Return to the Previous PageU.S. DEPARTMENT OF HEALTH & HUMAN SERVICES (DHHS)
HEALTH CARE FINANCING ADMINISTRATION (HCFA)
7500 Security Boulevard, Mail Stop C4-07-07
Baltimore, Maryland 21244-1850
MEDICARE AMBULANCE FEE SCHEDULE NEGOTIATED RULEMAKING
SUMMARY MINUTES
The first meeting of the HCFA Negotiated Rulemaking Advisory Committee on Medicare Ambulance Fee Schedule began at 9:05 a.m. February 22 in Ellicott City, Maryland. The meeting was facilitated by Commissioners Lynn Sylvester and Elayne Tempel from the Federal Mediation and Conciliation Services (FMCS), hereafter "the Facilitators." The objectives of this meeting are:
Handouts from this meeting are identified by a number assignment reflecting the meeting number as well as the order in which the topic was addressed. Handouts are listed at the end of the minutes, and have been made available to all Members. If enough copies were available, they were made available to Alternate Members as well. Copies of handouts will be available to the public from HCFA if a written request is received. Handouts will not be faxed to the public.
Advisory Committee Membership Attendance (See Attachment 1-1)
American Ambulance Association (AAA) - Darrel Grinstead
American College of Emergency Physicians (ACEP) and National Association of EMS Physicians
(NAEMSP) - Robert R. Bass, MD
American Health Care Association (AHCA) - Robert T. Deane, Ph.D.
American Hospital Association (AHA) - David Long
Association of Air Medical Services (AAMS) - Edward R. Marasco
Health Care Financing Administration (HCFA) - Nancy A. Edwards
International Association of Firefighters (IAFF) - Lori Moore
International Association of Fire Chiefs (IAFC) - Jack J. Krakeel
National Association of Counties - C. Ronald Aycock
National Association of State Emergency Medical Services Directors (NASEMSD) - W. Dan Manz
National Volunteer Fire Council - Steve Ennis
INTRODUCTIONS
Facilitators Lynn Sylvester and Elayne Tempel introduced themselves and spoke briefly
about the Federal Mediation and Conciliation Service, and the role they would be playing
in the upcoming negotiations process. HCFA representative Nancy Edwards, Acting Deputy
Director, Plan and Provider Purchasing Policy Group, welcomed Members and thanked them for
coming.
Agenda Review:
The February meeting will start each day at
9:00 a.m. and end at 5:00 p.m. on Monday and Tuesday, and 3:30 on Wednesday to facilitate
airplane departure times. The Facilitators expressed their flexibility if groups need to
caucus, but suggested that caucuses be scheduled around breaks, lunch, or before or after
formal sessions.
Facilitators emphasized that Members should
plan to attend every meeting for continuity. The Members are responsible for keeping their
Alternate(s) fully informed, in the event the Alternate must step in and take over for
their organization.
Project HOPE will make a presentation on the
second day of this meeting.
The Facilitators made a presentation of a
negotiation problem-solving model, noting that the Committee will need to reach a
consensus on the identification of the issues. The Federal Register notice of
January 22, 1999, pg. 3474, gave notice of HCFA’s intent to form this Negotiated
Rulemaking Committee.
There is time set aside on Wednesday’s
agenda for public input. This public comment period is the audience’s opportunity to
let the board know their concerns about the issues being discussed.
The agenda for this meeting was
approved by the Committee. (Attachment 1-2)
The Facilitators started the work of the Committee by
discussing the concept of consensus, and the role it plays in a Committee such as this
one. The following points were made:
- Members will agree to use consensus for all
decision making.
- If consensus is reached on an ambulance fee
schedule, HCFA will publish the Committee’s work as an NPRM.
- In the event the Committee fails to reach
consensus, this process should narrow the issues in dispute, rank priorities, and identify
potentially acceptable solutions. This will better facilitate HCFA in their rule-making
process.
A consensus is a group decision. The
consequence of the Committees not reaching a consensus will mean that decision making
about the contents of the NPRM will be decided by HCFA.
ATTACHMENT 1-3, pages 9-11 -- NEGOTIATED RULEMAKING
ORIENTATION
The "Negotiated Rulemaking Act of 1996" was cited:
§ 562. Consensus:
- means unanimous concurrence among the
interests represented on a negotiated rulemaking committee established under this
subchapter, unless such committee
Consensus Decision Making
Consensus decision making definitely takes more time, but is worth it in the end.
Advantages of Consensus Decisions
Elements of a Consensus Discussion
Consensus Guidelines
Still No Agreement?
