Reimbursement The Impact of Health Care Reform and Federal Issues

1. October 20, 2013 Maryland Association of Nurse Anesthetists ReimbursementThe Impact of Health Care Reform and Federal Issues Christine S. Zambricki DNAP, CRNA, FAAN

2. Our Agenda Context • Economic, health policy and political contexts • Federal health programs CRNA Issues • Legislative and regulatory issues • Affordable Care Act • Advocacy programs

3. Federal policy environment • Economic • Health • Political

4. Economic Factors Shaping Health

7. Is It About the Money?

8. Health spending in the U.S.www.cms.gov • $2.7 T in 2011, up 3.9% in 2011, about 18% of U.S. economy, average $8,680 per person • Three years in a row of stable growth • Economic downturn • Demand • Supply • Technology

9. Political Forces shaping the 113th Congress • 58.7% of vote eligible citizens, 10% latino, 13% black, 19% young voters • 65.9M to 60.9M votes, 51-47%, 332-206 • Continuing divided government • House • Senate • 114th Congress?

10. Political Forces shaping the113th Congress • Considerable change beneath the surface • 12 new Senators of 100, 67 new Representatives of 435. Most of Congress is new since 2006 • New leaders in some key health positions • Freshman class

12. IOM: The Future of Nursing • The Need to Transform Practice • Key Message #1: Nurses should practice to the full extent of their education and training. • The Need to Transform Education • Key Message #2: Nurses should achieve higher levels of education and training through improved education system that promotes seamless academic progression.

13. IOM: The Future of Nursing • The Need to Transform Leadership • Key Message #3: Nurses should be full partners, with physicians and other health professionals, in redesigning health care • The Need for Better Data on the Health Care Workforce • Key Message #4: Effective workforce planning and policy making require better data collection and an improved information infrastructure

14. Health Programs and CRNA Practice

15. Medicare & CRNAs • Part A: Hospital insurance • Conditions of participation • Physician supervision • Pass-through program • Part B: Physician services • Anesthesia payment • Medical Direction • Medical Supervision • Teaching rules • Reimbursement for other services • Parts C & D: Managed care, prescription drugs

16. Part A for CRNAs • Conditions of participation & of coverage • Anesthesia services • ASC surgical services • Reasonable cost pass-through • Certain qualifying rural and critical access hospitals • <800 cases or less • CRNA services as a hospital service, no Part B

17. Supervision • It is a Medicare requirement, a portion of a regulation, 42 CFR §482.52(a)(4) Anesthesia must be administered only by … (4) A certified registered nurse anesthetist (CRNA), as defined in 410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c)of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed ….

18. Historical Context Part of the Medicare conditions for participation • 1997: Proposed to be repealed • 1/2001: Repealed in a final rule • 2/2001: Suspended • 11/2001: Finalized as an opt-out process • 11/2001 to today: 17states have opted out • 2013: No rule regarding supervision but good CMS precedents

20. Part B for CRNAs • Anesthesia payment • Medical direction • Pain care • Teaching rules • Payment for other services

21. Fee-for-service • (Base + time) x ($CF) = anesthesia fee • (Relative value) x ($CF) = physician fee • Pays for a thing • Does not necessarily pay for • Quality • The right thing • Care coordination • Optimal efficiency

22. Medicare anesthesia payment • (Base + time units) x (anesthesia CF) • Rules determined by: • Statutes enacted by Congress • Regulations adopted by Medicare agency (CMS) • Sub-regulatory policy adopted by Medicare • Medicare Administrative Contractor that operates Medicare in each state, regionally

23. Most common anesthesia services • QZ, CRNA non-medically directed (NOT AA!) • QX, CRNA medically directed by an anesthesiologist • QK, anesthesiologist medically directing 2, 3 or 4 concurrent CRNA cases • AA, personally performed by an anesthesiologist

24. TEFRA medical direction rules • Anesthesiologist performs all seven tasks in each of up to four concurrent cases provided by a CRNA • Fee split 50/50 between CRNA and medically directing anesthesiologist • A payment model not a standard of care • Encourages higher-cost anesthesia delivery without demonstrated quality improvement

25. What are the TEFRA rules? • Performs a pre-anesthetic examination and evaluation; • Prescribes the anesthesia plan; • Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence; • Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist; • Monitors the course of anesthesia administration at frequent intervals; • Remains physically present and available for immediate diagnosis and treatment of emergencies; and • Provides indicated-post-anesthesia care. MCM Ch 12 Sec 50G

26. Medical Direction Undermined Anesthesiology 2012; 116:683-91.

27. Of the anesthetics you personally administer, how often is an anesthesiologist involved in the following activities? AANA 2011 member survey, unpublished. 2011-2 0809

28. Anesthesiologist Supervision Often Lapses Anesthesiology 2012; 116:683-91.

29. Part B Medical Direction vsPart A Supervision

30. Part B Medical Supervision • MDA supervises 5 or more CRNAs • MDA bills 3 base units + 1 base unit • CRNA bills QX (50%) • MAY NOT BE USED FOR FAILED MEDICAL DIRECTION • Failed medical direction: CRNA bills QZ and MDA bills “0” per CMS

31. AANA action on CRNA reimbursement • Anesthesia payment panels • Summit on Anesthesia Reimbursement • Member education on Business of Anesthesia • Building relationships with key payer leaders • Comment on changes impacting CRNA reimbursement • Development and support of State Reimbursement Director

