ADVANCING HIGHER EDUCATION IN NURSING

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1 September 4, 2012 Submitted via Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attn: CMS 1590 P P.O. Box Security Boulevard Baltimore, MD RE: CMS 1590 P Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule Dear Ms. Tavenner: On behalf of the American Association of Colleges of Nursing (AACN), I submit the following comments concerning the proposed rule, Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule (77 Fed. Reg , July 30, 2012). AACN is the national voice for America's baccalaureate and higher-degree nursing education programs. For over four decades, the association has established quality standards for professional nursing education to ensure that Registered Nurses (RNs) and Advanced Practice Registered Nurses (APRNs), which include Certified Nurse-Midwives (CNMs), Certified Registered Nurse Anesthetists (CRNAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNSs), are prepared to provide evidence-based, quality, and cost-effective care. AACN represents over 700 schools of nursing at public and private universities as well as senior colleges across the country that educates over 360,000 students and employ more than 16,000 full-time faculty members. The students our member schools educate go on to provide care as expert clinicians, and AACN commends CMS for recognizing the role these graduates will have in improving the quality, efficiency, and affordability of our nation s healthcare system through this proposed rule. Our comments have been developed in close consultation with our colleagues from the American Association of Nurse Anesthetists, the American College of Nurse-Midwives, and the Nurse Practitioner Roundtable to ensure a consistent message from the RN and APRN community is delivered regarding this important proposed rule. These comments request that CMS continue their efforts to ensure nurses are recognized and reimbursed for their contributions to areas such as pain management, care coordination, and ordering specific services for Medicare beneficiaries. ADVANCING HIGHER EDUCATION IN NURSING One Dupont Circle NW, Suite 530 Washington, DC tel fax

2 Section II: H. Primary Care and Care Coordination AACN commends CMS for its efforts in recent years to promote primary care and care coordination in various initiatives to achieve better health outcomes and reduce healthcare expenditures. As you are aware, primary care and care coordination are cornerstones of nursing education, particularly in programs preparing APRNs and Clinical Nurse Leaders (CNLs). CNLs are RNs educated at the master s level to improve the quality of patient care and oversee the care coordination of a distinct group of patients while actively providing direct patient care in complex situations. The CNL clinician puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery. This role has been embraced in healthcare settings across the country as a leader in implementation and care coordination. As CMS continues their efforts to design innovative models for care coordination, we urge you to include the CNL along with other RNs and APRNs in care coordination as they are experts in this field. AACN supports the agency s proposal to create a HCPCS G-code that defines post-discharge transitional care management services, including non-face-to-face services involving a beneficiary s transition from care provided in a hospital, skilled nursing facility, or community mental health center to care provided by the primary healthcare professional in the community within 30 calendar days of discharge from a designated facility. Still, we urge CMS to be inclusive of all providers, including RNs, CNLs, and APRNs, by using provider-neutral language that recognizes the important transitional care delivered by all qualified providers and also confirms that services delivered by RNs, CNLs, and APRNs will be recognized and fairly compensated. We also urge that CMS ensure RNs, CNLs, APRNs, and other qualified providers are eligible for payment for non-face-to-face care plan oversight services. APRNs are particularly qualified, given their education and training, to devise, implement, and oversee these plans of care. Additionally, AACN supports the requirement that post-discharge transitional care management be provided by a qualified healthcare provider who can assist the beneficiary in managing post-transition changes in conditions and treatment, such as a nurse practitioner. Overall, AACN supports CMS s efforts to develop innovative models for payment of fee-for-service primary care services that ensure care coordination and continuous assessment. APRNs have the educational background and expertise to lead practice models that call for patient-centered care in a team-based structure. In paying for these innovative models, we request that CMS exercise caution when cutting needed healthcare services. K. Certified Registered Nurse Anesthetists and Chronic Pain Management Services The Institute of Medicine (IOM) reports that 100 million Americans suffer from chronic pain at an annual cost of $600 billion per year. 1 This statistic is staggering and calls for direct attention by the full complement of healthcare providers who are trained to provide pain management services. CRNAs are educated at the master s or doctoral level in nationally accredited academic programs and graduate with specialized training, skill, and expertise in providing anesthesia and pain management. In order to address the needs of those Americans suffering from chronic pain, 1 Institute of Medicine. (2011). Relieving Pain in America. A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: National Academies Press; p. 5. 2

