MedPAC Focuses on Nurse Practitioners & Other Non-Physicians
What is MedPAC?
MedPAC advises Congress and CMS, the Centers for Medicare & Medicaid Services, on annual updates to Medicare’s many prospective payment systems, as well as cost-containing measures and quality and access of care for Medicare beneficiaries. Its formal recommendations and supporting data are contained in March and June reports to Congress, as well as testimony and letters to Congress. MedPAC’s seventeen commissioners include Jennie Chin Hansen, RN, MSN, FAAN, president of AARP, as well as several physicians, health policy and economics experts, and representatives of hospitals and insurers. The meetings draw over 100 representatives of health care interests, including staff of the American Medical Association and government officials. ANA is the only nursing organization to attend on a regular basis. MedPAC encourages written and verbal comments, and meetings with its staff members. Comments on current agenda items can now be submitted electronically, through MedPAC’s website, at http://www.medpac.gov. Payment updates and other issues and recommendations will be discussed fully in upcoming reports to Congress, issued each March and June, and also available through the website.
Recognizing the 40 percent of Medicare’s Non-Physician Providers
MedPAC has fairly consistently ignored the important role and contributions of non-physician providers, but change may be on the horizon. In a discussion of physician services, MedPAC staff reported that 40% of Medicare providers who bill under the Physician Fee Schedule are not physicians, but gave no further details. Commissioner Bruce Stuart, of the University of Maryland School of Pharmacy, led a discussion calling for MedPAC staff to research and report back on who these providers are, what services they provide, and how they can help the primary and mental health care shortages. Several commissioners, including physicians and the chair of MedPAC, Glenn Hackbarth, were supportive, particularly with respect to the importance of NPs and PAs in primary care. Commissioner Thomas Dean, MD, of Wessington Springs, South Dakota, noted that PAs & NPs have saved his practice a number of times. He also expressed concern that many are going into specialties versus primary care. The significant shortage of psychiatrists was also noted, with a call for more information on services provided psychologists. Such a review should also encompass the contributions of psychiatric/mental health advanced practice RNs.
Nurse Practitioners Certifying Patients for Home Health Services
MedPAC also came very close to recommending that Nurse Practitioners be allowed to certify Medicare patients’ eligibility for home health care services. Because of serious concerns about consistent quality of care, rising profitability, and documented fraud and abuse, a recommendation was made to require an in-person patient visit, as the basis for the certification decision. There was widespread agreement that NPs should be able to perform the in-person patient visit required for certification. This led to a discussion of whether NPs should also be allowed to sign the order for certification. Despite initial concerns by some commissioners, a consensus gradually emerged favoring NPs’ ability to certify as well. It was noted that proposed healthcare reform legislation would allow NPs to do this. This could also allow greater efficiency, as NPs may be more familiar with the patients and with the nursing services provided in home health care. Finally, one commissioner questioned the assumption that physicians would be more qualified and more ethical than NPs. Just as the commission was preparing to make this recommendation, Commissioner Nancy Kane of the Harvard School of Public Health voiced her discomfort at deciding the issue the first time it was raised, and as part of a payment update. She urged the staff to look at this and other issues in a future comprehensive review of home health care services. The chair agreed, holding the issue “in abeyance” until that time.
Improving Medicare’s Quality Infrastructure
This preliminary presentation, which will entail further discussion prior to consideration of formal recommendations, focused on variations in quality of hospital care. Hospital acute MI (myocardial infarction) readmission and mortality rates were compared. There was significant discussion of how to reward high performing hospitals for high quality of care, while helping the low performers that often treat the sicker, poorer and more minority patients. MedPAC staff’s “Policy Options” included suggestions for more transparent survey results; updating and expanding Medicare conditions of participation (COPs); and increasing quality standards, either on a voluntary or mandatory basis. There were several objections to using the COPs for this purpose, including practical concerns expressed by Commissioner Herb Kuhn, a former CMS deputy administrator. Several commissioners explored having high performing hospitals, and other quality experts or organizations, mentor the low performers. Chairman Glenn Hackbarth stressed the need for “concrete” measures such as readmission rates, incentives for high performance, and helping the poor performers.
2010 Recommended Prospective Payment System Updates
MedPAC made the following recommendations for payment updates in 2010, to be included in the March 2010 report to Congress:
• Hospital inpatient & outpatient services: Increase by hospital market basket index (MBI), 2.4 percent per current index, and require more quality reporting. Also recommended cuts of 2 percent per year, from 2011-2013, to offset gains from better documentation of secondary conditions under MS-DRGs.
• Physician services: Increase by 1 percent. Report will discuss accuracy of reimbursement under RUC (MedPAC has discussed with AMA). Staff reported that “[m]ost quality indicators were stable or improved from 2006 to 2008.”
• Ambulatory surgical centers: Increase of 0.6 percent, and require the submission of cost and quality data (CMS has delayed a proposal to require quality data).
• Outpatient dialysis services: Increase by ESRD (end-stage renal disease) MBI, less productivity adjustment (0.7 percent increase per current data).
• Skilled nursing facilities: No increase.
• Inpatient rehabilitation facilities: No increase.
• Long-term care hospitals: Eliminate the update for LTCs.
• Hospice: Increase by hospital MBI less productivity adjustment (1.1 percent per current data).
• Home health services: No increase; rebase rates to reflect average cost of care. Develop outcome measures, investigate unusual patterns and allow safeguards to avoid fraud & abuse (suspensions, pre-authorization, moratorium on new agencies, etc.).
Other Issues
MedPAC staff also presented data on the following issues, without making formal recommendations. These topics are likely to be discussed further in future meetings:
• Part D: trends in drug prices through 2008 and formulary designs for 2010: Data show significantly rising prices for medications without generic equivalents, such as antineoplastics (cancer drugs), anti-psychotics, and AIDs medications.
• Services provided under the in-office ancillary exception to the physician self-referral law: MedPAC staff noted an increase in such services, but need to compare these with increases in similar services in other settings. Several commissioners and public commenters stressed the value to patients of having diagnostic services in their physicians’ offices, particularly for elderly patients with serious illnesses.
Eileen Shannon Carlson, RN, JD
Tags: Archieve, Centers for Medicare & Medicaid Services, CMS, January 2010, Medicare, MedPAC