The Facilitators stressed their neutrality. They are interested in helping the Committee reach a decision that all Members can live with. They will try to help the Committee reach a consensus by (1) Keeping the Committee focused on issues (process checking); (2) Keeping the Committee on the process of problem solving. Facilitators may also be mediators. Private caucuses (sidebars) may be necessary between one or more Members and the Agency, but all decisions are made within the Committee at the public table. There is an issue of confidentiality: sidebars or discussions will not be divulged to anyone outside of that discussion. The role of recorder is also neutral. Because the Facilitators and recorder are completely neutral, they cannot be called to testify or turn over notes or any other material.
The track for this meeting was reiterated: for this committee to reach a consensus on the issues on the table. A Member asked whether there are rules on consensus or ground rules? The Facilitator said that ground rules will be discussed, and that every decision will be made by consensus.
The Facilitator noted that a decision made by the Committee may not be everyone’s first choice of solutions, but Members have heard the discussion and everyone can live with the final results. This process means that the group must agree to work together until they find a solution that doesn’t compromise strong convictions or needs. The final outcome of this Committee’s work is that HCFA will publish the their decisions in an ambulance fee schedule NPRM.
ATTACHMENTS 1-4.1 -- DRAFT NEGOTIATED RULEMAKING COMMITTEE
GROUND RULES, AND 1-4.2 -- SAMPLE NEGOTIATED RULEMAKING COMMITTEE GROUND RULES &
PROTOCOLS
The Facilitators and Committee again discussed the consequence if there isn’t a
consensus. Member discussion: In general, the Members voiced concerns about the tightly
defined parameters of a consensus, the fear that it would be difficult to reach unanimity,
a concern that the Committee would get bogged down, with the result that a consensus
wouldn’t be reached. The Facilitator pointed out that subsection 562: "Agrees to
define such term to mean a general but not unanimous concurrence." A Member inquired
whether HCFA will agree to go along with Committee decisions?
The HCFA representative said that the government is interested in an equitable outcome, wants the Committee to come to agreement, and to make everyone as happy as possible under the circumstances. There will be a good faith effort to work through issues on the table, and the government will agree to the concept of "unanimous concurrence." A Member noted that lack of unanimity on the Committee’s part would leave the decisions in HCFA’s hands.
Another Member voiced the concern that he doesn’t want to see a committee person railroaded, noting that there is potentially "a tremendous amount of peer pressure [to conform]." The Facilitator assured that consensus is possible in her experience, and offered to revisit the definition of consensus if the process isn’t working. Everyone will have an equal voice at the table. The Facilitator asked "Can you live with revisiting?" The Member agreed this would be an appropriate position to work toward. Speaking for the non-government members of the Committee, he felt that the group will probably work toward consensus, rather than leave the entire decision making process to HCFA.
The Facilitator asked, "Are we in agreement of the
definition of consensus? The Committee would need a consensus to revisit the issue of the
definition of consensus."
Q: Is there an advantage to the Committee in not reaching a consensus?
A: If consensus does not happen, public comments will be considered by HCFA when the NPRM
is published.
The Committee agreed to adopt the definition of consensus.
Handouts were then reviewed, and the Committee began the extensive process of hammering out the language for this group’s Ground Rules, using language from both handout samples, as well as their own definitions and language. The Recorder will collate both documents with suggested changes, and bring a draft document to Tuesday’s meeting for review and comment. A final set of Ground Rules will be distributed for signatures, photocopied, and distributed to the Committee before the end of this meeting.
The Facilitator asked the Committee about the inclusion of their names, addresses, & e-mail addresses on HCFA’s web site when Committee information is published. The Committee decided to include the Committee Member’s name & organization only. No address or e-mail addresses will be distributed. The mailing list will be updated and corrected at tomorrow’s session. As noted, the Committee minutes will be posted on HCFA’s web site. Distribution of information will be a paperless process to the extent possible. No mailings will be made if they can be avoided.
DATES FOR FUTURE MEETINGS:
The Committee was asked to establish a pattern for subsequent meetings. The recommendation
is this Committee conclude it’s work by June 30, 1999. Frequency, duration, and
locations of subsequent meetings were discussed. Some of the Members need to have a
Saturday night stay over to reduce air fares, so they suggested that meetings be held on
Sunday & Monday. The Committee agreed not to hold Sunday meetings. A
start time of 9:00 a.m., with a quit time around 5:00 p.m. on the first day was agreed to.
If necessary the meeting can extend on first day, then shorten on last day to meet airline
reservations. The meetings will alternately be located in Washington and Baltimore.
