Frank Purcell AANA Senior Director Federal Government Affairs CRNA Value in a Changing Environment Our Agenda Today Additional focus on CRNA reimbursement Regulatory reform supervision medical direction and optout ID: 909283
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Competition and Opportunity in Nurse Anesthesia to the Benefit of PatientsFrank Purcell, AANA Senior DirectorFederal Government Affairs
CRNA Value in a Changing Environment:
Slide2Our Agenda TodayAdditional focus on CRNA reimbursementRegulatory reform, supervision, medical direction and opt-out
Current issues with anesthesiologist assistants
Q&A time
Slide3Economic Factors Shaping HealthGoing Up
Going Down
Elderly as a share
of the population
Workers
/ retiree
Per-capita
health spending, more slowly
U.S.
health compared with industrialized world
U.S. debt, >$17TN
U.S. deficits annually
Economic
growth
Economic
growth
Public
coverage
Private coverage
Slide4What about CRNAs delivers value?
Slide5What do plans pay for?
Slide6Fee-for-service(Base + time) x ($CF) = anesthesia fee(Relative value) x ($CF) = physician feePays for a thingDoes not necessarily pay forQuality
The right thing
Care coordination
Optimal efficiency
Slide7Medicare & CRNAsPart A: Hospital insuranceConditions of participationPass-through programPart B: Physician servicesAnesthesia paymentTeaching rulesReimbursement for other services
Parts C & D: Managed care, prescription drugs
Slide8Part A for CRNAsConditions of participation & of coverageAnesthesia servicesASC surgical servicesReasonable cost passthrough
Certain qualifying rural and critical access hospitals
<800 cases or less
CRNA services as a hospital service, no Part B
Slide9Part B for CRNAsAnesthesia paymentMedical directionPain careTeaching rulesPayment for other services
Slide10Most common anesthesia servicesQZ, CRNA nonmedically directedQX,
CRNA medically directed by an anesthesiologist
QK,
anesthesiologist medically directing 2, 3 or 4 concurrent CRNA cases
AA,
personally performed by an anesthesiologist
Slide11SupervisionIt 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 ….
Slide12In the Day1997: Proposed to be repealed1/2001: Repealed in a final rule
2/2001:
Suspended
11/2001:
Finalized as an opt-out process
11/2001 to today:
17 states have opted out
Slide13Slide14What is required to opt out?Letter from Governor to CMS making the requestGovernor has consulted with boards of nursing and of medicine
Opt-out is consistent with state laws
Opt-out is in the interest of the people of the state
Effective upon receipt at CMS
Slide15Who opposes the opt-out?
Slide16What happens when you do opt-outThe California Society of Anesthesiologists (CSA) and the California Medical Association (CMA) sued Governor Schwarzenegger: February 2010.The
Colorado
Society of Anesthesiologists (CSA) and the Colorado Medical Society (CMS) sued Governor Ritter: September 28,
2010
Slide17A national opt-out?Would eliminate supervision in those states that could opt out but have notDoes not eliminate supervision in states with requirements
No reversal
of opt-out
Not “no” but not “now”
Slide18Slide19Supervision vs Medical Direction
Slide20What 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
Slide21TEFRA medical direction rulesAnesthesiologist performs all seven tasks in each of up to four concurrent cases provided by a CRNAFee split 50/50 between CRNA and medically directing anesthesiologistA payment model not a standard of careEncourages higher-cost anesthesia delivery without demonstrated quality improvement
Slide22Medical Direction UnderminedAnesthesiology 2012; 116:683-91
.
Slide23Of the anesthetics you personally administer, how often is an anesthesiologist involved in the following activities?0809
2011-2
AANA 2011 member survey, unpublished.
Slide24Anesthesiologist Supervision Often LapsesAnesthesiology 2012; 116:683-91.
