Advocacy / Day on the Hill (DOTH)

Thank you to those who attended Day on the Hill!

Tuesday, March 14th 
Washington, DC


FOCUS ON ADVOCACY | RESOURCES


AACVPR's Focus on Advocacy - The Issue in 2017

*The new US House bill H.R. 1155 has been released - US Senate companion bill # is coming soon! 

There are two issues cardiac and pulmonary practitioners, as well as our patients, need to bring to the attention of Congress in 2017.

The first is the site location of cardiac and pulmonary rehabilitation programs (CR/PR). Section 603 of the Bipartisan Budget Act (BBA) of 2015 mandates that any outpatient services that are new or that re-locate from an on-campus location (within 250 yards of the main hospital) to an off-campus location after 11-2-15 (date of BBA passage) are reimbursed by Medicare at the Physician Fee Schedule (PFS) rate and not the Outpatient Prospective Payment System (OPPS) rate, effective January 1, 2017. This would mean a dramatic reduction in payment for CR and PR, financially prohibiting any such re-location for program expansion. AACVPR recently met with CMS to explain the limitation this poses to CR and PR programs attempting to meet patient needs by expanding program capacity. CMS indicated the only option to address this is via legislation. This restriction impacts program growth and patient participation, so is an issue that programs and patients should care about greatly.

The second issue remains the technical correction that would allow nonphysician practitioners to meet CMS direct supervision requirements of daily supervision for CR and PR. Even CMS, in the coming Cardiac Rehabilitation Episode Payment Model, recognizes the barrier this requirement presents for utilizatin of CR/PR services. CMS will allow NPPs to meet this arbitrary rule only for CR programs selected as participants in the CR Incentive Payment Model. CMs has told AACVPR that a legislative fix is all that is needed to remove this barrier. Our previous companion bills, HR 3355 and S.488, will need re-introduction (new bill numbers in a new Congress) and larger support from your US Senate and US House of Representatives in this first session of the 115th Congress. This bill gained strong momentum last year with the help of ACC, AHA, WomenHeart, and numerous other supportive professional and patient organizations. Let’s keep that going and get this passed in 2017 with and for our patients.  

This bill would ask Congress to support legislation amending the Social Security Act and allow physician assistants, nurse practitioners and clinical nurse specialists to supervise cardiac and pulmonary rehabilitation programs on a day-to-day basis. This change would not alter the requirement for medical direction of these programs; it would simply remove the requirement for a physician to be immediately available and accessible at all times when services are being furnished under these programs.

 

Pulmonary Rehabilitation (PR)

The professional and patient organizations that work with and represent patients with pulmonary disease have collaborated to examine evidence that would support expanding eligible diagnoses for pulmonary rehabilitation services, program location, and unsustainable Medicare reimbursement for PR services. 

AACVPR leadership is considering legislative and regulatory actions to address these issues. Stay tuned to learn how Congress could help!

 

Background

In 2010, direct physician supervision was extended to non-physician practitioners for other outpatient services in regulatory guidance. However, language included in Public Law 110-275 (enacted in 2008) imposed a legislative requirement which inadvertently contained a legislative requirement for direct physician supervision that could not be reversed through regulation. As a result, cardiac and pulmonary rehabilitation require a level of physician supervision that is not commensurate with patient risk; this creates access issues in rural and other areas with physician shortages, as well as unnecessary costs for these low-revenue programs.

Cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are medically directed and supervised programs designed to improve a patient’s physical, psychological, and social functioning. Both programs utilize supervised exercise, risk factor modification, education, counseling, behavioral intervention, psychosocial assessment and outcomes assessment. A physician, who serves as Medical Director, is responsible for ensuring that the program is safe, comprehensive, cost effective, and medically appropriate for individual patients. This individual typically leads a multidisciplinary team of healthcare professionals that may include nurses, exercise physiologists, respiratory therapists, dietitians, health educators, behavioral medicine specialists, and other healthcare professionals.

“Direct physician supervision” is separate and distinct from medical direction and requires a physician to be immediately available for each session. This individual is typically not the Medical Director and is mainly responsible for responding if an emergency arises. In similar outpatient environments, non-physician practitioners, such as physician assistants and nurse practitioners, are allowed to provide certain aspects of “direct physician supervision” in accordance with scope of practice and state licensure laws. 

This authority was granted in regulatory guidance effective January 1, 2010. However, the public law that created the Medicare coverage of cardiac and pulmonary rehabilitation services included a provision that has been interpreted to preclude non-physician practitioners from acting in place of a physician in a supervisory capacity to meet Medicare requirements for physician supervision in any cardiac or pulmonary rehabilitation setting. The current regulations impose a more stringent requirement for physician supervision on CR and PR than they do on the staffing of emergency departments. Although the legislative sponsors made it clear that this was not their intent, CMS believes the law must be changed to allow them to extend the same flexibility to cardiac and pulmonary rehabilitation that is now available for other hospital outpatient services.

The change being contemplated would allow non-physician practitioners to provide day-to-day supervision of these programs. The Medicare statute identifies these individuals as physician assistants, nurse practitioners and clinical nurse specialists under the broad category of non-physician practitioners (NPPs). Today, NPPs are utilized in a number of critical care environments, including critical access hospital emergency departments (without an MD on site), hospitals and hospital clinics, emergency rooms, intensive care units, recovery rooms, cardiac catheterization laboratories, heart failure and arrhythmia clinics, community clinics, health centers, urgent care centers, walk-in clinics, and many other sites. These individuals are highly trained to respond should cardiac emergencies arise.