32. PQRS • Reporting program that uses incentive payments and payment adjustments to promote reporting of quality info by eligible professionals (EPs) • CRNAs are EPs • Report on 50% of Medicare patients by the end of 2013, get a .5% incentive payment • In 2015, not reporting results in a 1.5% "adjustment" (meaning reduction). • If not reporting, 1.5% cut in your Medicare payments in 2015, which will go to 2% in 2016. • CMS proposed rules: 9 measures, registries only

33. PQRS • CMS cannot accept data codes for reprocessing on a claim that has already been submitted. Providers have until Dec 31 2013 services to add the appropriate code to the claim. • There are also registry options. • Additional options for avoiding the negative adjustment: reporting one data code for one Medicare patient for one measure in CY13 would help avoid the ding in CY15. If they want a bump in CY15 they have to report 50% plus one. • CMS calculate administrative claims for incentives – deadline October 15. (Requires an Individual Access to CMS (IACs) Account). It can take more than a day to calculate.

34. PQRS • Payment adjustment information: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html. • 2013-2015 tip sheet: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013MLNSE13__AvoidingPQRSPaymentAdjustment_083013.pdf

35. Provider Nondiscrimination • Part of the Affordable Care Act (Sec. 1206) • Promotes consumer choice and cost savings, by prohibiting health plans from discriminating against qualified healthcare providers by licensure • Takes effect 2014, subject to notice-and-comment rulemaking • Attempts to amend to weaken or strike it

37. ASA on nondiscrimination • “(T)he Senate bill also includes gratuitous so-called “non-discrimination" language (Sec. 2706).  The intentionally vague language, inserted by supporters of paraprofessionals, seeks to prevent health insurers from "discriminating" against non-physician providers in deciding who may participate in their plans.  Its practical implications are to open the doors to various disruptive tactics within the insurance marketplace by paraprofessionals, putting Federal law on a collision course with each state’s scope of practice law.” http://www.asahq.org/news/asanews031210.htm

38. Non-discrimination • The Obama Administration will not issue regulations interpreting the AANA-backed provider nondiscrimination provision of the Affordable Care Act before it takes effect Jan. 1, 2014 • FAQ document issued by Medicare, IRS-Treasury and the Department of Labor • Non-grandfathered group health plans and health insurance issuers offering group or individual coverage are expected to implement the provision starting on January 1, 2014, using a good faith, reasonable interpretation of the law.

39. Non-discrimination • Rep. Andy Harris (R-MD), the only anesthesiologist in Congress, introduced HR 2817, on July 24 with the backing of the American Society of Anesthesiologists (ASA). • “We are deeply concerned that for certain covered services in a number of states, this new part of the Public Health Service Act will be interpreted to provide that all health professional groups be considered as if their education, skills and training were equal even if their state-based medical and healthcare professional licenses or certifications are very different…. This ACA [Affordable Care Act] provision disrupts over a century and a half of dynamic state-based licensure and certification, interjecting the federal government into interpreting the limits of scope of practice and procedure.” The letter was co-signed by medical societies representing dermatologists, family practice physicians, otolaryngologists, ophthalmologists, OB/GYNs and plastic surgeons. • Rep. Harris’ legislation was referred to the House Energy and Commerce Committee where he does not serve, and has no cosponsors and no Senate companion bill at this date.

40. AANA supports direct reimbursement to CRNAs providing pain management services

41. CRNA direct reimbursement for chronic pain management Medicare has paid CRNAs directly for chronic pain management services The AMA and the ASA oppose CRNAs providing chronic pain management Two Medicare contractors stopped paying CRNAs directly for chronic pain management services These two contractors required that a physician bill for the CRNA chronic pain management services. This is called “incident-to” billing.

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43. Physician Resistance • American Medical Association • Consistently issued resolutions, petitions, and position papers opposing scope of practice • AMA Citizens Petition to HCFA (2000) • AMA Scope of Practice Partnership (2006) • AMA Resolution “Independent Practice of Medicine by Nurse Practitioners” (2006) • AMA Scope of Practice Data Series (2009) • Health Care Truth and Transparency Act (2011) • CMS and CSA sued the State of California (2010)

44. Political Reality Opposition Institute of Medicine Report

45. Continued challenges: Imaging, MACs

46. What Medicare Ruled on Pain Care

47. What Does the Pain Care Rule Say • Medicare will cover services within CRNA scope of practice in a state • “The primary responsibility for establishing the scope of services CRNAs are sufficiently trained and, thus, should be authorized to furnish, resides with the states.”

48. Where They Stood For CRNA Pain Care • AARP • American Hospital Association and select State Hospital Associations • National Rural Health Association • Nursing Associations Opposed to CRNA Pain Care • AMA • “ASA Rebukes CMS Rule for Jeopardizing Patient Safety and Quality Health Care” Source: Comments at www.regulations.gov, and http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/ASA-Rebukes-CMS-Rule-for-Jeopardizing-Patient-Safety-and-Quality-Health-Care.aspx

49. Noridian - LCDs • Epidural Steroid Injections: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33835&ContrId=246 • Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33841&ContrId=246

50. IPRCC • HHS charged IPRCC to create a comprehensive population health level strategy for pain prevention, treatment, management, and research. • Structure includes 5 Working Panels • Professional Education and Training • Margaret Faut- Callahan, PhD, CRNA, FAAN • Public Health: Care, Prevention, and Disparities • Jackie Rowles, CRNA, MS