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C M S  R E F L E C T I O N S
 
26 July 2005  
  

My Life At HCFA: A True Parable

The bottom line is getting people the medical care
they need and deserve.


by Bruce C. Vladeck


The best four and a half years of my professional life—as administrator of the Health Care Financing Administration (HCFA)—involved many tense congressional hearings, White House meetings, late-night phone conversations with the health and human services (HHS) secretary’s office or the Office of Management and Budget (OMB), and other stuff of high drama. Those years also contained a constant flow of formidable intellectual challenges: how to improve the hospital wage index; how to reduce beneficiaries’ copayments for outpatient services without busting the budget; how to permit states flexibility to expand Medicaid without violating federal law; and so on. But perhaps my fondest memory concerns something more mundane.

Alone in my office one evening, I picked up the phone. On the other end was a young constituent service staffer from Rep. Louis Stokes’s office in Cleveland. Her call had obviously been misdirected, and she was flustered and embarrassed to find herself talking to me. She offered to call back in the morning, but I told her I would be happy to try to help her, and she told me the following story.

Her constituent was a man in his fifties who had lost an arm in an industrial accident, as a result of which he qualified for Social Security Disability Insurance (SSDI) and, thereafter, Medicare, which was his only health insurance. With the income SSDI provided, and good health, he had managed for years to support himself quite adequately in the community, having no family and living alone.

Then he developed carpal tunnel syndrome in his remaining hand. A sympathetic physician tried every form of medical and mechanical treatment for this painful and debilitating ailment, without avail. At that point, the surgical procedure of carpal tunnel release was the obvious and only treatment choice. It is routine and generally successful, with only one major problem: For six weeks after surgery, the patient has no effective use of the hand that has been operated on. For most patients, that’s a major inconvenience; for a one-armed man living alone, it would be catastrophic.

The sympathetic doctor proposed admitting the patient to a nursing home for the six postoperative weeks so he could have assistance with feeding, dressing, bathing, and so forth—but Medicare will only pay for skilled nursing stays immediately subsequent to a hospitalization of three or more days. So, the doctor said, he would have the patient admitted for the surgery, although it was almost always done on an outpatient basis. Then he learned that Medicare would only reimburse for carpal tunnel releases on an outpatient basis. At that point, the doctor gave up, the patient called his congressman’s office, and that office called me.

Thanks to the power of the administrator’s office and, more importantly, good staff work in HCFA’s Chicago regional office, we waived the outpatient-only requirement for the surgery (the three-day prior stay for the nursing home was not waivable under law). The man got his surgery and, I hope, lived happily ever after. I felt as though I had actually accomplished something.

Every day more than a million Medicare and Medicaid beneficiaries receive the medical services they need because of those programs, most with far less difficulty than Congressman Stokes’s constituent. Between them, Medicare and Medicaid consume a significant part of overstrained state and federal budgets, serve as the lifeblood of the nation’s largest industry, and preoccupy ideologues across the political spectrum. But the bottom line is getting people the medical care they need and deserve. Inside the Beltway, people can lose sight of that basic goal. The administrator’s job is to make sure that neither he nor his agency ever does.

Bruce Vladeck (bruce.vladeck{at}cy.com) is a principal at Ernst and Young LLP in New York City. He was administrator from May 1993 to September 1997. Before serving at HCFA, he was president of the United Hospital Fund of New York and a member of the Prospective Payment Assessment Commission. After leaving HCFA, he was appointed to the National Bipartisan Commission on the Future of Medicare.

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DOI: 10.1377/hlthaff.w5.335
©2005 Project HOPE–The People-to-People Health Foundation, Inc.