Medicare Direct Access to Audiologists – Defined!

1. Medicare Direct Access to Audiologists – Defined! Linda Jacobs-Condit Wayne Foster Tom Hallahan

2. What is Direct Access? Client PhysicianAudiologist Direct Access to Audiologist The ability to see a patient without a referral from a physician or other health care provider.

3. Current Status for Audiology ServicesImpact on Clients and Clinicians Limits beneficiary choice of providers Increases costs to Medicare program Increases wait time to see an Audiologist Inefficient use of physician resources Administrative burden on audiologists to track down referral if patient comes in without one

4. Current Medicare PoliciesAudiometric Testing Audiology services are recognized for Medicare purposes as a diagnostic test under the Social Security Act (Sec. 1861 (s)(3)) Regulations require that diagnostic tests be ordered by a treating physician for the purpose of using the results of the test in the management of the beneficiaries’ specific medical problem. (42 CFR 410.32)

5. Current Medicare CoverageAudiology Services • Testing must be for: • obtaining additional information necessary to make a diagnosis • evaluation of the need for the appropriate type of medical or surgical treatment of a hearing deficit or other medical problem. • Audiology services are not covered when the diagnostic services are furnished only to determine the need for a hearing aid. • Rehabilitative services are NOT covered.

6. Direct Access vs. SupplierStatusCurrent SLP Status Major Point: Supplier Status is not the same as Direct Access • Supplier status allows for the ability to enroll as a private practitioner in the Medicare program. • SLP services require physician oversight. • CMS physician certification on a plan of care and a 30 day recertification on (SLP) plan of care as a condition of payment. • Legislative process took 25-30 years.

7. Medicare Direct AccessWhat it would mean for Audiologists Beneficiaries could go directly to an audiologist. Audiology will remain a diagnostic benefit. Medicare will not pay for services deemed not medically necessary or perceived as a screen. Need to develop additional education of patients on Medicare coverage policies and exclusion of audiology services related to hearing aids.

8. Medicare Direct AccessChallenges for Audiology • Historical bias of the physician community that audiologists will not refer back when medical condition is detected • Centers for Medicare and Medicaid Services (CMS) • Cost/Fiscal Impact on the Medicare Trust Fund

9. Direct Accessto Audiologists Legislation • H.R. 3024 “Medicare Hearing Health Care Enhancement Act of 2009” • Section 3: Allows Medicare beneficiaries direct access to an audiologist • Section 4: Defines audiology services as a diagnostic benefit • Section 5: Nothing in the act will expand scope of audiology services for which payment can be made under Medicare • Currently 42 co-sponsors • H.R. 3024 was offered as an amendment during the Energy and Commerce mark-up on health care reform. The amendment was introduced and withdrawn due to cost issues. Direct Access is currently not included in health care reform. • The legislation is still active and gaining co-sponsors in 09-10 legislative cycle.

10. Direct Access to AudiologistsChallenge 1: Physician Community Patient Safety How to ensure FDA Red Flag regulations are followed by the audiologist

11. CMS initiative to enhance quality within the Medicare program by establishing incentives to providers to report quality measures in exchange for an annual bonus based on Medicare payments. Medicare Improvements for Patients and Providers Act (MIPPA) defined audiologists as eligible to participate in PQRI. Until recently no audiology quality measures existed that could be used by the profession. Possible Solution to Physicians’ ConcernsPhysician Quality Reporting Initiative (PQRI)

12. Audiology Quality Consortium (AQC) - organization of audiology groups convened by ASHA to develop quality measures for PQRI. AQC developed 12 measures – many based on FDA referral requirements. CMS, in the Medicare Physician Fee Schedule final rule announced three audiology referral measures for PQRI. Possible Solution to Physicians’ Concerns Physician Quality Reporting Initiative (PQRI)

13. Possible Solution to Physicians’ Concerns Physician Quality Reporting Initiative (PQRI) 2010 PQRI Quality Measures for bonus payment: • Referral for Otologic Evaluation those Patients with Visible Congenital or Traumatic Deformity of the Ear • Referral for Otologic Evaluation those Patients with History of Active Drainage from the Ear within the previous 90 Days • Referral for Otologic Evaluation those Patients with a History of Sudden or Rapidly Progressive Hearing Loss within the Previous 90 days.

14. Direct Access to AudiologistsChallenge 2: CMS* • CMS 2006 Report to Congress • Potential Devaluation of Codes • Diagnostic benefit – technical or professional services Let’s look at each of these challenges. * CMS – Centers for Medicaid and Medicare Services

15. Direct Accessa.CMS Report to Congress Findings Physician referral policy: • is a key means by which Medicare program assures that beneficiaries are receiving medically necessary services. • serves as a control to avoid potential payment for asymptomatic screening tests that are not covered by Medicare.

