A Hard Look at CMS' Responsiveness

by Matt Mahady

In June 2001, the Bush administration announced that the then Health Care Financing Administration would obtain a new appellation. In Harry Potteresque fashion, HCFA was transformed into the Centers for Medicare and Medicaid Services (CMS). The name change was touted by government officials as a symbolic first step in a comprehensive effort to dramatically streamline bureaucracy, simplify regulatory red tape, and enhance the agency's responsiveness to the health care industry representatives it interacts with on a daily basis.

More than a year has passed since Department of Health and Human Services (HHS) Secretary Tommy Thompson boldly announced that a new "culture of responsiveness" would accompany HCFA's rechristening. Has Secretary Thompson's "culture of responsiveness" promise turned out to be empty rhetoric or has it truly heralded a new era in government-health industry relations?

For long-term care stakeholders, the question holds special relevance. A significant proportion of long-term care organizations, providers, and residents are affected by the agency's actions on a variety of levels. The CMS-administrated Medicare program, for example, provides health care coverage to all Americans over the age of 65, many of whom reside in long-term care facilities. In addition, long-term care facilities are subject to the regulatory oversight of CMS, including but not limited to high-profile programs such as the Nursing Home Quality Initiative (see "Mixed Reaction to CMS' Release of Nursing Home Quality Data" and "Making (Up) the Grade: What You Need to Know About Nursing Home 'Report Cards'" in the August 2002 issue of Caring, p. 1 & 6, respectively).

Reorganization Basics

The "new" CMS was organized into three divisions (see the August 2001 issue of Caring, p. 6) and a $35 million national media campaign targeted toward beneficiary outreach and education was launched. An already established 800 number was expanded and improved. New features included around-the-clock service and more detailed information.

Additional changes instituted by the agency included the convening of nation-wide "Open Door Forums" to solicit feedback; the identification and assigning of senior staff members to work with providers; and expanded outreach to health practitioner associations.

Officials at the new CMS also moved to expand the role of the physicians' regulatory issues team, an agency-wide group that addresses provider issues within the system and identifies specific solutions to burdensome Medicare requirements encountered by physicians.

CMS Claims Success

According to CMS officials, flexibility, efficiency, and commitment to service are now core organizational values. They claim that responsiveness to beneficiaries, providers, plans, states, and other stakeholders has become the focus of the reformed agency.

On May 16th, CMS Administrator Thomas A. Scully testified before the US House of Representatives Committee on Small Business that his top priority has been to improve the agency's responsiveness and make it a better business partner (see box at bottom).

"We are committed to simplifying our rules, making them easier to understand, and less burdensome," said Mr. Scully. "We also are committed to opening up CMS and creating more ways for the entities we regulate to interact with us. I personally travel around the country, meeting with and listening to literally thousands of providers, suppliers, physicians, beneficiaries, and others who live and work with the regulations we create, so I can hear their concerns and better understand the changes we need to make."

The Open Door Policy Forum initiative (see box at right) is being coordinated by Thomas Barker, CMS' Senior Outreach and Policy Advisor to the Administrator. Mr. Barker bristled at the notion that HCFA's transformation to CMS was merely cosmetic. "We've held 66 open door sessions with 1,100 participants in person and 4,500 participants on the phone," he emphasized. "We have resolved hundreds of individual questions and used the sessions to help us understand how our policies are working in the real world.

"The initial open door session, for example, focused on long-term care," he continued. "Nursing home advocates were extremely active and added a lot to the initiative. In several cases, the open door sessions caused us to make a change as an agency. So I would say that there has been a true culture change. The agency is more responsive to the beneficiaries we serve and the providers who treat them."

Colleen J. Cooper, MD, Medical Advisor in the Facility and Provider Compliance Division of the Minnesota Department of Health in St. Paul (which serves as a state-level enforcement and investigative arm of the CMS), reported that, insofar as CMS' role in enforcing and investigating long-term care facilities is concerned, "things have not changed very much."