The following meeting dates were selected by the Committee:
March 22-23, 1999 D.C.
April 12-13, 1999 Baltimore
May 24-25, 1999 D.C. At this point we will take a look at the Committee’s progress,
and may have to schedule additional sessions.
June 28-29, 1999 Baltimore
INTEREST BASED NEGOTIATION -- ATTACHMENT 1-3, pages 12
& 13
Definition: A problem solving process conducted in a principled way that creates effective
solutions while improving the relationship. This works in a number of settings, and tends
to get people out of their "box."
Interest Based Principles
Strategies
Negative:
Positive:
Outcomes of interest based negotiation
Definitions
THE INTEREST BASED (IB) PROCESS (ATTACHMENT 1-3, PAGE 16)
ISSUES AND QUESTIONS TO BE RESOLVED (64 FR 3474) (HANDOUT 1-5)
These issues were published by HCFA in the Federal Register, Medicare Program: Ambulance Fee Schedule; Intent to Form Negotiated Rulemaking Committee. The Facilitators led the Committee through the issues as published.
1. The type of service furnished.
Discussion of this issue led to questions concerning: the level of the service being
provided, the basis of the payment rate, how many gradations should there be, how do we
establish relative values? The Committee agrees on type of service as an issue.
Q. What is HCFA’s perception of relative values?
A. A relative value will reflect a basic level of service. HCFA is open to any concept for
establishing a relative value system that works.
2. Definition(s) of type of provider and how that affects
the payment rate.
Hospitals are paid differently than other providers, and the payment amounts vary by
provider. That amount, theoretically, should be equal. Will it, or can it, be equal?
3. Definition(s) of appropriate regional differences and how they affect the payment rate. Metropolitan Statistical Areas (MSAs) are used for other HCFA payment rates. Is that appropriate for ambulance rates? HCFA is willing to consider regional variations, area variations, or whatever variation will work for the Committee.
4. Definition(s) of appropriate operational differences and
how they affect the payment rate.
Reasonable charges paid to independent companies have been paid by the carrier, and are
subject to an inflation index. Hospitals are reimbursed based on historical data.
Therefore, we may need to ‘gap-fill’ to determine appropriate rates. HCFA has
approximately 51 or 52 separate carriers.
Q: Do they all operate under generally applicable rules?
A: Yes. Congress is phasing out the concept of reasonable charge. Carriers have the
discretion of changing payment rates up or down.
5. Should mileage be paid separately from the base rate,
and if so, how should components of ambulance service be divided between the base rate and
mileage? There is an assumption that mileage charges reflect the vehicle costs (insurance,
depreciation, gasoline, etc.) Is there a standard definition of mileage charges, loaded
(that is, carrying a patient) from the scene to the hospital?
Comment from Member: Neither the base rate nor the mileage has anything to do with the
actual cost of doing business.
HCFA: There has been a historical problem of dealing with urban vs. rural, in terms of
fair compensation. How are variations in transports defined, such as BLS or ALS? HCFA is
bound by statute to the ‘fixed pot’ concept, and the overall spending for the
first year must not exceed $65 million less than budget neutrality.
Q: What if there is an increased patient pool?
A: There is an aggregate amount in the budget set by Congress, and we must set rates to
plan to split up the amount spent on the anticipated patient load. HCFA will use the
latest data set to make the determination.
Q. Will this amount have any relationship with Medicaid?
A. No, only Medicare.
Q: Will there be a ratio? Will the amount [of reimbursement] increase as population
increases and need goes up?
A. Yes, based on the actuary’s projection.
6. Phase-in methodology of the fee schedule from the existing payment method. Does the industry want to jump right in, or phase in gradually?
7. A mechanism to control expenditures.
Q. Can HCFA elaborate on this issue?
A: If volume goes up more than the allowance, there will be an adjustment of the
conversion factor to reflect budget neutrality. In subsequent years, there will be
incremental annual adjustments, upward or downward. The Committee needs to address
inflation & control of expenditures in setting the base rate. To meet Congress’
mandate, the Committee can consider shifting from lower cost services to higher cost
services. Also to be considered are "new" providers, or providers who
hadn’t been paid by Medicare before [implementation of a fee schedule]. There is a
perception that ambulance charges are going up. The Medicare population is increasing. The
Actuary is aware of that. One issue might be inter-facility transfers and changes in
demand for services. Some ambulances are being subsidized, and that might change. Also,
the fee schedule might encourage some to bill who have never billed before.
