Provisions Relating to Part B
Subpart A: General Provisions - Continues payment reductions under part B (Supplementary Medical Insurance) of the Medicare program made pursuant to the Balanced Budget and Emergency Deficit Control Act of 1985 through the first half of FY 1990. Provides for the gradual transition, from 1992 through 1995, to the determination of Medicare payments for physician services pursuant to a fee schedule which takes into account the relative value of the work, practice expenses, and malpractice risks associated with each physician services. Allows for geographic variations in resource values and fee schedule adjustments which take into account inflation, changes in demand for and the technology of a physician service, and inadequate access to such service. Sets Medicare payments for nonparticipating physicians' services at 95 percent of the fee schedule amount. Prohibits payments for the same physician service from varying on the basis of whether or not the physician is a specialist. Sets forth sumptuary provisions. Limits nonparticipating physicians' actual charges for unassigned claims. Requires that payments for physician services to Medicaid-eligible Medicare beneficiaries be made on an assignment-related basis. Increases the incentive payment for physicians' services furnished in manpower shortage areas from five to ten percent of the payment for such services. Sets forth miscellaneous study and reporting requirements. Amends the Public Health Service Act to create a new title to establish, within the Public Health Service, the Agency for Health Care Research and Policy (Agency) to enhance the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad base of scientific research, and improvements in clinical practice and in the organization, financing, and delivery of health care services. Requires that the agency be headed by an Administrator for Health Care Research and Policy, to be appointed by the President. Directs the Secretary of Health and Human Services, through the Administrator, to carry out the new title. Sets forth the general authorities and duties of the Administrator, including conducting and supporting research, demonstration projects, evaluations, training, and the dissemination of information. Prohibits the Administrator from restricting the publication of data or results from projects conducted or supported under the new title, but prohibits disclosure of identifying data without consent. Directs the Administrator and the Director of the National Library of Medicine (the Library) to enter into an agreement for indexing, abstracting, translating, publishing, and other services leading to a more effective and timely dissemination of information on research, demonstration projects, and evaluations. Directs the Administrator to promote the development and application of appropriate health care technology assessments. Establishes at the Library an information center on health care technologies and health care technology assessment. Directs the Administrator and the Director of the Library to enter into an agreement providing for the information center the Administrator to make recommendations to the Secretary with respect to whether specific health care technologies should be reimbursable under federally financed health programs. Establishes within the Agency the Office of the Forum for Quality and Effectiveness in Health Care, to be headed by a director to be appointed by the Administrator. Directs the Administrator, through the Director, to establish the Forum for Quality and Effectiveness in Health Care to develop, review, and update: (1) clinically relevant diagnosis and treatment guidelines for physicians and health care practitioners; and (2) standards of quality, performance measures, and medical review criteria. Requires the Director to contract with public or private nonprofit entities and convene panels of qualified experts, practicing physicians, and health care consumers for the development of such guidelines and standards. Amends part A (General Provisions) of title XI of the Social Security Act to direct the Secretary, through the Administrator for Health Care Research and Policy, to: (1) conduct and support research with respect to the outcomes of health care services and procedures to identify how diseases and disorders can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically; and (2) assure that Medicare needs and priorities are reflected in treatment-specific or condition-specific practice guidelines. Directs the Secretary to establish priorities with respect to the diseases and disorders for which outcome evaluations are to be conducted. Imposes additional duties on the Secretary concerning the administration of outcomes research and information dissemination. Authorizes appropriations for outcomes research for FY 1990 through 1994. Amends the Public Health Service Act to establish the National Advisory Council for Health Care Policy, Research, and Evaluation to advise the Secretary and the Administrator with respect to activities of the Agency for Health Care Research and Policy. Requires that technical and scientific peer review be conducted on each application for a grant, cooperative agreement, or contract under the new title of the Public Health Service Act added by this Act. Prohibits application approval by the administrator unless the application has been recommended for approval by a peer review group. Directs the Administrator to: (1) establish guidelines for uniform methods of developing and collecting data under the title added by this Act; (2) assure that statistics developed under that title are of high quality, timely, comprehensive, specific, standardized, and adequately analyzed and indexed; and (3) disseminate the statistics and widely as possible. Authorizes appropriations for FY 1990 through 1992 to carry out the title added by this Act. Requires, in addition, that a portion of amounts available under specified existing provisions of the Public Health Service Act relating to evaluations of programs be made available for evaluations under the title added by this Act. Removes from the Public Health Service Act provisions establishing the National Center for Health Services Research and provisions providing for grants for a council on health care technology. Directs the Secretary to