed, patients receiving skilled nursing care have lost access to CSW services as of January 1, 1999. In order to ensure that nursing home residents continue to have access to these services, the Health Care Financing Administration ("HCFA") says the Medicare law must be changed.

Currently Available Mental Health Services Threatened

Currently, clinical social workers, psychologists and psychiatrists bill Medicare Part B directly and are directly reimbursed by Medicare when providing mental health services to nursing home residents and skilled nursing facility ("SNF") patients. In 1996, the Department of Health and Human Services' Office of Inspector General published a report on the quality of mental health services in nursing homes, entitled "Mental Health Services in Nursing Facilities." This study's findings support the need for CSW care in nursing homes. Seventy percent of the nursing home respondents reported that allowing CSWs and clinical psychologists to bill independently had a beneficial effect on the provision of their mental health services. But now, this beneficial effect is threatened by laws and regulations which single out CSWs and effectively stops them from independently billing Medicare for the mental health services they provide.

The Problem

Three issues combine to jeopardize nursing home resident access to CSW services:

  1. Implementation of the Medicare SNF Prospective Payment System ("PPS") unfairly ends independent CSW billing. PPS, which covers Medicare Part A services offered in a SNF, was mandated by the Balanced Budget Act of 1997 ("BBA"). Beginning January 1, 1999, PPS will require SNFs to pay for mental health services when provided by CSWs. Generally, all SNF-provided patient care under PPS is included in the Medicare per diem payment. However, the BBA creates an exception, allowing psychiatrists and psychologists but not CSW's to bill Medicare directly. Thus, the financial incentive for the SNF, and the ultimate impact, is to move the mental health services component off the SNF's budget and directly back to Medicare Part B, effectively ending CSW services.
  2. The Impact of Consolidated Billing by SNFs for all Medicare Part B services discriminates against CSWs. Consolidated billing for Part B services also was mandated by the BBA. Beginning July 1, 1997, nursing homes were supposed to have been responsible for the billing of all Medicare Part B services offered to nursing home residents. Here again, psychiatrists and psychologists are exempt. This ability to continue to bill Medicare directly creates an incentive for the nursing facility to avoid the burden of consolidated billing for mental health services by not using CSWs. While HCFA has delayed implementation of Part B consolidated billing for an indefinite time, these facts remain: there are not enough psychiatrists and psychologists to meet the patients' needs, especially in the rural areas; psychiatrists' and psychologists' fees are higher, increasing Medicare's costs; and, combined with the break in CSW services caused by PPS, admittance to a nursing home will end any ongoing CSW/patient treatment relationship. Quality of care is harmed when the continuity of patient care is broken.
  3. The definition of CSWs in the Medicare statute is open to misinterpretation. The definition of CSWs for Medicare purposes was amended by the Omnibus Budget Reconciliation Act of 1989 ("OBRA 1989"). In the final regulations issued in April 1998, HCFA's interpretation of this statutory definition ended SNF patient access to independent CSWs. HCFA maintained that a SNF's responsibility for meeting the mental health needs of its patients includes providing any and all services that an independent CSW might provide. HCFA delayed implementing the regulation for two years, but the facts remain: PPS for SNFs is limited and insufficient to allow the facility to employ qualified, independent CSWs. Generally, lesser qualified, non-clinical social workers are on the nursing home staff. And, even Medicare and state laws recognize the distinction between "personal assistance" social work and the mental health diagnosis and treatment services inherent in clinical social work.

The Solution

To solve this problem, two parts of the Medicare statute must be amended:

Congress should--

  1. Add CSWs to the list of Medicare service providers who are excluded from PPS and consolidated billing; and
  2. Amend the CSW definition by deleting the part that denies reimbursement to independent CSWs who provide mental health services in a SNF.

WE URGE YOU TO SUPPORT H.R. 655, THE MEDICARE SOCIAL WORK EQUITY ACT OF 1999

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