Slide25Medical Direction vs Supervision
Medical Direction
Supervision,
generally
By
an anesthesiologist
By operating practitioner,
or by an anesthesiologist who is immediately available if needed
Seven
services r
equired in
order to claim medical direction reimbursement (50% of a fee, up to 4 concurrent cases (TEFRA rules)
Required
as a condition of participation for your hospital, or a condition of coverage in your CAH or ASC
Opt-out does not apply
Opt-out does apply; 17 states have opted-out
Slide26Anesthesiologist AssistantsOverview of AA PracticeASA support of AAs
AA education, practice under state law or delegation
Distinctions between AAs and CRNAs
Current legislative battles
Slide27Anesthesiologist AssistantsApproximately 1,800 AAs have been produced in the U.S. since the 1970s10 current
AA educational programs
Explicit recognition in more states.
14 states and DC (includes states that authorize PA/AA practice)
Slide28Anesthesiologist Assistants AANA has not taken an official position on AAs. SGA
works closely with state associations on addressing AA
issues.
ASA
has supported AAs after years of neutrality.
The
ASA sponsors the
CAAHEP Accreditation
Review Committee on Education for the Anesthesiologist Assistant (ARC-AA).
Slide29AA Education Admission criteriaBaccalaureate degree in the arts or sciences from an accredited institution.
CAAHEP
standards
No minimum hours for core courses
Limited scope of training
Masters degree
Slide30AA PracticeScope of PracticePractice Setting
Salary
Safety
Record
Coverage by health plans
Slide31Anesthesiologist AssistantsLaw
Regulations
Licensure
Certification
Alabama
Alabama
Alabama
Colorado
Colorado
DC
DC
DC
Florida*
Florida
Florida
Georgia
Georgia
Indiana
Indiana
Kentucky**
Kentucky
Kentucky
Missouri
Missouri
Missouri
Where are AAs Authorized to
Practice
(includes states that authorize PA/AA practice)
?
Slide32Anesthesiologist AssistantsLaw
Regulations
Licensure
Certification
New
Mexico
New Mexico
New Mexico
North Carolina
North Carolina
North Carolina
Ohio
Ohio
Ohio
Oklahoma
Oklahoma
Oklahoma
South Carolina
South Carolina
Vermont
Vermont
Vermont
Wisconsin
Wisconsin
Where are AAs Authorized to Practice (cont’d)?
Slide33Anesthesiologist AssistantsAA Legal Authority to Practice Under Physician DelegationAA Practice Prohibition
Laws: Louisiana
Slide34-
Locations of AA programs
Slide3520112012
2013
2014
Nevada – failed
Colorado
– passed with amendments
California – carried
over
California - failed
New Mexico - failed
Kentucky - failed
Indiana
– passed Senate and House, vetoed by governor
Indiana - passed
Texas - failed
New York – failed
Kentucky - failed
Kentucky - failed
Utah
- failed
Wisconsin
– passed with
amendments
Michigan –
carried
over
Michigan
- TBD
New Mexico – 2 bills, one failed, one passed (negotiated)
Nevada – rule withdrawn
New York –
carried over
New York - TBD
Oregon - failed
Texas - failed
Utah - failed
Slide36Coverage of AA ServicesMedicare recognizes AAsAANA secured CMS statement that it pays AA claims only when they are medically directed by an anesthesiologist
VHA recognizes AAs
Low ranking as GS-9
CRNA services provide maximum flexibility
Slide37AA Resources Tool KitAA Fact Sheet
CRNA-AA Comparison Table
SGA Staff
Slide38Slide39Slide40Questions about AAsAANA Division of State Government Affairs(847) 655-1130sga@aana.com
Slide41We’ve learned aboutReimbursement and CRNA services value and marketsSupervision, medical direction and opt-out processes
Anesthesiologist assistants
Slide42Thank You from Your AANA FGAFrank Purcell, Senior Director Federal Gov’t AffairsKate Fry,
Associate Director Political Affairs
Emily Forrest
, Assistant Director Federal Government Affairs
Romy Gelb-Zimmer,
Associate Director Federal Regulatory and Payment Policy
Randi Gold,
Associate Director Federal Regulatory and Payment Policy
Ralph Kohl
, Associate Director Federal Government Affairs
Octavia Thompson
, Administrative Assistant
AANA Division of Federal Government Affairs
25 Massachusetts Ave., Suite 550
Washington, DC 20001-1450
202 484 8400 // www.aana.com // info@aanadc.com