Q: There is an issue of medical necessity with respect to emergency transport vs. other
transport.
A: This is something the Committee will have to determine.
Q: Is transport appropriateness based on prospective or retrospective diagnoses?
A: We can’t make decisions about a coding system right now due to HIPPA constraints,
and these decisions will require discussion. For example, we must define the components of
ALS and BLS. This approach might cause some providers to only provide ALS. HCFA might
benefit from an easier system of definitions (coding) than ICD-9-CM.
Q: Are the codes based on dispatch or outcome of the service provided? A dispatcher must
decide to send an ALS unit based on the information received. This might not ultimately be
the correct unit, but that won’t be known until the ambulance arrives at the scene.
A: The Committee will need to define ALS vs. BLS services. The services required at the
scene will determine what the appropriate level of payment should be. The fee schedule
must relate to the level of services actually furnished, not necessarily what was
dispatched.
There was a general question about what types of things can be "on the table" for discussion. HCFA noted that everything already finalized in the coverage rule published in the Federal Register, January 25, 1999 is not up for discussion; that is, is not subject to change.
The aggregate amount of reimbursement for the ambulance fee schedule is reduced by $65M. The law does not make this budget neutral. The amount of $65M is off the table.
Q. How was the amount of $65M decided upon?
A. This amount was the projected cost-savings for the year 2000. The projection had been
made in 1997. This amount reflects an actuarial decision by HCFA.
HCFA staff described the four billing methods which the program allows. Two are very rarely used. The other two split the universe. Historically there have been four different ways to bill:
- Method 1 is a single, all-inclusive charge reflecting all services, supplies, and mileage
- Method 2 is one charge reflecting all services and supplies, with separate charge for mileage
- Method 3 is one charge for all services and mileage, with separate charges for supplies, and
- Method 4 is separate charges for services, mileage, and supplies.
There was discussion of the issues surrounding billing.
Q: Is HCFA planning to cover services separate from transport?
A. Coverage issues are not on the table. If a service is not already covered, it
won’t become covered just because of the presence of a fee schedule.
Q: When determining a base year, if the claims data closes
on June 3, will HCFA collect data through the first six months, then extrapolate for the
balance of the year?
A: No. HCFA doesn’t have enough reliable data to do that. We have aggregate data for
1997. The billing data for Part B is relatively stable. However, Part A, hospital data,
will not be definitive enough.
HCFA: the method of defining ALS vs. BLS will not be done by this committee. It is out of the scope of this group. The Committee must define the services that qualify for each of the levels of payment sets.
Q: Are payments based on retrospective definition of the
patient’s problem?
HCFA: Concerning ICD-9-CM codes -- it wasn’t HCFA’s intention to use I-9 codes
after the fact. That is, the carrier would review transport information, based on the
understanding that paramedics are not permitted to diagnose. Codes describing the event
would be assigned based on what’s actually happened with the patient at the time.
Pre-hospital teams will be providing care based on the patient’s symptoms. It is
anticipated that users will be given a limited group of codes to describe their
activities.
Member: In the field, there are theory, practice, and reality - presently, claims are being denied because the patient’s symptoms do not match their diagnoses. Because of HCFA’s position on chest pain [that chest pain which is not a myocardial infarction], claims are not being paid. Ambulance personnel don’t have time for the 12-hour test after the fact. They have to treat the patient based on good faith. There needs to be a communication effort with the carriers. Re: use of the correct diagnostic codes - an unconscious patient could have any number of diagnoses.
The arena of coding is suitable for a report and review of a subgroup. A subgroup of
experts, including HCFA, is needed to determine the answer to this issue. There is a
requirement for some technical attention.
HCFA: what criteria or information is needed to dispatch an ALS ambulance? The statute
tells us to relate the payment to the service provided. Can the number of calls resulting
in an unnecessary ALS dispatch be estimated?
Q: Does the definition of services depend on that which is called for, or that which is
dispensed? What is the best way to determine medical necessity? Assessment? According to
one Member, a code can’t be put on some of the symptoms with which the patients
present.
Another Member mentioned that cost averaging to cover cases where an ambulance was not
needed would be a good idea.
TUESDAY, FEBRUARY 23, 1999
The session began with a welcome from Kathy Buto, Deputy Director of CHPP, HCFA.
A Member brought up the concept of designing a relative value scale. One of the Organizations at the table (the American Ambulance Association - AAA) began looking for a research group in August 1998 to carry out a study of ambulance costs. AAA asked for a spot on the agenda for a presentation from Project Hope with this question to be answered by the Committee: "Can this cost study be used by this Committee?"
