11-11-1999

LOBBYING & LAW: Knocking on Medicare's Door

For months, members of Congress and their staffs have been whipsawed by
health care lobbyists peddling horror stories about the impact of Medicare
cuts that were mandated under the 1997 Balanced Budget Act. This month,
Congress and the White House agreed to a settlement designed to increase
Medicare reimbursements to doctors, hospitals, nursing home operators, and
other traditional providers.


But Congress is already bracing for the next assault--by lobbyists who are
looking to get their clients a piece of the action.


In the late 1980s, Medicare--a three-decades-old program that underwrites
health care for elderly Americans--opened its doors to such practitioners
as physical therapists, clinical social workers, speech pathologists, and
audiologists. Many other groups, however, were left out--and these
outsiders are finding life increasingly difficult in an era of managed
care.


"The private market now follows Medicare's lead," said Jill
Rathbun, a lobbyist who was recently retained by the National Vision
Rehabilitation Cooperative, a group of community organizations that
provides services to blind or visually impaired elderly Americans.
"Because of managed care, Medicare is almost the gold standard. If
you can get into Medicare as a recognized provider, the likelihood that an
HMO will let you in goes up."


Some groups that advocate higher reimbursement rates for traditional
Medicare providers say openly that their needs should come before those of
providers who are not in Medicare at all.


Robert Greenwood, the public affairs director for the American Association
of Homes and Services for the Aging, acknowledges that Congress should
consider the pleas of noncovered providers--but only after nursing homes
and other current claimants begin getting what they deserve. "We're
seeing shortfalls, so we don't support adding to that problem" by
letting other providers in, he said.


Naturally, those outside Medicare disagree. Consider the American
Association of Oriental Medicine, which is working with Rep. Maurice D.
Hinchey, D-N.Y., to get Medicare to pay for acupuncture services.


David Molony, a licensed acupuncturist who also serves as executive
director of the association, cites a Swedish study that found that
acupuncture saves money. According to the study, the cost to treat a group
of patients with a combination of traditional medicine and acupuncture was
$26,000 less per patient than the cost to care for a group that received
traditional medical treatment only. "One of the neat things about
acupuncture," he said, "is that it's malingerer-proof. It's not
like people will want to get needles stuck in them unless it's actually
doing them some good."


Molony came down from the association's headquarters in Catasauqua, Pa.,
to personally work the halls of Congress. "It's not difficult to make
our arguments if we actually get a chance to talk to people about
it," he said. "The difficulty is always with anyone who wants to
do anything with Medicare. People on Capitol Hill always freak out if you
tell them you want to touch Medicare."


Supporters of a coronary treatment developed by physician Dean Ornish of
Sausalito, Calif., are also beating on the doors. Ornish's treatment
includes an extremely low-fat diet, exercise, support-group meetings, and
stress-management techniques, such as yoga. This summer, Ornish's
Preventive Medicine Research Institute signed up Richard A. Lauderbaugh of
the lobbying firm Health Policy Alternatives, who has also represented
such groups as the American Association of Health Plans, the American
Hospital Association, and the Federation of American Health Systems. (In
an interview, Lauderbaugh said his firm is doing mostly technical work for
Ornish's group rather than lobbying Congress directly.)


Although some of the medical facets of Ornish's regimen are already
covered by Medicare, others are not, so he and specialists who help
patients carry out his regimen want the program to be covered as a bloc.
Ornish won a victory in October, when Medicare agreed to cover as many as
1,800 elderly people with serious heart conditions who want to try
Ornish's program instead of heart surgery.


Another group that signed up a Washington lobbyist this summer is the
National Vision Rehabilitation Cooperative. The cooperative, which is
based in Provincetown, Mass., is a coalition of 16 community organizations
that provides services to blind or visually impaired elderly people. The
coalition hired Rathbun, who came to the lobbying firm Smith, Bucklin and
Associates after serving as an aide to former Sen. Nancy Landon Kassebaum,
R-Kan.


The vision organizations want Medicare to reimburse licensed workers who
help elderly people learn to cope with daily activities. Many such
services are already cleared for Medicare reimbursement, Rathbun said, but
many of her clients' practitioners are unable to become certified Medicare
contractors.


