Trump Executive Order on Medicare Pay for NPs, PAs

[SoCal_PA]

https://www.medscape.com/viewarticle/919415

 

Here is the text for those who cannot see it all. 

 

Proposals on Medicare Pay for NPs, PAs

 

WASHINGTON — President Donald Trump today ordered federal officials to consider pegging Medicare reimbursement more closely to time spent with patients, seeking to address potential pay disparities between physicians and other healthcare professionals.

These directives are among the tasks Trump gave to the Department of Health and Human Services (HHS) in an executive order. The order also demanded HHS develop several proposals related to insurer-run Medicare Advantage, including one regarding payments for new technologies.

Trump signed the executive order after giving a speech at a rally in Florida

The executive order gives HHS a 1-year deadline to propose a regulation that Trump describes as intended to let healthcare professionals spend more time with patients.

This regulation is meant to ensure that services, whether done by physicians, physician assistants (PAs), or nurse practitioners, "are appropriately reimbursed in accordance with the work performed rather than the clinician's occupation," the order said.

The order also tasks HHS with proposing a regulation to end what Trump called Medicare's "burdensome" requirements that are "more stringent" than federal and state laws require. The president intends to remove barriers that keep some personnel "from practicing at the top of their profession."

On a Thursday morning call with reporters, HHS Secretary Alex Azar said Medicare policies now sometimes "prevent people like nurse practitioners, PAs, et cetera from really maximizing the full value and training and licensure that they have through supervision requirements or other artificial limitations."

But it's unclear when and if the items listed in Trump's executive order will ever take effect.

In the order, Trump asked HHS to begin work on new regulations. There are many potential obstacles in attempts by any administration of any political party at promulgating rules. These include pushback from industry, congressional disapproval, and competing demands on the attention of leaders within an administration.

State or Federal?

Still, Trump's executive order serves as another example of what seems to be growing interest in Washington in examining how Medicare pays and regulates the practice of different kinds of healthcare professionals.

In the draft 2020 Medicare physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) included a proposal that would largely defer to state law and state scope of practice for PAs. States should have "the flexibility to develop requirements for PA services that are unique and appropriate for their respective state," CMS said in the draft rule, published in August in the Federal Register.

In a comment submitted to CMS in September, the American Medical Association (AMA) recommended Medicare instead maintain the current regulations on physician supervision for physician assistant services. If CMS does opt to finalize the proposed changes, AMA asked the agency to further revise the regulation to ensure physicians maintain the ultimate responsibility for coordinating and managing the patient's care.

In the letter, AMA also urged CMS to remove certain proposed regulatory language: "In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA's approach to working with physicians in furnishing their services."

"Some states require physician collaboration, which still requires that physicians maintain the ultimate responsibility for coordinating and managing the patient's care," wrote James L. Madara, AMA's chief executive officer, in a September 24 comment to CMS.

"Yet, this proposed language could be interpreted to preempt these state laws to, in effect, have the unintended consequence of eliminating any physician oversight of physician assistants, opening the door for independent practice of PAs," Madara added.

And, as Medscape Medical News previously reported, an influential panel in June recommended Medicare end a policy that lets medical practices bill at higher physician rates for services provided by certain other members of medical teams.

In a report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended eliminating "incident-to" billing for advanced practice registered nurses (APRNs) and PAs.

Instead, APRNs and PAs should consistently bill Medicare directly under their own national provider identifier for the services they provide, MedPAC said.

 

Edited October 8, 2019 by SoCal_PA
Formatting

[thinkertdm]

19 minutes ago, SoCal_PA said:

"Yet, this proposed language could be interpreted to preempt these state laws to, in effect, have the unintended consequence of eliminating any physician oversight of physician assistants, opening the door for independent practice of PAs," Madara added.

He also said:

"...yet I have no problem with having NP's practice independently.  I have to cut this interview short, because I have to go spend my checks from the NP associations".  Madara said, smugly.  "To have PA's practice independently..Human sacrifice, dogs and cats living together, mass hysteria!"

[Cideous]

1 hour ago, thinkertdm said:

  "To have PA's practice independently..Human sacrifice, dogs and cats living together, mass hysteria!"

A well placed Bill Murray Ghostbusters quote if I have ever seen one....

[Hope2PA]

The possibilities are exciting and scary! Don’t get me wrong, if given independence, I feel it should only follow certain criteria such as 3-5 years supervised or collaboration with physician for both PA Andy NP. But at this point, best take anything offered to NP with same limitations or lack there of. Holding my breath that PA leaders, or others, don’t automatically take PA off the table and hand the golden egg to NP exclusively, like done in VAMC by saying PA are trained rob “assist” not practice medicine, while NPs who are trained to advanced nurse ,yet practice medicine. . That would really screw the future of PA’s!!! 

[Lightspeed]

37 minutes ago, Hope2PA said:

The possibilities are exciting and scary! Don’t get me wrong, if given independence, I feel it should only follow certain criteria such as 3-5 years supervised or collaboration with physician for both PA Andy NP. But at this point, best take anything offered to NP with same limitations or lack there of. Holding my breath that PA leaders, or others, don’t automatically take PA off the table and hand the golden egg to NP exclusively, like done in VAMC by saying PA are trained rob “assist” not practice medicine, while NPs who are trained to advanced nurse ,yet practice medicine. . That would really screw the future of PA’s!!! 

