VENTURA COUNTY PERSPECTIVE : Rule Lacks Logic

Ventura County is right to vigorously challenge an arbitrary federal rule that would deny full Medicare reimbursement to most of the county’s health clinics because they happen to be located too far from the Ventura County Medical Center.

If all county residents lived near the hospital, there would be little need for neighborhood clinics.

In the latest of a series of expensive setbacks for Ventura County’s medical operations, the federal Health Care Financing Administration has declared that 34 of the county’s 43 clinics should not be billing Medicare at a higher, hospital-based rate because they operate independently of VCMC. The basis for that contention? The clinics are more than nine miles away.

The county has appealed the ruling to the Department of Health and Human Services in Washington, D.C., maintaining that the clinics are outpatient satellites of the public hospital. That designation qualifies the county to receive about $2 million more each year in Medicare reimbursements than if all the clinics were considered free-standing.

At a time when the county is scraping to repay $15.3 million it faultily billed as a result of last year’s failed attempt to combine its mental health and social services departments, that $2 million a year difference is especially worth a struggle.

Where did this nine-mile rule come from?

Federal law says hospital-based clinics must be close to the hospital but leaves it to each regional health care office to set the distance limit. Medicare payments to county hospitals in California, Arizona, Nevada and Hawaii are overseen by the office in San Francisco--which decided nine miles was the magic number. That might seem like a substantial distance in dense-packed San Francisco but not in a semirural county like Ventura.

Ventura County has brought many of its fiscal problems on itself by playing fast and loose with billing requirements. In this case, however, there is good reason to question the logic behind the nine-mile rule.

We urge the federal appeals panel to see the wisdom of Ventura County’s argument that the preventive care offered by the clinics is a cost-effective way to preserve the health of county residents and that nothing is gained by making them travel to within nine miles of the county hospital.