Hospitals and lobbying groups at odds over Medicare policy
A congressional advisory panel said hospitals and the trade groups that represent them disagree whether a rule requiring a physician to aid and direct other hospital staff on certain procedures would be harmful if enforced.
The Medicare Payment Advisory Commission on Friday released a report that revealed the discord. The 21st Century Cures Act required the advisory group to examine the impact of the so-called direct-supervision requirement. The rule was first introduced in 2009, but its enforcement has been delayed several times.
Hospital associations told the CMS that small rural hospitals don't have enough staff to comply. But while conducting surveys, MedPAC revealed a divide between trade groups and on-the-ground hospital officials.
Hospital representatives did not warn of any significant economic burden as a result of the rule, which kicked in Jan. 1, 2017. Nor did they say they lacked staff to provide supervision. Rather, they said they had trained current staff to adjust.
For example, hospital representatives told MedPAC that in the case of two of the most common therapies that fall under the supervision requirement, oncology and cardiology, if a specialist isn't available, an emergency department or family physician would supervise. Others schedule chemotherapy infusion appointments only when an oncologist is present.
"In contrast to hospital association statements, they said that the direct-supervision requirements for outpatient therapeutic services are not limiting the types of services they provide," MedPAC said.
The disconnect could be because associations aren't aware that the CMS has dropped some services from the list that would require direct supervision, according to Brock Slabach, senior vice president of the National Rural Health Association.
MedPAC also suggested that the CMS had not clearly told hospitals the direct supervision could be done by any physician.
The American Hospital Association, which has been the chief critic of the direct-supervision policy, stands by its remarks that the policy as a whole is burdensome to its members and supports a permanent repeal of the requirement.
It argues a physician is not the only clinician who can provide safe and high-quality outpatient care. Hospital staffers besides physicians are professionally competent and are licensed to provide services, the group said.
"Some critical-access hospitals and small rural hospitals have already been forced to discontinue important services or limit the days or hours of services that are offered in order to comply with these burdensome requirements," said Roslyne Schulman, director of policy at the American Hospital Association.
The CMS will not enforce the policy in 2018 and 2019 despite inconclusive evidence that the policy poses harm.
Officials at the CMS told MedPAC they were not enforcing the rule because there it did not have a way to monitor this requirement. Medicare would likely learn of scofflaws through a whistle-blower, however no such reports have been made.
MedPAC is not suggesting the supervised requirement be killed, only tweaked. The CMS should consider whether telehealth could help hospitals comply with the requirement even though that might require statutory changes.
"Although particularly relevant for rural hospitals that face physician shortage issues, clarification of the supervision requirements can benefit all hospitals," MedPAC said.
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