Providing the Data to Design a Medicare Fee Schedule for Ambulance ProvidersProject HOPE staff Penny Mohr and Cindy Good were introduced. Ms. Mohr described this project as a challenging opportunity, given the types of service/providers, whose cost structures are very different, and noted there are incredible local variations in costs.
Ms. Mohr described Project HOPE as a company formed in the early 1980's to provide unbiased studies for government and industry. Project Hope’s objective is primarily research. The firm has developed what they describe as an objective expertise in studies.
Attachment 1-6, Providing the Data to Design a Medicare Fee Schedule for Ambulance Providers
Study Objectives:
To Provide the basis for the development of an equitable and credible
Medicare fee schedule for ambulance services
Project components:
- validation study
- simulation using Medicare claims data
- national survey of ambulance providers (NASP)
Design of the NASP:
Design of the Validation Study:
The Ambulance Service Provider Survey 1999 was discussed at this point. It is proprietary, and will not be a part of the handouts.
Medicare Claims Analysis:
Process:
Ms. Mohr reported that comments had been received from all the groups listed above. Not all comments were implemented. A Member commented that this team is "deep" with expertise.
Conceptual Framework: Ways of Measuring Costs:
Conceptual Framework: What factors affect service costs?
Output:
Defining Output: Issues
Input prices:
Measuring Prices: Issues
Quality:
Measuring Quality: Issues
Other Factors Affecting Costs:
Issue: Industry Variation in Cost Accounting and Terminology
Defining Urban/Rural
Status
Cindy Good mentioned that the preliminary test was done for feedback purposes, and that it is not statistically accurate. It has been the experience of Project HOPE that respondents take 3 hrs and 45 min to complete survey. Therefore, it is time consuming to get cost data.
Schedule: Data Collection, Analysis and Report
The next slide represented a time line for completion of the project. The entire time line
represents seven months of collection and reporting activities. These activities are
overlapping as they are performed concurrently. Project HOPE estimates the following
activities and their timing:
Schedule: Simulating the Impact of Proposed Fee Schedule
Another slide showed the following activities and their proposed time line
Q: HCFA wanted to know whether Project HOPE was serving the
AAA or the Committee?
A: Ms. Mohr indicated that Project HOPE is currently under contract to AAA.
Q: HCFA "You’re further along in conceptualizing
the issue [than if you were going to begin after this meeting]. Will the study drive the
Committee, or will the Committee drive the issue?"
A: Ms. Mohr noted that Project HOPE has already worked with most of the people around the
table. AAA recognized that there would be a time crunch with the F.R. notice, so they
contracted with Project HOPE last summer [August 1998]. Does the Committee think that
results of study can be incorporated into the fee schedule?
Q: Member - "If this study is not used, what will
be?"
A: HCFA - "We’ll start at square one."
HCFA suggested that the study should not drive the fee schedule. Time is one of the
issues. AAA mentioned that they would like to have the involvement of the Committee, and
realize that this will require more time than is currently projected for completion of the
NPRM. AAA noted that "Others [Organizations] are welcome to jump in with [financial]
support." Members voiced concerns about the burden of time and the short time frame
re: Federal Register notice.
Q: Member: "What happens to raw data once the survey
is completed?"
A: Project HOPE said the raw data belongs to Project HOPE and AAA. Project HOPE will give
the data all to AAA, after having stripped it for confidentiality. Joint sharing of data
between Project HOPE and AAA is provided in the contract. Confidentiality will be achieved
by scrambled identifiers.
Q: Members asked how they would differentiate between fire
departments, hospitals and the state and local governments?
A: Project HOPE explained that to reach an aggregate conclusion, they would estimate
separate values, combine them, and present the average in a proposed fee schedule.
Member concern: "From the hospital perspective, we can
envision a [newspaper] headline casting a negative connotation on the industry. How would
HCFA use the data?"
A: First the Committee needs to decide if it wants to go forward with Project HOPE. HCFA
has its own charge and claims data, and will use this data for determination of the
proposed fee schedule. Our question to AAA is, do we as a Committee have to decide to
either use Project HOPE or not by the end of this meeting tomorrow?
A: AAA responded that the decision to use Project HOPE, or not, does have to be made now. One of our issues is commitment of funds, and resolution of the question of who will share the cost of any further work done on the contract. Ms. Mohr mentioned that because of diversity in the field, she would caution a long phase-in period.
Q: Member "There are three indicators for quality? Is
that relevant and necessary?"
