Hospitals and physicians urged CMS to withdraw its proposal to allow non-physician practitioners to fulfill inpatient rehabilitation coverage requirements that are currently completed by rehabilitation physicians, citing quality concerns.
The traditional providers warned that patients, especially people with complex conditions, could receive lower-quality care if non-physician practitioners like physician assistants can independently perform preadmission screenings, develop a plan of care or carry out other duties currently limited to physicians. Critics say non-physicians don't have the education, clinical training or qualifications to do that work or lead an interdisciplinary care team in an inpatient rehabilitation facility.
"These facilities would simply no longer be IRFs if NPPs replaced rehabilitation physicians because they could not meet the needs of the highly complex patients that are increasingly in IRFs," according to a letter signed by the American Academy of Physical Medicine and Rehabilitation, American Medical Association and dozens of other physician groups.
But physician assistants, nurse practitioners and other clinicians argue that CMS should move forward with its proposal because it would allow non-physician practitioners to take full advantage of their education, clinical training and experience by practicing at the top of their license. According to supporters, it would free up physicians to focus on the areas where they're needed most and allow facilities to run more efficiently.
Regulators again find themselves in the middle of a turf war among providers. Policymakers have often looked to expand the role of advanced practice practitioners in the healthcare delivery system to lower healthcare spending and address provider shortages. But physicians have consistently opposed those efforts, even though there's little evidence it harms patient care. Hospitals are often caught in the middle of disputes between physicians and non-physicians, but doctors usually have more power and influence inside health systems than other provider types.
Comments on the proposed rule were due Monday.
General acute-care hospitals worry they could be negatively affected if they refer patients to inpatient rehabilitation facilities that rely more on non-physician practitioners and quality suffers, the American Hospital Association said.
But supporters maintain there's no reason to think quality will suffer because non-physician practitioners have considerable experience caring for complex patient populations with no decline in quality. In many instances, they're already doing the work under the supervision of a physician.
The proposed rule wouldn't require non-physicians to carry out CMS' coverage requirements or expand their scopes of practice beyond what state laws already allow. According to CMS, inpatient rehabilitation facilities would decide what type of clinician should oversee a patient's care so long as their decision follows state law.
"These changes would simply remove federal barriers to practice in excess of state law and facility policy," the American Association of Nurse Practitioners said.
CMS said the rule change could save Medicare money and reduce administrative work for physicians. The agency said that it could also help address physician shortages and improve access to care in rural areas.
Groups that oppose the rule say the change won't create cost savings for Medicare because quality will decline, causing patients to require more services. It's also unclear to what extent the proposal would address physician shortages in rural areas since other clinician types tend to live in the same places as physicians.
"We call upon the agency to develop and incorporate evidence on the comparative outcomes of IRF care overseen by rehabilitation physicians in contrast to that of NPPs," AHA said in a letter commenting on the proposed rule.