CMS keeps physician Medicare input link intact; AMA urges local presence

Carrier advisory panels and medical directors are seen as ways doctors can influence coverage decisions.

By Markian Hawryluk, amednews staff. Dec. 24/31, 2001.

San Francisco -- Rumors of the demise of Medicare carrier advisory committees and medical directors in each state may have been greatly exaggerated.

At the recent AMA Interim Meeting, an official from the Centers for Medicare & Medicaid Services voiced strong support for the continued need for the committees and medical directors.

"The agency fully supports carrier medical directors and carrier advisory committees," said Barbara Paul, MD, director of the Physicians' Regulatory Issues Team at the CMS Center for Medicare Management. "We really believe in their value to the program, and there has been no pulling back from both CMDs and carrier advisory committees. So I want you to hear that loud and clear."

Dr. Paul spoke to delegates as they debated and later passed a resolution calling for the AMA to push CMS to retain the physician input that the committees and medical directors provide. In August, CMS had issued a draft policy that would give Medicare contractors the flexibility to change the advisory panel and medical director system structure and process, including eliminating individual state entities and moving to regional ones.

Joseph Bailey, MD, a rheumatologist from Augusta, Ga., said having physicians who can advise the carrier and communicate with other doctors in the state is vital to maintaining a positive relationship between physicians and Medicare.

"After 10 years of repetitive difficulty, we had found in the forum provided by the carrier advisory committee, and through the medical director for the carrier, the opportunity to do something constructive to influence the program in Georgia," Dr. Bailey said. "We felt that if this is extended to a regional level of activity, that it will decrease the various states' individual input into the issues about Medicare."

Most Medicare coverage policies are set by local carriers.

But Dr. Paul said there might have been some misunderstanding about CMS' commitment to the committees and medical directors because one carrier threatened to let go of its medical directors and because the agency had been seeking "input and fresh thinking" about their roles.

"We want to be smarter about this," Dr. Paul said. "We realize that carrier medical directors are not all made alike. And just popping a doctor in the slot is not what we need. We need the right doctors with the right job description in that slot."

Dr. Paul said CMS was considering using the carrier medical directors in an educational role, allowing them to become "outreach problem solvers." Initially those positions were intended to serve a program integrity function.

Dr. Paul also urged physicians to make contact with their specialty society representative on their carrier advisory panel to maintain an avenue of communication between physicians and carriers and vice versa.

"We rely on carrier advisory committees not only to give us input into the agency and into the program, but to give information back out to the physician community," Dr. Paul said. "I've been repeatedly surprised at how many physicians don't know who their carrier advisory committee representative is."

The AMA is considering increasing its dialogue with the advisory panels and carrier medical directors. According to AMA Trustee Duane M. Cady, MD, the board is considering inviting the committees and directors to the interim and annual meetings to receive their input on Medicare issues and to have a chance to convey physicians' concerns to the carriers.

The advisory committees and medical directors have long served as a means by which physicians can impact the Medicare program, particularly on local medical review policy.

Carriers currently determine an estimated 80% to 90% of Medicare coverage policies locally, while national coverage decisions account for the remainder.

Contractor reform concerns

Physicians' fear of losing local contacts has been magnified by recent legislative action. The regulatory relief bill passed by the House in early December also included contractor reform and consolidation provisions, but it did not address the advisory bodies and carrier medical directors.

In a letter to CMS, the AMA urged the agency to retain the local entities, especially if it consolidates contractors as CMS has indicated it would like to do. "The possibility of contractor reform and consolidation only increases the need for Medicare to have a local presence in each state, whether or not claims processing and other carrier functions are performed in each state," the AMA said.

If physician access to advisory committees and medical directors is limited through consolidation, Medicare beneficiaries might not obtain coverage for certain services, said John Kincaid, MD, a neurologist on the faculty of the Indiana University School of Medicine, Indianapolis.

"In Indiana, over the years we've had a very successful dialogue with our carrier and have been able to advance the molecular diagnostic and other neurological treatment options for patients in our state because of this ongoing dialogue," Dr. Kincaid said. "Web sites and 800 numbers are fine, but that local across-the-table dialogue has been most important in giving our patients the best care possible."