A: Ms. Mohr "Yes. Project HOPE can say what quality entails. If everyone is moving
toward certain standards, we can determine the cost of that quality. There is room for
discussion, as long as there is a mechanism for expanding the scope of work (SOW) of the
project."
AAA: Project HOPE has narrowed down the scope of the study in getting at the costs.
Member concern: "Now I am being asked to ante up [to pay for this study], but also
privately pay for HCFA regulations. Should this [study] be paid for by HCFA?"
HCFA: "I see that HCFA has a role to play in this, but would have to ask for
additional funding. If government funding is not available, we will use the data we have
without the study."
AAA: "We are willing to continue [the study] without [financial] support from other members, but the [Committee must understand that] survey results will belong to Project HOPE and AAA. AAA realized early on that data wasn’t available from HCFA or the private sector. Our fear was that AAA would be at the mercy of the charge data that exists [at HCFA]. However, fairly and objectively, we have to cover the cost of the [ambulance] service, and the charge data doesn’t reflect this. So we commissioned the study in our own self-interest to survive and provide quality, but [another objective is that we] also want fair reimbursement for the industry as a whole. AAA is willing to share the study data with anyone else who is willing to share the cost of the study. We will not stop the study without additional input, but it would be fair for the rest of the industry the share [in the cost of the study]."
A Member questioned whether other data is being collected?
The Committee’s opinion was that there wasn’t much. One member would like HCFA
to work with the study data. A Member asked if any national data has been collected from
the "fire-sector." The reply was that there is not good industry-wide data which
reflects the real costs of providing services. This [lack of data] then begs a broader
policy question - if it cost $100 to make a call, and HCFA is willing to pay $50, then
where do we go from there?
Member opinion: "Study participation is an important step to take so we have accurate
data. Our enemy is the time constraint, but [collection of accurate] data is important,
and we should be willing to go forward with it. Additionally we can use the data for other
purposes."
Ms. Mohr: "AAA is willing to turn over data results if other organizations buy into the study. This type of study has never been done."
Member comment: "Clearly there are policy issues that go beyond the group sitting at the table. Members need sufficient time to look at this [concept] in depth."
AAA noted that it intends to use the data for backup in case HCFA sets an unreasonably low fee schedule. AAA sees the following issues:
A Member wanted to know if there is any government group that can do the same study, rather than relying on the data provided thru a contract by one member? There are agencies who can do studies such as this, but time is a factor. HCFA reiterated that the projected time for establishment of the fee schedule is the end of June 1999.
Ms. Mohr noted that AAA would be willing to modify the contract. Time is the biggest issue. A discussion followed about any information collected and used by HCFA being in the public domain.
Copies of Phase I report and handouts can be obtained from:
Ms. Cindy Good
Project HOPE --301-656-7401
e-mail: cgood@projhope.org
Additional questions for Project HOPE:
Q: The time line. How can we participate in the study when the projections look like it
would take about seven months or more?
A: At the end of four months, we’ll have some data to feed the Committee. Project
HOPE has subcontractor groups who will participate in data collection. There will ben an
intensive field period, with intensive follow-up, then they’re finished with their
part of the project. At this point we’re waiting on the Committee for go-ahead, then
the project will start.
Q: A Member asked what do some of the terms really mean,
for example BLS and ALS? Who decides what the definitions of the industry’s term are?
A: Ms. Mohr: It is important to know what the data collection subcontractors need to
collect from the outset. For example, the study can collapse service units into
"emergency" and "non-emergency," or ALS and BLS, or mileage. Is
"waiting time" really important? It is not being collected now. Study
constraints - we can’t collect data on something that isn’t currently be
collected, so if the current definitions are changed too much, there will be no results.
There can be linking to Medicare claims data. We can look at diagnosis codes, but because
that’s immensely complicated, we hope the Committee doesn’t go down that path.
The Facilitator then raised some questions about the study,
making a list for the Committee’s consideration.
Q: "There are concerns about data. Regardless of finances [i.e., who pays for the
study], where does the data end up, and in what form?"
A: AAA answered and said that to finish the contract will require about another $200,000.
About $100,000 has been spent to date. Total cost of the completed study will be close to
$280,000 - $300,000.
Q. "Can this fee schedule project be the end use of
the data?"
A: Project HOPE is unwilling to consider that - they want to use the data to publish
papers in scientific journals.
Q: "Can we get this data [for the fee schedule] any
other way?"
A: To address any privacy concerns, AAA can limit access to the data. AAA will entertain
[the concept of] access to data by certain providers if they are willing to pay for it.