request the Institute of Medicine of the National Academy of Sciences to enter into a contract to: (1) recommend priorities for the assessment of specific health care technologies; and (2) assist in the establishment of the information center. Authorizes appropriations for FY 1990 for carrying out such contract. Provides for the transfer of information and materials developed by the council on health care technology to the Secretary in establishing the information center on health care technologies and health care technology assessment. Amends part B (Supplementary Medical Insurance) of the Medicare program to reduce Medicare payments for a specified list of physicians' services furnished during the last three quarters of 1990. Reduces payments for radiology services (other than portable X-ray services). Requires the Secretary to establish a relative value guide for use in all carrier localities in making payment for physician anesthesia services. Prohibits the rounding of fractional time units in calculating Medicare payments for anesthesia services. Delays the Medicare economic index adjustment to payments for physicians' services from January 1, 1990, to April 1, 1990. Extends Medicare physician and supplier participation agreements for which a termination is not requested before December 31, 1989, through March 31, 1990. Limits increases in the Medicare economic index for the final three quarters of 1990 to: (1) zero percent for radiology services, anesthesia services and other physicians' services on a specified list; and (2) two percent for other physicians' services, excepting primary care services. Requires the Secretary to set the customary charge for new physicians' services for the last three quarters of 1990 at 85 percent of the prevailing charge for such services. Limits payment for physician services furnished by more than one specialty. Prohibits Medicare carriers from recovering certain part B overpayments made between July 1, 1985, and March 31, 1986. Reduces payments for the capital-related costs of outpatient hospitals services for FY 1990 by 15 percent, except when the hospital is a sole community hospital. Eliminates the requirement that a fee schedule for clinical diagnostic laboratory tests be established on a nationwide basis. Lowers the payment ceiling for a clinical laboratory test to 93 percent of the median of all fee schedules established for that test for that setting. Allows medicare payments for such tests to be made to the referring laboratory only if: (1) it is located in, or is part of, a rural hospital; (2) it submits payment requests for tests of which no more than 30 percent in any year are performed by another laboratory; or (3) it is involved in a common ownership relationship with the laboratory performing the test. Delays current cost-of-living updates of payments for durable medical equipment until 1991. Establishes a 15-month cap on rental payments for an enteral or parenteral pump. Requires the payment of reasonable pump maintenance and servicing fees after the expiration of such period. Reduces payments for seat-lift chairs and transcutaneous electrical nerve stimulators furnished on or after April 1, 1990, by 15 percent. Treats power driven wheelchairs as routinely purchased durable medical equipment for Medicare payment purposes. Requires the Secretary to specify criteria to be used by carriers in deciding on a case-by-case basis whether to classify power-driven wheelchairs as customized items for payment purposes. Treats ostomy supplies as home health services which home health agencies must provide to beneficiaries who need them. Eliminates the restriction of covered psychologist services to services furnished at community mental health centers. Covers clinical social worker services pertaining to the diagnosis and treatment of mental illnesses. Directs the Secretary to develop criteria requiring covered psychologists to consult with their patients' physicians within a reasonable time after initiating treatment so as to consider physical conditions that may be contributing to their patients' symptoms. Eliminates the dollar limitation on part B coverage of mental health services. Covers the services of nurse practitioners working in collaboration with a physician in a nursing facility. Makes Medicare payments for such services to the nurse practitioner's employer. Requires Medicare carriers to permit routine part B payments for up to 1.5 monthly visits per resident of a nursing facility by a member of a team which includes a physician and physician assistant and/or nurse practitioner. Directs the Secretary to establish at least one demonstration project applying such limitation on visits on an average basis over the aggregate total of nursing facility residents served by team members. Covers a screening pap smear for women who have not undergone such a test during the preceding three years or for a shorter period set by the Secretary for women at higher risk of developing cervical cancer. Covers outpatient rural primary care hospital services. Directs the Secretary to develop and implement a prospective payment system for determining payments for such services by January 1, 1993. Subpart B: Technical and Miscellaneous Provisions - Permits the coverage of additional inserts for therapeutic shoes for individuals with severe diabetic foot disease and the substitution of shoe modifications for inserts. Extends indefinitely the coverage of certified registered nurse anesthetist services as inpatient hospital services when furnished at rural hospitals with 500 or fewer surgical procedures requiring anesthesia services per year. Increases the payment limit for physical and occupational therapy services. Requires studies into payments for portable X-ray services, ambulance services, hospital outpatient services, assistants at surgery, blood clotting factor for hemophilia patients, and standards for the use of and payment for durable medical equipment. Amends the Consolidated Omnibus Budget Reconciliation Act of 1985 to terminate four specified municipal health service demonstration projects by January 1, 1994. Amends the Medicare program to narrow the range of acceptable purchase prices for durable medical equipment. Covers diagnostic tests performed in physician office labs which meet specified certification requirements.