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In August and September 2008, ANA commented on three proposed rules for Medicare programs, involving: Rural Health Clinics and Federally Qualified Health Centers; the Physician Fee Schedule; and the Hospital Outpatient Prospective Payment System. If you should have any questions about these, or suggestions for future ANA comments, please contact Eileen Carlson at Eileen.carlson@ana.org. Rural Health Clinics and Federally Qualified Health Centers (RHCs & FQHCs) The proposed regulation issued by the Centers for Medicare & Medicaid Services (CMS) contains substantial changes for these programs, particularly in the timeline and exception process, and reimbursement. The new location requirements could require up to 1,600 existing RHCs to seek an exception. ANA supported the requests of organizations such as the National Rural Health Association and the American Medical Association, as well as prominent members of Congress, for additional time to evaluate the practical impact of the proposed regulations. We expressed our opposition to policies which would compromise health care access and availability for our nation's patients, particularly our most vulnerable populations. Several provisions would offer additional opportunities for advance practice registered nurses (APRNs). ANA strongly supported the proposal to allow "nonphysician practitioners" to furnish services under contract to an RHC, and pointed out that clinical nurse specialists (CNSs) - which are recognized as qualified providers under Medicare Part B - have been completely shut out of RHCs. In another positive development, the proposed rule would add the term "certified" to the definition of "nurse-midwife." The proposal's definition of "nurse practitioner" is contrary to current standards for academic preparation and certification, and we urged CMS to work with ANA to develop a definition which more accurately reflects the current role and qualifications of NPs. We noted that NPs now complete, at a minimum, graduate-level educational preparation that leads to a master’s degree, and most are nationally certified in their specialty area of care. And contrary to language in the proposed rule, NPs are not certified in "primary care." ANA also endorsed new rules allowing for the administration of chemotherapy and other high-cost medications, and mandating the presence of automated external defibrillators (AEDs), as well as certification in basic life support training (BLS), at a minimum, for all primary care providers. The proposed rule appears at 73 Federal Register 36696, June 27, 2008. Physician Fee Schedule and Other Revisions to Part B for CY 2009 This proposed rule would update the qualifications which NPs and CNSs must meet in order for their services to be covered under Medicare Part B. NPs who enroll in Medicare after 2002 must be "registered professional nurses," authorized by State law to practice as an NP, nationally certified as an NP, and must have a master's degree in nursing or a Doctor of Nursing Practice (DNP). CNSs must have a master's degree in a defined clinical area of nursing, or a DNP. ANA's comments supported this update in APRN qualifications, and elaborated on the current roles and qualifications of both NPs and CNSs. In rules for the Competitive Acquisition Program (CAP) for medications, "physician" was defined as specifically including NPs, CNSs, and physician assistants. It also appeared to include other practitioners who legally prescribe drugs, and we noted that certified nurse midwives (CNMs) and certified registered nurse anesthetists (CRNAs) would also fall within this definition. A proposal regarding independent diagnostic testing facilities (IDTFs) authorized payment for procedures performed by NPs and CNSs. But they may be subject to requirements for special training and certification which would logically apply only to radiology and other technicians, so ANA urged CMS to clarify that NPs and CNSs can serve patients by performing diagnostic tests to the full extent of their ability and credentials. We also advocated for the inclusion of CNMs and CRNAs in the list of allowed providers. PQRI (the Physician Quality Reporting Initiative) was mentioned in the proposed rule. ANA advocated for improving the inclusiveness and transparency of this program, by replacing "Physician" with "Provider" or "Practitioner." We also urged CMS to formally recognize and acknowledge the important roles which all types of Medicare providers, particularly APRNs, play in quality measures and quality of care. The text of this rule can be found at 73 Federal Register 38501, July 7, 2008. Outpatient Prospective Payment System CMS proposed initiating the use of "healthcare-associated conditions," similar to "hospital acquired conditions," which would trigger lower reimbursement rates if acquired during outpatient care. Falls was one of the suggested conditions, and ANA comments emphasized that fall incidence should be measured and reported, in addition to fall prevalence, should that measure be included. The National Quality Forum nursing-sensitive measures consider fall incidence, rather than fall prevalence, as fall incidence data are readily available from incident reports and count every fall that occurs. The proposed rule was published at 73 Federal Register 41416, July 18, 2008. | ||