Member comment: "Aggregated data from rural providers
may pull down the fee schedule."
A: Data will be weighted; adjusted. These are relative costs, not actual costs. We will
have to impute wages for some of the volunteers. We will determine an average cost, then
the Committee will vary reimbursement, possibly based on wages. AAA is willing to amend
the contract so that participants only receive data on their own industry. Project HOPE
will hold the data; each industry will get their own data plus the aggregate data that
goes to the entire Committee, if they participate financially.
The Facilitator suggested that this idea be put in writing to preserve the academic integrity to Project HOPE, yet provide that information will not be released which would impugn the integrity of any of the committee. This may be an ideal area for a subgroup to discuss. The Committee needs a consensus document with which Project HOPE could agree in terms of principles. AAA voiced a concern that this was probably not possible, and said that it will take another month and a subgroup to figure this out. Emphasis was placed on the need to finish this decision-making at this meeting. Another Member noted that interested parties are pretty close to a decision already, because of the discussion. The caucus (subgroup) will present back an agreement of principles to which the Committee would adhere, regarding data, its availability, its formatting. This subgroup has as its goal to determine guiding principles with regard to data which will be presented as a contract-modification to Project HOPE.
The Committee discussed the Facilitator’s list of
questions, but not in numerical order.
Facilitator’s Question #5: Regardless of finances what happens to the data? Who has
access? Where is it kept? What form will it be kept in?
HCFA comment: "If HCFA financially supports the data, it becomes public domain."
A Member noted that Project HOPE will want full rights to the data so they will be able to publish the results in their own way.
HCFA: Project HOPE’s ‘deal breaker’ is that they need the organizations [to participate in the survey] in order to get the raw data.
The published material will be confined to issues that impact relative value units. Project HOPE agreed that the data gathered by them was for use by HCFA for the creation of a fee schedule. The data would not be relevant to comparisons between provider types.
Facilitator Question #1. Will Committee members encourage
their organizational members to participate in the survey?
Answer: Yes, if Question #5 is resolved.
Facilitator Question #2: Does the committee support
completion of the survey?
Answer: Yes, if Question #5 is resolved.
Facilitator Question #3: Are Committee Members willing to
contribute financially to the survey?
Answer: The Committee determined that this is an individual decision which must be made by
each member. The Facilitator then asked if the Committee wanted HCFA to contribute
"to the pot," with the clear understanding that if HCFA helps purchase this
data, then the results become public domain. The Committee agreed it does not want
HCFA to contribute financially to Project HOPE. Therefore the aggregate data will
not be in the public domain.
Facilitator Question #4. What is the implication of
financial contribution [by Committee Member’s organizations]?
Answer: Contributors will have access to only their organization’s data. If an
organization wants to get their own data, they are permitted, and all contributors will
receive aggregated data. The current contract between Project HOPE and AAA specifies that
Project HOPE cannot sell the data without AAA approval.
Facilitator Question #6. Are there other items to include
in the survey (such as waiting time)?
Answer: The Subgroup will deal with Project HOPE about additional items.
AAA mentioned that they want this [survey] to get started before the next meeting.
Member: What about Committee input? The idea of additional items to be added was
entertained, with the suggestion that additional survey items will be circulated by mail
or e-mail.
Question: Is the survey tool a product of Project HOPE, or of this Committee?
Answer: "The survey is a product of Project HOPE. Any changes to the survey at this
point will slow up the process. All interested organizations have had an opportunity to
contribute to the survey tool - what else is there to discuss?" AAA recommends that
there be no changes to the survey tool.
Facilitator Question #7: Are there limits on further use of
the data?
Answer: This is covered in Question #5.
The Committee was directed back to Question #6 -- are there
any other items to include in the survey?
One Member observed that one or two questions should be added on quality improvement.
Another Member noted that there is a formal quality assurance process, and suggested there
should be a physician committee which is actively involved in the process. A Member
suggested that quality issues could be pulled out as separate line item(s).
AAA: "If that’s the range of issues, Project HOPE won’t have any trouble
adding this to their survey. Can the Committee come to agreement while we’re all
here? Would it be agreeable to the Committee to agree to the principal, and let Project
HOPE craft the questions?"
One final issue: Do providers of ambulance services have a quality process in place, and
"Is there a medical director who is committed and actively involved?" Two
Members will report back on this idea tomorrow.
