Reimbursement - Maryland Association of Nurse Anesthetists

October 20, 2013
Maryland Association of Nurse Anesthetists
The Impact of Health Care Reform and Federal Issues
Christine S. Zambricki DNAP, CRNA, FAAN
Our Agenda
• Economic, health policy
and political contexts
• Federal health programs
CRNA Issues
• Legislative and regulatory
• Affordable Care Act
• Advocacy programs
Federal policy environment
• Economic
• Health
• Political
Economic Factors Shaping Health
Going Up
Going Down
Elderly as a share of the
Per-capita health
spending, more slowly
U.S. debt, >$16.7 T
Workers to retiree ratio
Economic growth
Public coverage
Economic growth
Private coverage
U.S. health compared with
industrialized world
U.S. deficits annually
Is It About the Money?
Health spending in the U.S.
• $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
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?
Political Forces shaping the
113th 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
IOM: The Future of Nursing
• The Need to Transform Practice
– Key Message #1: Nurses should practice to
the full extent of their education and
• 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.
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
Health Programs and CRNA Practice
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
Part A for CRNAs
• Conditions of participation & of coverage
– Anesthesia services
– ASC surgical services
• Reasonable cost pass-through
– Certain qualifying rural and critical access
– <800 cases or less
– CRNA services as a hospital service, no Part B
• 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 ….
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: 17 states have opted out
• 2013: No rule regarding supervision but good
CMS precedents
Part B for CRNAs
• Anesthesia payment
– Medical direction
– Pain care
– Teaching rules
• Payment for other services
(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
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
Most common anesthesia services
• QZ, CRNA non-medically directed (NOT AA!)
• QX, CRNA medically directed by an
• QK, anesthesiologist medically directing 2, 3 or
4 concurrent CRNA cases
• AA, personally performed by an
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
What are the TEFRA rules?
1. Performs a pre-anesthetic examination and evaluation;
2. Prescribes the anesthesia plan;
3. Personally participates in the most demanding procedures in
the anesthesia plan, including induction and emergence;
4. Ensures that any procedures in the anesthesia plan that he
or she does not perform are performed by a qualified
5. Monitors the course of anesthesia administration at
frequent intervals;
6. Remains physically present and available for immediate
diagnosis and treatment of emergencies; and
7. Provides indicated-post-anesthesia care.
MCM Ch 12 Sec 50G
Medical Direction Undermined
Anesthesiology 2012; 116:683-91.
Of the anesthetics you personally administer, how often is
an anesthesiologist involved in the following activities?
Pre-anesthetic assessment (n=5,764)
Prescribe anesthetic plan (n=5,748)
Present for emergencies or urgent
situations (n=5,755)
Perform post-anesthetic assessment
Periodically Monitor Anesthetic
Course (n=5,753)
Present at induction (n=5,764)
Present for emergence from
anesthesia (n=5,759)
Most of the time
AANA 2011 member survey, unpublished.
Anesthesiologist Supervision Often Lapses
Anesthesiology 2012; 116:683-91.
Part B Medical Direction vs
Part A Supervision
Medical Direction
Part A Supervision
By an anesthesiologist
By operating practitioner, or by
an anesthesiologist who is
immediately available if
Seven services required in
order to claim medical
direction reimbursement (50%
of a fee, up to 4 concurrent
cases (TEFRA rules)
Opt-out does not apply
Required as a condition of
participation for your hospital,
or a condition of coverage in
your CAH or ASC
Opt-out does apply; 17 states
have opted-out
Part B Medical Supervision
MDA supervises 5 or more CRNAs
MDA bills 3 base units + 1 base unit
CRNA bills QX (50%)
• Failed medical direction: CRNA bills QZ and
MDA bills “0” per CMS
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
• Development and support of State
Reimbursement Director
• 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
• 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.
• Payment adjustment information:
• 2013-2015 tip sheet:
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-andcomment rulemaking
• Attempts to amend to weaken or strike it
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.”
• 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.
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
“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.
AANA supports direct reimbursement
to CRNAs providing
pain management services
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.
>> More...
>> More...