3 particularly in rural and underserved areas, AACN urges CMS to finalize rules restoring direct Medicare reimbursement for chronic pain management services provided by CRNAs. The IOM recommends that the Medicare program include coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physician services are now covered. 2 For over a decade, Medicare has reimbursed CRNAs directly for pain management services as it is within their scope of practice. However, patient access to these services was put at risk in 2011 when two Medicare administrative contractors began denying reimbursement for CRNA chronic pain management services. AACN urges Medicare to issue a final rule that restores direct reimbursement to CRNAs for chronic pain management services, while not additionally burdening states to define what is related to anesthesia. While states set scope of practice, they do not typically define what is related to anesthesia. If states are required to define this, patient access to care could continue to be impaired. Advanced practice nursing services, such as pain management, that are within the scope of practice under applicable state law should be paid just as physician services are paid. To ask otherwise in the absence of quality and outcome data creates an unnecessary regulatory barrier to these needed services. L. Ordering of Portable X-Ray Services AACN supports the proposed regulation to clarify the authority of APRNs and other eligible nonphysician providers to order portable x-ray services. However, we request CMS to recognize that the proposed regulations surrounding the ordering of portable x-ray services would not result in a change in agency policy, but rather serve as clarification of previous conflicting guidance. Ordering of these services falls within the scope of APRN practice and has been recognized in Medicare regulations that authorize the ordering of diagnostic x-rays. AACN also supports the agency s efforts to prevent wasteful and fraudulent ordering of services that burden the system, however, we urge CMS to recognize there are many instances in which the delivery of portable x-ray services on the same day as services provided in a clinical setting is appropriate patient care. We urge your careful consideration of any policies that would interfere with or create disincentives for patients to receive necessary portable diagnostic x-ray services and to consult with providers and suppliers on the impact of any policies on patient access to care. Section III C. Durable Medical Equipment (DME) Face-to-Face Encounters and Written Orders Prior to Delivery AACN broadly supports the agency s effort to reduce inappropriate billing for durable medical equipment by expanding the category of frequently ordered high-cost durable medical equipment vulnerable to fraud and abuse that would require a detailed written order prior to delivery and require a face-to-face encounter with the patient. However, the current statute does not allow NPs and CNSs to independently document the face-to-face encounter despite the fact that they are authorized to conduct examinations and order DME. Little evidence exists to suggest NPs and CNSs engage in 2 Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. Washington DC: The National Academies Press; p. 9. 3

4 fraudulent or abusive ordering of DME, and there is little efficiency in relying on documentation by a physician who has not evaluated the patient rather than the NP or CNS who has. AACN is also concerned that the broad list of proposed covered items includes several that NPs and CNSs order routinely for frequent conditions and diagnoses, such as glucose monitors. Requiring physician documentation before these items may be supplied could lead to delays in patient care and the potential for serious complications or conditions. We urge CMS to eliminate these statutory obstacles to providing prompt, cost-effective care to beneficiaries. Additionally, CNMs are not expressly identified in the face-to-face requirements detailed by the proposed rule with respect to DME. However, CNMs and other APRNs are included in the face-toface requirements proposed for ordering home health services as required by Section of the Affordable Care Act. Periodically, CNMs need to order DME products for their Medicare and Medicaid patients and such activity is well within their scope of practice. Again, we realize the agency is implementing a flawed statute, but we urge the Secretary to carefully consider the impact on patients, particularly in rural and urban underserved areas, if CNMs are not able to fulfill the faceto-face requirement for DME products. F. Physician Compare Web Site AACN commends CMS for focusing on the patient experience of care via the Physician Compare website and for the PQRS Group Practice Reporting Option (GPRO). However, we find it problematic that the agency is proposing to use as its survey tool the Clinician/Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey; a primary-care focused tool that chiefly seeks to capture the patient and caregiver experience with physicians. The CG-CAHPS does not adequately capture the patient and caregiver experience with APRNs and RNs whose care is unquestionably critical to primary care patients. We request that the agency not use the CG-CAHPS to inform public policy decision making and urge the use of a measurement that captures the impact patients have with the full complement of healthcare providers. G. Physician Payment, Efficiency, and Quality Improvements Physician Quality Reporting System (PQRS) AACN commends CMS s efforts to increase quality measurement and reporting by physicians and other eligible healthcare providers, which includes APRNs, as a means to improve quality care. As noted in this proposed rule, it is the belief of CMS that quality reporting programs will lead to greater overall participation in these programs, as well as minimize the reporting burden on eligible professionals. We agree that it is important to align PQRS and the Electronic Health Record Incentive Program to benefit eligible practitioners who wish to take part in both programs. We also agree with the proposed PQRS Quality Measures outlined in the proposed rule and linking them to the National Quality Strategies six priorities, which include patient and family engagement, patient safety, care coordination, population and public health, efficient use of healthcare resources, and clinical process/effectiveness. RNs and APRNs provide services that are integral to meeting these priorities and should be a part of the development and assessment to make sure they are achieved. We also want to note that under the preamble regarding the proposed payment adjustment amount for the physician value-based payment modifier, CMS mentions that there is a downward payment adjustment for physicians who are not meaningful users of electronic health records (EHR) (p ). However, the text does not clarify whether this adjustment applies only to those who are 4

5 eligible for the EHR Incentive Program. Providers such as CRNAs who are currently ineligible for federal incentive payments to adopt interoperable health information technology must not be penalized in Medicare payment for not having the EHR systems that federal programs currently deny them. To the extent that the value-based payment modifier could apply to all eligible professionals, including CRNAs, we ask that CMS clarify that CRNAs and other providers who were not eligible for the EHR incentive payment/modification under the enabling statute not be subject to the downward payment adjustment in the value-based payment modifier for not being reported as a meaningful user of EHR. Thank you for the opportunity to respond to this call for comments. Please contact Dr. Suzanne Miyamoto, AACN s Director of Government Affairs, for any additional information at ext. 247 or smiyamoto@aacn.nche.edu. Sincerely, Jane Kirschling, DNS, RN, FAAN President 5