Rep. Michael Capuano, D-Mass.--whose mother received services from vision
rehabilitators in the Boston area, Rathbun said--has introduced a bill
with 37 co-sponsors that would enable such providers to receive Medicare
payment. Grass-roots supporters of the bill are set to home in on Congress
in January during the cooperative's national meeting in
Washington.


Like advocates for the other Medicare outsiders, vision rehabilitators
need to convince Congress that Medicare should spend additional money for
their services. The vision rehabilitators similarly contend that their
services will actually save money in the long term by obviating the need
for more expensive treatments later. Rathbun cites a study by the Alliance
for Aging Research, which found that vision impairment was one of four
factors that generated $26 billion in health costs a year.


Yet another group seeking inclusion in Medicare is the International
Association of Psychosocial Rehabilitation Services, a Columbia, Md.-based
group that represents professionals who help the mentally ill function
with greater independence. Many recipients of psychosocial rehabilitation
services are younger people who qualify for Medicare coverage because they
are seriously disabled, said Paul J. Seifert, the group's government
affairs director. Such services can be covered under Medicaid, but they
are not reimbursed under Medicare--an arbitrary distinction, the group
argues.


Some of the most prominent clusters of health care providers seeking entry
into Medicare are involved in mental health programs. The American
Association for Marriage and Family Therapy hired the lobbying firm
Capitol Associates earlier this year to represent its interests. "At
the time Medicare was enacted, our discipline was not
well-established," said John Ambrose, the association's director of
legal and government affairs. "We have now grown greatly, and the
science that supports it is very strong, so we're just asking that this
oversight be corrected. It's at the very top of our agenda."


Another mental health group angling for inclusion is the American
Counseling Association, which represents licensed professional counselors.
Medicare already allows payments to psychiatrists, clinical psychologists,
and clinical social workers, but licensed professional counselors are in
the same boat as marriage and family counselors--they're not included.
Such counselors have typically earned a master's degree and have at least
two years' and thousands of hours of experience; they must also pass a
national exam and abide by a code of ethics.


"The levels of education and training are on par with those of
clinical social workers, so if you cover one, it does not make sense not
to cover the other," said Scott Barstow, the public policy director
for the 52,000-member American Counseling Association. "If you looked
through a window at a counseling session, you would not be able to tell if
you were looking at a psychologist, a clinical social worker, or a
licensed professional counselor. They're all doing the same
thing."


Not everyone buys such arguments. Although Russ Newman, the executive
director for professional practice at the American Psychological
Association, said that his group is mostly "agnostic" on
marriage therapists or counselors being granted Medicare reimbursements, a
spokesman for the American Psychiatric Association--whose members all
sport medical degrees--said his group has serious doubts about the
newcomers' requests, noting that providers who lack medical training could
pose problems for patients.


"Medicare patients typically have multiple illnesses, and treating
them ought to require substantial medical and scientific knowledge to
understand all potential impacts," he said. "I'm no clinician,
but some anti-depressants have cardiological effects, and if you recommend
that for a depressed patient who has a heart condition, you'd better be
sure about what you're doing. It's not clear to me what marriage and
family therapists and counselors would bring other than numbers and a
desire to get reimbursed."


Then there's the American Chiropractic Association, which fought a long
battle to win inclusion in Medicare, but now complains that its services
are being unfairly shunned by health maintenance organizations that treat
Medicare patients. The group--which has sued the Health Care Financing
Administration, the agency that runs Medicare--backs three supportive
congressional bills. A bipartisan group of lawmakers--including Rep.
Barbara Cubin, R-Wyo., Sen. Kent Conrad, D-N.D., and Sen. Orrin G. Hatch,
R-Utah--are working closely with the association, said Richard Miller, a
lobbyist on the association's staff.


Indeed, attracting bipartisan allies is almost a must for potential
Medicare gate-crashers. Acupuncturist Molony said that while he has worked
closely with Reps. Hinchey and Bob Filner, D-Calif., he has now made a
point of cultivating Republicans, too. "One of the things we know is
that any Democratic bill is less likely to go through," he said.
"That's just something we have to be realistic about."`


Louis Jacobson

National Journal