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)
Political Reality
Institute of Medicine Report
Continued challenges: Imaging, MACs
What Medicare Ruled on Pain Care
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.”
Where They Stood
For CRNA Pain Care
• American Hospital
Association and select
State Hospital
• National Rural Health
• Nursing Associations
Opposed to CRNA Pain Care
• “ASA Rebukes CMS Rule
for Jeopardizing Patient
Safety and Quality Health
Source: Comments at, and
Noridian - LCDs
• Epidural Steroid Injections:
• Facet Joint Injections, Medial Branch Blocks, and
Facet Joint Radiofrequency Neurotomy:
• HHS charged IPRCC to create a comprehensive
population health level strategy for pain
prevention, treatment, management, and
• 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
IPRCC Structure
VHA Nursing Handbook Update
APRNs as LIPs – Cathy Rick, CNO
IOM “Future of Nursing”
Consistent with current anesthesia handbook
Dear Colleague Letter: The Honorable Eric
Shinseki. Secretary of Veterans Affairs
• ASA Campaign
• Over 40 nursing groups co-signed letter to
Shinseki this week
• Met with Interim CNO – Christine Engstrom
ASA message and response
ASA said CRNA LIPs would be “required” to function without physician oversight. In response,
the AANA-AVANA letter stated that “the truth is that neither the VHA draft Nursing
Handbook nor the term ‘Licensed Independent Practitioner’ suggest that CRNAs and other
APRNs would be ‘required’ to function without physician involvement should the VHA
designate APRNs as LIP.”
ASA said the Nursing Handbook would result in “effectively eliminating physician-nurse teambased coordinated care. In response, the AANA-AVANA letter stated, “The ASA statement is
false. While the VA Anesthesia Handbook supports care provided in teams, it does not
require anesthesiologist supervision of CRNAs. Consistent with the Anesthesia Handbook,
several VHAs are staffed solely by CRNAs working without anesthesiologist supervision….
Overall care of the patient remains a collaborative effort among physicians, APRNs, nurses
and other healthcare professionals, as it should.”
ASA cited its long-discredited “Silber” study as justification for concluding “anesthesia care is
improved with the involvement of a physician anesthesiologist in a team.” In response, the
AANA-AVANA letter stated that “This ASA statement misrepresents the findings of a claimsdata based study, the results of which have not been replicated and have been disregarded
by Medicare.”
Anesthesia Payment Teaching Rules
• What Medicare pays for services when
education of anesthesia students or residents
is involved
• When it’s 1:1, payment is as though qualified
provider (CRNA, anesthesiologist, or medically
directed CRNA) is delivering the service
74 FR 61738, 61867. 11/25/2009.
Teaching Rules: 1 to 2
• CRNA uses QZ modifier,
present during pre- and
post-anesthesia care
and during concurrent
• Anesthesiologist uses
AA + GC modifier,
present during critical
or key portions,
immediately available
Teaching rules: Medically directed
• Medically directed
CRNA gets 50% of a fee
in one SRNA case, and
discontinuous time in
each of two concurrent
SRNA cases
Teaching Rules inequity issue:
MD with resident vs MD with SRNA
Medicaid and CHIP
• Federal-state program for indigent pregnant
women or women with children, and for
indigent seniors in post-acute nursing home
• Covered services vary by state
• Affordable Care Act expansion of Medicaid
Private coverage
• Insurance
• Self-administered plans
• By type:
– Fee for service
– Preferred provider organization
– Health maintenance organization
– High deductible health plan
Comparing average 13-unit anesthesia fee
Reimbursement of CRNA services
Periodic SGR cuts
50/50 public/private
Small share Medicaid
Present and Future
FFS, ACOs, bundled global
& capitated systems
Will they fix SGR?