But, she added, "it does seem to me, on both the state and federal level, that there is genuine, heartfelt interest in making this system more effective. This is reflected by all the listening sessions and the expansion of the 1-800-MEDICARE hotline. There is definitely more outreach to both the public and to the provider community."

The team responsible for enforcing CMS regulations must often walk a precarious tightrope, said Dr. Cooper. "It's really a tricky situation. There is a tension between providers who want us to be more cognizant of the impact of regulations on their ability to function as a business and nursing home advocates who want to make sure the conditions that led to the nursing home regulations of the 1970s are not allowed to occur again."

Cautious Optimism

When asked to assess the performance of CMS, the general response of long-term care industry representatives and front-line providers is that the agency is off to a good start, but still has a long journey to travel.

Barry A. Lazarus, Vice President and Director of Reimbursement for Toledo, Ohio-based HCR Manor Care, a chain of more than 500 long-term care facilities, commented that "with the change from HCFA to CMS, the agency has made significant strides in opening the lines of communication with the public and the provider community. While communication has improved, from a practical perspective we are still dealing with a very complex organization and the resolution of issues continues to require working your way through the bureaucratic maze."

AMDA Past President Cheryl Phillips, MD, CMD, Medical Director for Skilled Nursing and Chronic Care at Sutter Health in Sacramento, CA, and current Chair of AMDA's Public Policy Committee, said that "obviously, culture change and outside perceptions require much more than a mere name change to effect a difference. Most looked upon the name change with considerable skepticism. However, I do believe that the goal of responsiveness is much deeper than the new letters of the name. I do believe that both Secretary Thompson and Mr. Scully have made significant attempts to understand those regulatory barriers that get in the way of quality improvement and are slowly pushing the glacier in a different direction."

"They are trying," concurred Jonathan Musher, MD, CMD, Corporate Medical Director for Beverly Enterprises in Chevy Chase, MD. "I do think that they are trying to change and trying to solicit information and opinions. Nothing comes about overnight and the agency still has a long way to go. We [CMS and the long-term care industry] could still do a better job at trying to work together as a team to ensure appropriate care for residents in nursing homes and the elderly in general."

Bruce G. Rosenthal, Director of Media Relations for the American Association of Homes and Services for the Aging in Washington, DC, also gave CMS' freshman year a passing grade. "The agency is on the right track," he said. "It is providing consumers and providers with improved information and services. The nursing home quality initiative, launched as a pilot in six states last April, signaled a new emphasis by CMS on quality improvement in nursing home care."

However, Mark Agronin, MD, of the Miami Jewish Home & Hospital for the Aged in Miami, FL, cautioned that "although such information can be incredibly helpful to individuals seeking to evaluate nursing facilities, it can also be misinterpreted in ways that may wrongly damage an institution's reputation."

Although criticism of CMS was fairly muted, long-term care stakeholders were not unanimous in their praise. Gary J. Kennedy, MD, President of the American Association for Geriatric Psychiatry in Bethesda, MD, held that "even minimal change has yet to emerge. The system-wide issues of discrimination against mentally ill patients and their providers; chaotic and inconsistent Medicare carrier policies; and lack of clarity in documentation and reimbursement procedures continue to demoralize patients, their families, and their doctors."

More Than a Name Change

The overall consensus is that the "culture of responsiveness" that Secretary Thompson spoke of last year seems to have taken root as a sincere, organization-wide commitment. It is too soon to tell, however, if the cultural change at CMS will translate into tangible benefits for long-term care providers and residents.

Even if CMS reforms are wildly effective and beneficial to all long-term care stakeholders, the overarching question of Medicare's solvency as a funding mechanism remains. Moreover, the increase in CMS responsiveness is not likely to soften the blow of pending decreases (of approximately 10%) slated for the Medicare program as a whole and the corresponding pressure that this shortfall will have on rates of provider reimbursement. As Dr. Cooper noted, "all we have seen so far are the efforts. We do not know the outcomes yet."

Matt Mahady is a medical journalist.

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