Monday, December 28, 2009

Beyond the Legislation

What a year. After months of grueling debates, public clamor and hundreds of legislative proposals, national health reform legislation for the United States is almost here. The House and Senate versions of the legislation will be reconciled and a final bill will be signed by the President early next year. Some have predicted a quick resolution of the differences between the House and Senate bills but my guess is that there will be several sticky problems forcing the debate to drag on for a few more “fun” weeks.

Once we have recovered from the year-end legislative blitz, and sampling too many holiday cookies, ATA will be developing a detailed analysis of the provisions in the House and Senate versions of the legislation (a combined total of over 3,000 pages) for how they affect the use of telemedicine. However, from a preliminary analysis of both bills it appears that Congress has ceded a large amount of the details to the administration to develop. The bulk of the bills’ substance is on various financial approaches to extend care to the uninsured as well as other basic structural changes. There are very little across-the-board modifications made to the types of services currently covered or the way in which they are delivered.

So don’t look in the legislation hoping to find a wholesale endorsement of telemedicine or any other new service or delivery mechanism.

It is not that Congress disagrees with these approaches. Instead, both the House and Senate bills provide for a number of demonstrations and have set up numerous independent processes and panels to evaluate them, implement the successes and spread the word about how they can be adopted, all without having to go back for Congressional approval. Consequently, the latest buzz-phrases in Washington are now “comparative effectiveness research” and “regional extension centers.”

Why did this happen? My guess is that the multitude of voices and horde of lobbyists and other interests advocating different approaches and services probably scared the staff and Members of Congress away from making any firm decisions. In fact, most pundits agree that Congress will be reluctant to bring up any other healthcare proposals next year after the major health reform legislation is finally passed.

This approach holds a lot of potential for telemedicine. In fact, it might accelerate what we have been trying to achieve. For example, the health reform bills include plans to test out “independence at home,” “accountable-care organizations” and “care coordination” approaches. These could end up endorsing remote monitoring and pave the way for its reimbursement. In other places, the bills call for a new CMS Innovation Center, Independent Payment Advisory Board, Patient-Centered Outcomes Research Institute and, in the House bill, a Telehealth Advisory Committee. These independent bodies could bring about significant changes in Medicare and even affect private insurance plans in ways that will help integrate telemedicine into the normal delivery of care.

But the real work is just starting. Soon, attention will turn to how the administration will implement the reform measures. Many of the proposals require regulations. Demonstrations will get underway. Various advisory panels will be appointed and given formal authority and directives. Studies will be launched.

But this will all be done in a different environment than what we have been seeing this year. There is a completely different set of lobbyists and interest groups that focus on the administration, rather than Congress. Some interests that have powerful Congressional allies are weak when it comes to the federal agencies. It is hard to predict how this will affect the final outcome of health reform on any specific topic. The press attention will shift away and the decision making will be made by the agencies largely outside of the public spotlight. This includes officials within CMS, which is still operating without an appointed director.

If we are lucky, we may get someone in the leadership at CMS that understands technology. But even then, it will be an important task for ATA and our members to get the embattled workforce at the agency to embrace new ways of delivering care.

This is the largest piece of legislation passed in many years and its full impact will not be felt, or understood, for a long time. As members of ATA, you can expect to hear many details over the coming months and may be asked to weigh in on a number of pending issues as the details of the legislation are put into place.