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2005 Proposed Physician Fee Schedule
September 23, 2004
Mark McClellan, MD
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building , Room 445-G
200 Independence Avenue, SW
Washington , DC 20201
Re: Notice of Proposed Rulemaking; 2005 Physician Fee Schedule Rule
Dear Dr. McClellan:
On behalf of the more than 50,000 clinically practicing physician assistants (PAs) who are represented by the American Academy of Physician Assistants (AAPA), we appreciate this opportunity to comment on the Notice of Proposed Rulemaking (NPRM) for the 2005 Physician Fee Schedule rule, published in the August 5, 2004 Federal Register.
AAPA is the only national professional organization representing PAs in all medical and surgical specialties. AAPA estimates that in 2003 approximately 192 million patient visits were made to PAs. Many of those visits were from Medicare beneficiaries.
The value and cost-effectiveness of providing preventive health services to patients has been an accepted tenet in health care for many years. The PA profession strongly believes that an increased focus on delivering appropriate preventive medicine services will have the immediate effect of improving the quality of life for Medicare beneficiaries, while reducing Medicare beneficiary treatment costs over the long-term.
Preventive Services
The initial preventive physical examination, also known as the "Welcome to Medicare" exam, along with increased coverage for cardiovascular disease and diabetes screening tests are important steps in the right direction. Implementation instructions in the proposed rule specifically allow PAs to perform the preventive physical exam and order diabetes screening tests as "qualified nonphysician practitioners." Missing from the general conditions of coverage for cardiovascular screening (proposed 410.17) is the ability of PAs to order cardiovascular screening tests. This appears to be an oversight as opposed to a planned policy decision in light of PAs being fully included in the other preventive service areas. AAPA encourages the Centers for Medicare and Medicaid Services (CMS) to specifically include language in 410.17 allowing PAs to order cardiovascular screening tests by adding language that allows "qualified nonphysician practitioners," as defined in proposed 410.16, to order cardiovascular disease screening tests.
Care Plan OversightWe appreciate the proposed special rules for payment when physician care plan oversight (CPO) services are provided by PAs. The language, allowing coverage for PAs to deliver CPO services after the patient has been certified for home health services, brings clarity to the present confusing and conflicting Medicare policy.
While allowing payment for PAs delivering CPO services, current CMS policy does not allow PAs to certify the need for home health. AAPA believes that PAs should be authorized to certify the need for home health care under Medicare. PAs are authorized by the Medicare program to deliver physician services when those services are within the PA's scope of practice as determined by state law, and delegated to the PA by the PA's supervising physician. Additionally, the Balanced Budget Act of 1997 further expanded the ability of PAs to deliver medical services that would otherwise be provided by the physician. Clearly, certifying the need for home health is a physician services and within the scope of practice of PAs. Allowing PAs to certify the need for home health care will increase beneficiary access to care and improve continuity of care. AAPA encourages CMS to review its interpretation of home health certification and include PAs as health care professionals who may certify the need for home health .
Physician Scarcity Areas
Section 413(a) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, provides a five percent incentive payment to physician who deliver services in physician scarcity areas (PSAs). The benefit, which can be received in addition to the existing 10 percent bonus for services delivered in Health Professional Shortage Areas (HPSA), recognizes the unique difficulties of assuring the availability of health care professionals in underserved communities.
The calculation for primary care and specialty care PSAs will be determined by the ratio of primary and specialty physicians to Medicare beneficiaries in a given county. To the extent that there are physicians in a particular county who are retired from practice, but still hold a license, we believe that care should be taken to assure that only physicians in active practice be used in the formula to determine PSAs.
The PA profession was started on the principle of increasing access to care for rural and underserved populations. Substantial number of PAs can be found providing health care to underserved communities throughout the nation. If the goal of the scarcity payment initiative is to increase the number of qualified health care professionals in underserved areas, it would be a logical step to extend the five percent scarcity payment to services provided by PAs. AAPA encourages CMS to extend the five percent physician scarcity area incentive payment to services delivered by PAs in PSAs.
Reassignment Provisions
The change in the Medicare reassignment provision that allow health care professionals to reassign payments to an entity regardless of where the service is performed is a welcome update to a policy that was out of touch with practice staffing arrangements and the manner in which health care professionals are utilized. This increased billing flexibility simply permits the most efficient utilization of health care professionals, such as PAs, and eliminates some of the administrative difficulties that had been in place .
Finally, we applaud the continued inclusion of PAs as health care professionals who are able to order durable medical equipment under the expanded guidelines; furnish telemedicine services; and provide outpatient therapy/speech- language services or have those services provided "incident to" a PA.
Again, AAPA appreciates the opportunity to comment on proposed changes to the Physician fee Schedule rule. If we can be helpful in supplying additional information or details on our comments, please do no hesitate to contact us.
Sincerely,
Stephen C. Crane, PhD, MPH
Executive Vice President & CEO
Last Revised: 10/20/04