The safety of cardiac rehabilitation in a medically supervised, community-based program is well established. The requirement that a physician be immediately present (i.e., physically within a short distance) makes it difficult for cardiac and pulmonary rehabilitation programs to operate in rural areas where physicians are scarce and imposes unnecessary costs in both rural and urban areas. Program closures result in a lack of access for patients to receive the standard of care for these high value medical services. This change is supported by the American Heart Association, the National Association for Medical Direction of Respiratory Care (NAMDRC), along with other professional associations concerned about access to these beneficial services for all Medicare beneficiaries.

(Pictured Above) ACC President, Dr Richard Chazal (key note speaker at AACVPR's 31st Annual Meeting in New Orleans) with ACC Advocacy Conference attendees, recognizing US House of Representatives Member Ron Kind (D-WI) for his commitment to improve the delivery of health care in this country. 

Mr. Kind was an early cosponsor of HR 3355 (October, 2015), thanks in large part to WISCHPR's efforts. On September 13, 2016, support for HR 3355/S.488 was a priority request by 400 ACC members in Washington, DC to US House and Senate Members.


Advocacy Resources

Electronic-Only Resources:

State-specific Survey Results - Collected in February and March 2017

CR/PR Payments from Physician Fee Schedule 3-year review of Medicare data

On-Site Resources:

- DOTH Capitol Hill Visit Report Form

- Letter to your US Congressional Members to Cosponsor NPP Bill

- Tips for a Successful Meeting and Sample Thank You Letter

- Follow-up to Visit Email Template

HR 1155 Bill

- Supervision of Cardiac and Pulmonary Rehabilitation Services - click here to view the Word Document - Last Updated in March 2017

- Talking Points for HR 1155 Bill & S___ Bill - Last Updated in March 2017

- CMS Waiver for Physician Supervision Federal Register

- Letter to Dr. Berwick, former Administrator of CMS - April 2011
- Berwick's Response from Senate Finance Committee Members - April 2011

- 115th Congress, 1st Session, Senate Finance Committee Roster & Website - Last Updated in March 2017
- 115th Congress, 1st Session, Senate Finance Committee Subcommittee on Health Roster & Website - Last Updated in March 2017

- 115th Congress, Energy & Commerce Health Subcommittee Roster & Website - Last Updated in March 2017
- 115th Congress, Energy & Commerce Roster & Website - Last Updated in March 2017

- 115th Congress, Ways & Means Committee and Health Subcommittee Roster - Ways and Means Website - Subcommittee Website- Last Updated in March 2017

Click here to review HR 3355 cosponsors at end of 114th Congress
Click here to review S488 cosponsors at end of 114th Congress

Check to see if your current US Congressional Members in the US House of Representatives and US Senate signed the bill in the 114th Congress (they will need to re-sign):

1. Click on link below to go to search tool at Congress.gov
2. Select ALL LEGISLATION in the box on left
3. Enter bill number (HR3355 or S.488) in the search bar
4. Under “Congress”, uncheck the box for 115th Congress and check the box for 114th Congress
5. Press search bar
6. Your bill should appear at top of list-Select your bill
7. Click on Cosponsors tab to see names of cosponsors in the last Congressional Session

Check the links below to search for and see if your US Congressional Members have already signed our bill:

Cosponsors of US House of Representatives bill #1155 (previously #3355) (as of December 2016): click here to use the search tool (by number).

Cosponsors of US Senate Bill # S.488 (new US Senate Bill # coming soon) (as of December 2016): click here to use the search tool (by number).

 

 

How to find your U.S. House Representative:

For the contact information of your House Representative, click here.

How to find your U.S. Senators:

For the contact information of your two Senators, click here.

How to find Critical Access Hospital (CAH)s per state:

For a list of CAHs per state, a complete list of CAHs and a map of all CAHs, click here.

Contacting and Locating Your U.S. Senators in Washington D.C.:

  1. Click here to find D.C. address and office main phone #.
  2. Ask for the person responsible for health care issues.
  3. Request a meeting with that person AND the Senator.
  4. You may be told you will be meeting with someone else and you may be instructed to schedule an appointment through a scheduling person. Each office varies and you will be assisted through the process for that particular Senator. 

How to communicate with your U.S. Senators' and U.S. House Members' Washington, DC offices:

  • Call the office and ask first for the name of the person who is responsible for health care issues.
  • Ask if that person prefers to be contacted by telephone or by email on an issue of concern to you.
  • If by email, send it to health staffer with a brief summary of what you are asking for.
  • Let him/her know you will call on ___ (date) (5 days is fair) for the Senator’s decision or to answer any questions he/she may have.
  • Continue calling weekly until you receive an answer (or unless you are told to proceed otherwise by the health staffer).
  • If health staffer prefers telephone over email for initial contact, follow talking points below to explain your task. 

Communication Tips:

  • You are representing cardiac and pulmonary rehabilitation for your state’s providers and patients.
  • Try to immediately speak with the person responsible for health issues, but understand that every office operates by its own rules and email may be the preferred method of initial contact.
  • Address an email to the congressional member AND to the person whose name you’ve been given as responsible for health care issues for the member.
  • Follow-up when you said you would and keep trying. It is their job to be aware of and care about health care issues that could ultimately help or hinder access of vital services for Medicare beneficiaries.

Map of Capitol Hill and Congressional Buildings:

You may find it helpful to print out this map:
http://www.aoc.gov/sites/default/files/Visiting_Capitol_Map_0.jpg 

Map of Washington D.C. Metro Line:

You may find it helpful to print out this metro line map (color version is more helpful if possible):
https://www.wmata.com/schedules/maps/index.cfm?t=maps-rail-wrapper

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