You’d get used to the new reality real quick, then look back on your old stance with a sheepish grin forming at the thought of once upon a time wishing to be under the yoke of mandated supervision. 
 

But I don’t agree that it’s the emancipation proclamation for PAs... that’s just the AMA reps boogeyman. He thinks that since it sounds scary to him, it’s scary to everyone. But it’s not. However, because licensing is handled at the state level,  state dictates will apply to supervisions mandates. But this makes it a little bit easier for PA independence. It’s not a step back, I don’t think. 

[Hope2PA]

Lighspeed, I am ALL for a new norm. While physicians are top dog and always will be, Ive seen PA’s and well as NP’s that went above basic educational and CEU requirements that could out perform many lackadaisical physicians. Still hold my belief that NO new PA or NP should be independent just out of school. Any one of them that is worth their grain of salt would agree. Those who think they can be competent out of the gate are the scary ones. My concern is that some PAs want to hold on to and prevent progression of the profession to keep PAs dependent and speak out against a potential ruling. Thankfully there are currently some good progressive leaders.  If all providers are allowed equal opportunity to practice , the market will weed out those who only do minimal to advance knowledge. 

[ventana]

all we have to do is one of two options (or both)

 

1) copy the SLP and have a one year mandatory supervision after graduation

2) above can be waived if you do a 1yr residency

 

boom problem solved....

[Lightspeed]

9 hours ago, Hope2PA said:

Lighspeed, I am ALL for a new norm. While physicians are top dog and always will be, Ive seen PA’s and well as NP’s that went above basic educational and CEU requirements that could out perform many lackadaisical physicians. Still hold my belief that NO new PA or NP should be independent just out of school. Any one of them that is worth their grain of salt would agree. Those who think they can be competent out of the gate are the scary ones. My concern is that some PAs want to hold on to and prevent progression of the profession to keep PAs dependent and speak out against a potential ruling. Thankfully there are currently some good progressive leaders.  If all providers are allowed equal opportunity to practice , the market will weed out those who only do minimal to advance knowledge. 

I agree that supervision in the initial stages is important. It was one of my requirements I looked for when choosing among employers. Where I’ve always seen the most benefit in being independent is simply in the employment framework.... no formalized arrangement that puts the provider in a position of being dependent on another employee for you guys (and nurses in states without independence) to perform your job. That freedom from such an arrangement pays dividends in several ways, but most importantly, it makes you’re profession your own. I think the stats are out there that around the same number of NPs own their own practice as PAs, so that kind of squashed the popular image of the freewheeling NPs going out in their own without a net simply because they can. Folks like me choose to primarily be employees. But what I do know is that I’m a better paid employee because I have that freedom, especially in psyche, because of a few factors, one being that potential bosses know I’m more mobile. Also, I can legally take call without a net underneath me, so admitting patients to the hospital, and handling them without a backup physician gives me tools to being to the table in that regard. Just two examples that might not even be a big deal to folks outside of my specialty. 
 

Overall, I just think it would suit you guys a lot better than some of you might think. There would be a handful of folks that would try to open their own shops if they had more avenues to do it, but the vast majority of you all wouldn’t still perform in your respective realms as you do now, albeit with some more autonomy where some of you would like it. It would help many of you in terms of negotiations, mobility, professional interactions, professional self esteem, etc. I think it would open the door to innovations that are yet unimagined by providing options in the healthcare realm. Professionally, it would open management roles that o know a lot of you would be ready for if burnout sets in. But you have to take the good with the bad to realize the full potential of independence... ie, some PAs will hit the market and flame out when they take on more than they should. It will be a small portion that will operate with unwise boundaries after graduation, or bite off more than they can chew. You want circumstances that maximize your bargaining power, and you just can’t do that by being half slave to the medical establishment as dependent providers... I see it as all or nothing. 
For you guys, there isn’t an all or nothing technicality that will free you from dependence. It’s got to be state by state. Some measures can set the stage for more latitude, but then the baton has to be taken up at the state level. There are 55+ state and territorial jurisdictions to deal with individually, and the federal government can change terms of funding and things like that, but it doesn’t erase anything imposed on the state level.... and PAs are still 0-50 on that. But if only one state flipped..... that would be bigger than any news from the federal government. 
 

But yeah, you guys could handle independence. Maybe a lot better than NPs have, even. But wouldn’t it be better to have the reins in your own hands to decide your fate than having it imposed upon you.
 

I’m not sure what form that independence will ever show up as for the PA profession, but I think there will be different aspects that will lean towards it. You might see some places that cut you guys loose, and there will be a varying amalgamation of jurisdictions that are more favorable than others. NPs have a huge head start on you all, as you know, so independence for them is actually more uniform than you’ll ever see it for PAs I think. A compact for NPs is in the works that will be the next big feature that will advance the profession. but things like that are what you can work towards when you aren’t wedded to another profession.