CBO Proposes Medicare Amendment To Reduce Deficit

CBO just released a score of the Medicare legislation (HR 6331, with a proposed amendment) under consideration in the House. In total, CBO estimates that the bill would reduce deficits by $0.3 billion over the 2008-2013 period and by less than $50 million over the 2008-2018 period.
The five-year savings would decline to $0.1 billion if the pending supplemental appropriations act is cleared before H.R. 6331.
Honorable John D. Dingell
Chairman
Committee on Energy
and Commerce
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
The Congressional Budget Office has prepared the enclosed table (PDF) summarizing the budgetary effects of an amendment in the nature of a substitute to H.R. 6331, the Medicare Improvements for Patients and Providers Act of 2008. CBO estimates that enacting H.R. 6331 with that proposed amendment would reduce direct spending by $0.1 billion over the 2008-2013 period and increase direct spending by $0.3 billion over the 2008-2018 period. In addition, the Joint Committee on Taxation estimates that enacting the bill would increase federal revenues by $0.2 billion over the 2008-2013 period and by $0.4 billion over the 2008-2018 period. In total, CBO estimates that the bill would reduce deficits (or increase surpluses) by $0.3 billion over the 2008- 2013 period and by less than $50 million over the 2008-2018 period. (The five-year savings would decline to $0.1 billion if the pending supplemental appropriations act is cleared before H.R. 6331.)
The bill would cancel a reduction in Medicare’s physician fees scheduled to occur under current law on July 1, 2008. The bill would freeze those payments at their current levels for the remainder of the year and increase them by 1.1 percent in January 2009. Future payments beyond 2009 would revert to the levels under current law, necessitating a 21 percent reduction in payments under the physician fee schedule in 2010. The bill also would extend many expiring provisions in Medicare, expand Medicare’s coverage of preventive services, and modify the rules governing eligibility for the Medicare Savings Program.
New spending under the bill would be offset largely by reductions in payments to Medicare Advantage plans. The bill, with the proposed amendment, would phase out payments for indirect medical education made to plans and hospitals for Medicare Advantage enrollees, leaving in place the separate payments for indirect medical education made directly to teaching hospitals that treat Medicare Advantage enrollees. It also would require private fee-for-service plans to establish networks of providers, comparable to requirements for other Medicare Advantage plans, but with some exceptions, which CBO estimates would lead to decreases in enrollment and reduced outlays. Other savings would come from modifications to the Physician Assistance and Quality Initiative fund and changes to Medicare’s payments for home oxygen therapy.
In addition, the bill would delay a program of competitive bidding for durable medical equipment and reduce the Medicare payments for those items until the program is resumed.

Complications From Screening Endoscopic Procedures Underestimated

Screening procedures are often considered to be benign. While this is true compared to the diseases being screened for such as colon cancer, a new study reports the rate of serious side effects from endoscopic procedures (endoscopy and colonoscopy) is actually 2- to 3-fold higher than recent estimates.
Daniel A. Leffler, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues have published the results of their study in the Oct. 25 Archives of Internal Medicine. Rather than relying on the standard physician reporting method of adverse events, the researchers used electronic medical records to track patient emergency visits and hospital admissions that occurred within two weeks of their endoscopic procedure.
A total of 15 to 20 million endoscopic procedures are performed annually in the United States. The American Society for Gastrointestinal Endoscopy (ASGE) survey from 1976 remains one of the most commonly cited and states the complication rate of 0.13% for upper endoscopy and 0.35% for colonoscopy.
Leffler and colleagues evaluated 6383 upper endoscopies (EGDs) and 11 632 colonoscopies within the BIDMC system. The EMR captured 419 ED visits and 266 hospitalizations which occurred within 14 days after the procedure.
Nearly a third of the ED visits (134 of 419, 32%) and hospitalizations (76 of 266, 29%) were found to be related the procedure. Only31 of these incidents were recorded by the standard physician reporting system.
The most common reasons for the ED visits related to the endoscopic procedures were abdominal pain (47%), gastrointestinal bleeding (12%), and chest pain (11%). The mean time for a trip to the ED after a procedure was six days for EGDs, and 5.2 days for colonoscopies.
The researchers found procedure-related hospital visits occurred in 1.07% of all EGDs, 0.79% of all endoscopies, 0.84% of colonoscopies, and 0.95% of all screening colonoscopies.
This 1% incidence of related hospital visits within two weeks of outpatient endoscopy is more five times the 1976 stated risk of o.13% for upper endoscopy. It is nearly three times higher than 1976 stated risk of 0.35% for colonoscopy.
Using Medicare standardized rate, the researchers estimated the mean costs at $1403 per ED visit and $10 123 per hospitalization. Across the overall screening/surveillance colonoscopy program, these episodes added $48 per examination.
As this study could only capture the ED and hospital visits within the BIDMC, there may have been some missed if other hospitals were used by the patient. Regardless, the procedures and possible risks must be discussed and considered with patients.
This small risk should not prevent patients from screening for serious diseases such as colon cancer or Barrett’s esophagitis which may lead to esophageal cancer.