Can you say "interfacility"? SCT rule gets changed again

CMS has addressed the definition of specialty care transport (SCT) yet again in the recent final rule mostly devoted to the 2007 Medicare physician fee schedule (on display November 1, 2006, to be published December 1, 2006, effective January 1, 2007).  (See pp. 501-510 of the display copy of the rule, which includes a history of many of the definitions and guidance documents relating to SCT.)  SCT is the highest level of service provided by ground ambulance, as defined by CMS — it includes interfacility ambulance services which may be provided only by a paramedic with additional training or a more highly-trained professional (e.g., nurse or physician).

The defintion of SCT in the regs (42 CFR 414.605) reads as follows:

Specialty care transport (SCT) means interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the EMT–Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

CMS and its public have struggled with the definition of interfacility (hospital-to-hospital? hospital-to-acute care hospital?) for over five years, and CMS included another stab at it in the draft version of the 2007 physician fee schedule rule.

Based on the comments received (including a suggestion to reconvene the negotiated rulemaking workgroup to decide what "critical care" means), CMS, in a measured tone that — to my reading — thinly veiled its exasperation, decided to withdraw its proposed clarification at the regulatory level, and to expand its "guidance" on the issue. 

The current CMS view goes beyond prior guidance: the word "interfacility" for SCT purposes now explicitly includes Medicare-certified SNF-to-hospital (AND hospital-to-SNF) ambulance runs (assuming clinical appropriateness/need for SCT-level service); this has already been permitted by liberal carriers, and CMS expects this will remain a small fraction of the total SCT volume.  "Hospital" is defined broadly to include anything that would be considered a "hospital-based facility" under CMS "provider-based" rules, 42 CFR 413.65.

Here’s to a definition that should stick.

— David Harlow

Is CMS overselling (and overpaying) Medicare Advantage plans?

The NY Times reports that Democrats in Congress have sent a letter to CMS regarding alleged inaccuracies in the 2007 Medicare handbook sent to all beneficiaries, noting that it’s slanted in favor of Medicare Advantage plans (Medicare HMOs).  (See additional coverage here.) 

Congressman Pete Stark (one of those who signed the letter) has been after Medicare Advantage plans for a while; several months ago, he noted that a study called for by congressional committees found that MA costs were 11% higher than fee-for-service Medicare.

— David Harlow

2007 Medicare physician fee schedule finalized

CMS is spinning the 5% cut in physician payments under the 2007 Medicare Physician Fee Schedule by emphasizing the increases in the RVU work component for E&M services. 

Formula-driven cuts have been mandated for each year since 2002, but Congress has overriden itself annually with one-time increases, and may well do so again after next week’s elections.  (See earlier post here.)  The rule went "on display" today, is scheduled to be published December 1, and will be effective January 1.  The display copy is available here

Update 12/4/06: The rule was published Friday in the Federal Register.

See the CMS press release for other highlights, including:

  • Expanded coverage for certain preventive services, as required by the DRA
  • Physician office imaging reimbursement capped at hospital payment levels, per the DRA (these cuts could be rolled back by pending legislation; see earlier post here)
  • Adoption of IDTF supplier standards
  • Adoption of ambulance fee schedule inflation adjustment factor of 4.8%
  • Clarification of the Specialty Care Transport rules 

— David Harlow

Experiments in health care delivery from all over

The mantra of improving quality of care while holding costs in check produces a continual stream of experiments in health care delivery. 

This month, we learn that Washington, D.C. is seeing the return of the house call — as a cost-saving measure — and that provision of free preventive care to patients with chronic conditions can reduce the need for more expensive free care down the road.

In other news, a physician-owned freestanding emergency room opens in Houston, providing 24/7 emergency care as an alternative to overcrowded hospital emergency departments.  The center does not participate in Medicare, but offers a maximum wait of 30 minutes, valet parking and gourmet coffee.

— David Harlow

CA ED overcrowding issues laid at PCPs' feet

The California Health Care Foundation released today a report on ED overcrowding (link to press release, report and other related information here), and recommendations for shifting nonemergency care to other settings.  Top of the list of reasons for ED overcrowding, based on a survey of patients, was the inability to get an appointment for an office visit.

Readers: Do you buy this explanation, based on a patient survey? (Advanced access is not a new idea, after all, and surely must have some adherents in California.)  A variety of solutions for ED overcrowding have been put forward in recent years (see discussion of one or two here) — what’s your favorite?  How well has it worked?

— David Harlow

Insurers at the gates: Who gets the state imprimatur under the Massachusetts universal health care law?

Yesterday’s Boston Globe highlighted a potential problem with the creation of new insurance markets under the Massachusetts universal health care law.  One currently-licensed "limited benefit" insurance company, within weeks of being touted by the Insurance Commissioner at a Health Insurance Connector Authority meeting, was being sued by the Attorney General based on allegations of deceptive marketing practices and improper denial of claims.

The Insurance Commissioner says that consumers need choices, and that her agency can monitor the activities of individual insurance companies to ensure they operate according to the law.  At least one advocate says there should be high standards for insurers participating in the programs endorsed by the Connector, so as to protect the interests of consumers.

A Healthy Blog is not convinced that state monitoring is the way to go here, and asks whether high-deductible, low coverage plans put lower-income consumers at risk, and what the Connector can do to protect consumers.

As I noted in an earlier HealthBlawg post, the recently published RAND meta-analysis of consumer behavior within consumer-directed health plans and health savings accounts shows that this is indeed a valid area of concern.

In terms of screening insurers, the Connector, in the time remaining before the program goes live, can probably do little more than examine ratings of insurers offered by other organizations or agencies, and develop a composite scoring system, weighted based on the relevance of the other rankings — on measures that may range from financial stability to quality of care to consumer satisfaction to regulatory compliance in Massachusetts and beyond –to the matter at hand.

The Connector has its work cut out for it.

— David Harlow