GOVERNMENTLocal commotion: The flip side of national Medicare policy-makingWhen carriers make restrictive local Medicare coverage decisions, it can derail relations with the physician community.By Markian Hawryluk, amednews staff. Aug. 5, 2002. Former House Speaker Tip O'Neill coined the phrase "all politics is local." The same could be said about Medicare coverage decisions. While a national coverage decision process exists, most policy is made by individual Medicare contractors -- carriers that administer the program on a state or regional basis. And when local decisions restrict coverage, it can cause a lot of commotion in the physician community. That's exactly what happened with a treatment for kidney dialysis patients. Last year, Jacksonville, Fla.-based First Coast Service Options Inc., Florida's Medicare contractor, adopted a more conservative policy on vitamin D replacement therapy for such patients. The move caused an uproar among doctors but still became the engine driving interest in similar policies in other states. The case points to the advantages and disadvantages of local decision-making in Medicare. It also highlights issues ripe for debate as carrier consolidation and the work of a national policy advisory body spark a trend toward more uniformity in coverage policy. In Florida, First Coast's original proposed policy would have covered just the oral formula of the medication initially and reserved use of intravenous treatment for patients who responded poorly to the oral vitamin D therapy. The company later abandoned that plan but announced it no longer would cover the drug Zemplar (paricalcitol) but would cover the drugs Calcijex (calcitriol) or Hectorol (doxercalciferol). First Coast estimated the move would save Medicare millions in Florida alone without harming patient care.
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Copyright 2002 American Medical Association. All rights reserved.
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