Trend toward more public
as share of retirees grows
Medicaid expansion
The Affordable Care Act of 2010
• Expansion of coverage
– Medicaid expansion, subsidies in exchanges
• Insurance reforms
– State-based exchanges for marketing coverage
– Nondiscrimination, consumer protections
• Delivery system reforms
– Accountable Care Organizations
– Innovation Center
– Independent Payment Advisory Board
• Financing
Workforce Provisions
• Title 8 Reauthorization
• Graduate Nursing Education
• National Healthcare Workforce Commission
Title 8 Funding, $MM
Title 8 NWD
Title 8 AEN
Graduate Nursing Education
• Part of ACA, funded through GME
• Four-year, up to $200MM total to expand
education of APRNs in five hospitals
Duke (Durham)
Memorial-Hermann Texas Medical Center (Houston)
Penn (Philadelphia)
Rush (Chicago)
Scottsdale Healthcare Medical Center (Scottsdale)
• Evaluation
Coverage Provisions
• Medicaid Expansion
– Increase eligibility for Medicaid
– Additional federal funding for new participants
• Exchanges
– A regulated means to market health plans
Supreme Health Reform Decision
• Is requiring a person to purchase health
coverage or pay a penalty constitutional?
• Is expanding Medicaid, a state-run program
with some federal funds, constitutional?
Medicaid expansion in the ACA
• For beneficiaries up to age 65 up to 138% FPL
(FPL = $15,415 for an individual in 2012)
• Starts in 2014, feds pay 100% of expansion,
declining to 90% by 2020 and years thereafter
• Supreme Court: Unconstitutional to take away a
state’s Medicaid for refusing to expand it
• Mississippi is rejecting Medicaid expansion
(Gov. Bryant, 11/7/12)
Exchanges (Marketplaces) and Essential
Health Benefits
• Exchanges are for marketing health coverage
in a state
– State-based exchange (As of Oct. 1 working well)
– Federally facilitated exchange (disaster so far)
– Combination ( jury is out)
• Essential Health Benefits link to benchmarks
of small business plans in a state
Delivery System Reforms
• Accountable Care
• Center for Medicare &
Medicaid Innovation
• Independent Payment
Advisory Board (IPAB)
Implementation Timeline
• 2011: Various pilot projects and advisory
panels launch, Title 8 reauthorization,
beginning of Medicaid expansion
• 2012: Graduate Nursing Education
• 2012: Supremes decide constitutionality
• 2013: Finalization of plans
• 2014: Provider nondiscrimination, state based
exchanges take effect
Budget Sequestration
• Sequestration is $1.2 trillion in automatic
spending cuts due to go into effect over the next
10 years
• $85 billion 3/1/12
Half by dollar value from national security
Medicare, -2%
Other health and research, -8%
National security, -9%
Exempts Medicaid, Veterans benefits, most student
• Agency flexibility in apportionment?
Pew: Increase, decrease or same?
Aid to world’s needy
Aid to needy in U.S.
Health care
Social Security
Veterans benefits
Pew Research Center, 2/13-18/2013.
AANA supports permanent repeal and replacement of the SGR formula
with a payment system that accurately reflects
the cost of providing anesthesia care.
Briefing: SGR
•The Sustainable Growth Rate
(SGR) is a Medicare Part B
payment formula for CRNA and
physician services
•SGR is based on the economy
•Reduced payment has been
threatened since 2002
•Every year Congress defers
rather than repeals the SGR cuts
•2012 CRNA payment will
decrease by 26.2% in MARCH
What’s a 26.2% Medicare Cut?
• If a CRNA performs 900 12-unit 100% Medicare cases,
that yields $236,700 in fees
• Minus 30% = $165,690
• Difference of -$71,010 if 26.2% cuts hit 3/1/2012
• Congress continues struggling with paying for relief
from 26.2% Medicare Part B payment cuts scheduled for
March 1. The AANA and CRNAs have weighed-in and
continue to, but the outlook for long-term relief is dim
and short-term relief appears more likely.
• Approximately $365.00/week
What’s new with SGR
• Energy and Commerce plan to replace SGR with a qualitybased plan that would update payments by .5 – 1 % each
• Update Medicare payment rates by 0.5 percent until 2019,
until performance-based payment methods: the Quality
Update Incentive Program and the Alternative Payment
Model, which could increase doctors’ payments by as much
as 1 percent.
• The CBO scored the SGR reform bill $175.5 billion over 10
• Freezing SGR payments will cost $139.9 billion. $36 billion
comes from the cost of replacing that system with a
quality-based payment plan.