16. CMS Report to Congress (continued) Direct Access Conclusions • Diagnostic tests are not considered reasonable and necessary unless they are ordered by the patient’s physician or non-physician practitioner who will employ the tests to diagnose and treat the patient’s symptoms and conditions. • The referral policy is a key means by which the Medicare program assures that beneficiaries are receiving medically necessary services, and avoids potential payment for asymptomatic screening tests that are not covered by Medicare. • Absent referral, CMS has concerns that there are no reasonable alternative mechanisms to assure that Medicare avoids payment for non-covered screening tests.

17. Direct Accessb. CMS Devaluation of Codes • In the 2010 Medicare Physician Fee Schedule final rule, CMS stated that it will not reimburse any audiology service that can be construed to have an evaluation and management or therapeutic component. • Impacts tinnitus code, auditory rehabilitation and cochlear implant codes. • CMS made this ruling based on the fact that audiology services are covered as part of the diagnostic benefit.

18. Direct Accessc.CMS defines Audiology as a technical NOT professional services • CMS views diagnostic services as technical in nature with no professional components. • Audiology is reimbursed under the diagnostic benefit. • Private payers often mirror CMS coverage policies.

19. Direct AccessPotential Solution to CMS Concerns Comprehensive Audiology Benefit • Work with Congress to define in statute a comprehensive audiology benefit that would include both diagnostic and therapeutic intervention. • Comprehensive benefit would include direct access to audiology services. • Not include coverage of hearing aids.

20. CMS had indicated concerns with increased cost Historically Congressional Budget Office (CBO) factors in woodworking effect*. No concrete data on cost of direct access or comprehensive benefit High cost requires an off-set in the Medicare program Comprehensive Audiology BenefitCost/Fiscal Impact on the Medicare Trust Fund * Woodworking Effect: If benefit is available –more providers will enroll and beneficiaries will access.

21. Comprehensive Audiology BenefitPotential Solutions - The Elephant in the Room • There has been little to no discussion/study on the fiscal impact of direct access and/or a comprehensive audiology benefit. • More research needs to be done on this issue for more effective advocacy at both Congress and CMS.

22. Direct AccessStrategies for facilitating change Direct Access is only one facet in Medicare recognition of audiology services. Need recognition of full scope of services – rehabilitative and habilitative treatment Medicare audiologic benefit would improve services to clients

23. Direct AccessStrategies for facilitating Change Collaboration with AAA, AAO-HNS Need for more information on cost of direct access/ expansion of services Buy-in from Medicare Continue to convene the audiology consortium addressing PQRI

24. Questions/Discussion

25. Direct Access References/Resources National Institute on Deafness and Other Communication Disorders (NIDCD). National Strategic Research Plan: Hearing and Hearing Impairment. Bethesda MD: HHS, NIH, 1996. National Institute on Deafness and Other Communication Disorders (NIDCD), National Institutes of Health, Hearing Loss in Older Adults, http://www.nidcd.nih.gov/health/hearing/older.asp. National Institute on Deafness and Other Communication Disorders (NIDCD), National Institutes of Health, Presbycusis (2009), http://www.nidcd.nih.gov/health/hearing/presbycusis.asp

26. Direct Access References/Resources Lethbridge-Cejku M, Schiller, JS, Bernadel, L. Summary health statistics for U.S. Adults; National Health Interview Survey, 2002. National Center for Health Statistics. Vital Health Stat 10(222). 2004. Cruickshanks KJ, Wiley, TL, Tweed, TS. Et al. Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin: The Epidemiology of Hearing Loss Study, American Journal of Epidemiology 148(9): 879-886, 1998. Marcincuk MC, Roland PS (2002). Geriatric hearing loss: Understanding the causes and providing appropriate treatment. Geriatrics Advisor, 57(4): 44-59.

27. Direct Access References/Resources Kochkin, S. Better Hearing Institute, http://www.betterhearing.org/hearing_loss/myths.cfm. Abrams H, Chisolm TH, McArdle R. A cost-utility analysis of adult audiologic rehabilitation, Journal of Rehabilitation Research & Development, 2002: 39:5:549-558. Letter from Robert H. Roswell MD, Under-Secretary for Health, U.S. Dept of Veterans Affairs to Senator Ben Nighthorse Campbell, April 15, 2003. Blue Cross & blue Shield, Federal Employee Program, http://www.fepblue.org/benefits/benftindex1.html

28. Direct Access Acknowledgements Ingrida Lusis, Director, Federal & Political Advocacy, ASHA Jim Potter, Director, Government Relations & Public Policy, ASHA 2009 GRPP Board