Understanding Washington: a nephrologist's perspective from inside the Beltway.

The major principles that drive U.S. federal health policy-making are: (1) fixed or reduced costs, (2) ensured outcomes (or no evidence of undertreatment), (3) streamlined administration, and (4) political viability. A corollary is that providers are uniquely sensitive to financial incentives. Understanding these principles is vital to understanding federal health policy. Critically, these principles are nonpartisan and have been supported and used by all administrations since President Reagan. This article examines the end-stage renal disease (ESRD) prospective payment system, colloquially called "The Bundle," in the context of these major principles. Successful health policy, successful legislation, and successful regulation building all require executive leadership, mutual trust, and compromise. This is demonstrated by the events surrounding the passage of the Medicare inpatient prospective payment system, which governs hospital reimbursement for Medicare beneficiaries, including those not covered in the ESRD program. Given that the ESRD benefit consumes 6.3% of the Medicare budget for approximately 2% of Medicare beneficiaries, if nephrology is to experience future success, we must change how both policymakers and the wider field of medicine perceive our specialty. Understanding the major principles behind health care policy may facilitate this goal.

Modernizing Medicaid eligibility criteria for children with significant disabilities: moving from a disabling to an enabling paradigm.

Children with significant disabilities may qualify for Medicaid benefits, regardless of household income, if their state elects to offer the Tax Equity Fiscal Responsibility Act (TEFRA) option. However, a significant number of children with serious medical problems presently are being denied eligibility for, or terminated from, this Medicaid program. This Article describes the ways in which the existing health insurance system inadequately meets the needs of children with significant disabilities, recounts the history and development of the TEFRA Medicaid coverage option, and analyzes the eligibility criteria used by the various states. It proceeds to consider how disability should be legally defined in the health care context and proposes reforms to modernize the eligibility standards so that these benefits can be more effectively, efficiently, and fairly allocated. To accomplish this goal, the federal statute and regulation that define disability, as well as corresponding state laws, must be reformed so that the law can keep pace with advances in modern medical science, and people with disabilities are not, in effect, penalized for receiving currently accepted preventative care that maintains health but will never cure the underlying disease.

The TEFRA medicaid eligibility option for children with severe disabilities: a national study.

The Tax Equity and Fiscal Responsibility Act (TEFRA) Medicaid Eligibility Option, also known as the Katie Beckett Option, was developed to allow children with disabilities from near-poor and middle-income families to qualify for Medicaid. TEFRA has been available since 1982; however, little is known about the number of children served and their qualifying disability. This first national study found that 20 states enrolled nearly 25,000 children in 2001. Only 10 of these states allowed children to qualify because of a mental health disability. Additional research is needed to understand the role of TEFRA in providing insurance to children with disabilities.

Implications of the Balanced Budget Act of 1997 for general hospital psychiatry inpatient units providing medical and psychiatric services.

Since 1983, the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 has determined payment for services in most psychiatry units located in general hospitals. This system provided reimbursement on a cost-per-discharge basis. In 1997, a Balanced Budget Act (BBA) was passed by Congress which has replaced the TEFRA system of 1982 (H.R 2015). As a result of this law, many general hospital psychiatry units, particularly those that address the needs of elderly patients with high levels of medical comorbidity, will experience a reduction in their reimbursement when compared with the old TEFRA system. This reduction will average 7.8% and affect up to 84% of health care organizations. Those with higher TEFRA target amounts, such as is found with most general hospital programs, will have proportionately greater reductions. This article summarizes legislation affecting Medicare reimbursement and suggests a service reorganization approach that would allow billing to both medical and psychiatric payers. Finally, it encourages active participation in psychiatric access and quality standards development and with legislation, such as The Medicare Psychiatric Hospital Prospective Payment System Act of 1999.