SGR Key Talking Points
• 4 years ago Medicare
said anesthesia services
were undervalued
• CRNAs do not control
service volume
• CRNAs provide access
to care in rural America
• CRNAs are 25% more
cost effective
• Quality of CRNA care is
• All barriers to the use of
CRNAs should be
What Can AANA & CRNAs Do?
• Know the issues
• Participate in AANA advocacy programs
– Mid-Year Assembly
– FPDs & Key Contacts
– CRNAdvocacy Email Alerts
– Initiatives in reimbursement – SRS
– State level GRC, PAC and BOD
SRS Program
SRS Background
• AANA Anesthesia and Payment Policy Coordinating
Panel (APPCP) recommendation to the AANA BOD
• AANA BOD approved September 2012
• Goal: reimbursement advocacy in each state
• The SRD
– repository of state reimbursement information
– coordinator of state advocacy work.
State Reimbursement Specialist program
• At the direction of the Board
• A focal point in each state for CRNA
reimbursement knowledge, and for advocacy of
CRNA reimbursement interests
• Development of key relationships
– Private payors – three largest health plans in state
– Public payors – Medicaid, exchanges, MAC
– Other interests – Hospital, rural health and health
plan associations
• Coordinated by your AANA FGA team
• Monitor trends
• Serve as a resource
• Work with state association to establish key
SRS Position Requirements
• Keen interest in reimbursement
• Willing to enhance knowledge
• Represent with professionalism and
• Willing to disclose conflicts of interest
Job Description
– Coordinate and improve payment
processes and reimbursement in your state
– Accomplish this task by working with
others based on state association’s needs
and resources
Job Description
Establish key contacts with
• Top three health plans in your state
• Exchange Boards
• Medical Director for Medicare Administrative
• Medicaid Director
• Insurance Commissioner
• State Hospital Association
• State Ambulatory Surgery Center Association
• State Rural Health Association
Job Description
– Serve as a repository of information by monitoring
state reimbursement activities:
• Medicare Local Coverage Determinations
• Medicaid payment policy
• Commercial insurance reimbursement
• Accountable care organizations (ACOs)
• State exchanges
Job Description
– Assist with state reimbursement issues as
a first responder
– Communication with state leaders
– Enter state reimbursement information into
special SharePoint site
– Alert the AANA to any emerging issues
who get
others to
volunteer or
Volunteers contributors
Everyone who voted for the candidate
Voters who voted for the wrong candidate
Registered voters who don’t vote
Voting age not registered to vote
What is CRNA-PAC?
• Separate fund, 100% from
CRNAs’ voluntary
contributions, not dues
• Ensures CRNAs have
access to DC, where our
issues are decided
• Not partisan
• Always working for the
profession of nurse
CRNA-PAC’s Mission Statement: Advancing the profession of nurse anesthesia
through federal political advocacy.
Stats that Make Us Proud
Largest federal nursing PAC in the country
Top ten PAC nationwide for healthcare professionals
$1.1 million impact on the 2012 national elections
with 94% of CRNA-PAC supported candidates
elected to office.
2013 CRNA-PAC Highlights
$1.75 million goal for 2013-2014
“CRNA-PAC Loves the 80’s” Party at Mid-Year Assembly
“Remember the RatPAC” Party at Annual Meeting
Refreshed Care to Be Counted website,
• Student-specific engagement
• New Incentive Club levels
Does This Work? A case study
• Problem: Present threat to CRNA pain practice
• Strategy: Research. Grassroots. Local & national
allies. Advocacy. Response. Comments.
• Outcome: Medicare rule covering all CRNA
services within state scope of practice published
12/2012, effective 1/2013
Thank You from Your AANA FGA
Frank Purcell, Senior Director Federal
Goverment Affairs
Christine Zambricki, Senior Director
Federal Affairs Strategies
Kate Fry, Associate Director Political
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
Candida Richardson, Administrator
AANA Division of Federal Government Affairs
25 Massachusetts Ave., Suite 550
Washington, DC 20001-1450
202 484 8400 // // [email protected]

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