Final portion of discussion about Project HOPE and any financial issues with other parties: AAA briefed the Committee about the contents of the formal contract, and reiterated that they have funded the initial phase of the process. The remainder [to get data results] will be ~$150,000 - $200,000. HCFA has agreed to provide government data without additional cost. Copies of the contract were distributed to Committee Members. A memo was prepared by an Alternate on behalf of AAA with proposed changes to the contract. This memo was also distributed to attendees.
Ground Rules, Attachment 1-4.3
The next order of business was to finalize the Ground Rules which were discussed
yesterday. The Committee reviewed and discussed the draft. Corrections were made. It was
clarified that information given to all committee members becomes part of the public
record. Informal communications do not become a part of the public record. Attachment A
concerning the Facilitator’s role will be affixed, corrections will be made tonight,
and a final copy will be distributed for signature tomorrow. After all attending Members
have signed off, photocopies of the Ground Rules will be distributed to the Committee and
Alternates.
Additional Committee Member
The City of New York has applied for membership on this committee. A letter (Attachment
1-7) was sent to HCFA by the Mayor’s Office in accordance with 64 FR 3476. However,
this letter was not received timely, though it was sent, so Mr. Louis Marshall addressed
the Committee. He mentioned that they want to represent large cities, currently 1.3
million calls, resulting in 700,000 transports. New York has a large staff, as well as a
large amount of data, with a separate cost center. His office, Director of Quality
Assurance, is currently involved with a survey of ambulance providers.
It was noted that other organizations have applied for Committee membership. The criterion for membership requires representation of a unique entity. This request from NY City is coming at the last minute because of the timing problem. One Member mentioned he would be more comfortable adding another organization if a "League" were represented, and suggested that perhaps large cities may have representation at the table already. Another Member questioned whether there would be a requirement to discuss every other letter submitted for potential membership? A Member suggested that NY be treated the same as every other applicant, then the Committee doesn’t set any precedent for accepting additional Members out of sequence. It was mentioned that the deadline for receiving applications is technically closed at this time, and that the Federal Register was the official public notice. The Committee was advised that they can make the decision that the deadline has closed, and no more request will be honored. A Member suggested that the Facilitators advise the applicant of his representative on the committee. There was a consensus that NYC will not become a member, but in subsequent discussion, NYC was invited to join several committee members already seated. There was also a consensus that committee membership will remain as it was, and that no new requests for membership will be heard.
IDENTIFY ISSUES TO BE REVIEWED BY THE COMMITTEE
The Facilitators identified the next Committee activity. The Facilitators have five
overall issues with sub-issues gathered into groupings. The Committee will divide into
smaller groups, and put these issues into logical order. This process will identify the
scope and range of the Committee’s purpose/issues. The end result is that the
subgroup will define or identify all the issues the Committee will consider. After some
discussion, the Committee agreed to break up into subgroups, discuss these topics, and
come to agreement about the issues.
Identification of Issues
1. How will the schedule be structured?
2. What adjustments need to be made to the schedule?
3. Definitions of terms?
4. Implementation?
5. Expenditure Control?
A Member presented a question to HCFA: "Can we talk
about some process for eligibility for reimbursement?"
HCFA: We won’t be using this Committee to talk about things we’ve never covered
before.
Q: What, pertaining to ambulance services, is meant by "medically necessary"?
HCFA: We will address this to the extent that we can clarify it at this meeting. For the
carriers, HCFA has historically defined terms. Carriers still have discretion about what
they will cover, given the absence of national policy. There is a group of carrier medical
directors (CMDs) who have attempted to look at this nationally, but have not yet made a
recommendation to Central Office for a national policy.
Member suggestion: We need to have an approach which is consistently applied, affects all
transporters equally, and the guidance must come nationally instead of locally.
HCFA: Carriers have asked for guidance, and this Committee’s decisions will affect
national decision making. HCFA sees this as a win/win situation.
Member: "How was the Part A reimbursement
determined?"
HCFA: We can tell the Committee how Part A numbers are determined, but it’s not open
for discussion, as that part of the process is already set. HCFA has been collecting data
(since 1998) concerning separate ambulance costs. Parts B & A billing data is complete
for 1997. HCFA is now required to determine a reimbursement amount to test theories
concerning projections over the cap, under the cap, etc. The amount by which the
"pot" will be reduced ($65 million) to account for the BLS-ALS proposal has been
set by Congress and is off the table. This is not a negotiable amount. The Secretary of
DHHS, Congress, and the Office of Management and Budget have defined this amount.
Member: "With regard to billing methodologies and
bundling approaches -- is the discussion of how this is structured in the future on or off
the table?"
HCFA: "The basic billing method of base rate plus mileage is off the table. However,
the Committee may determine how many base rates there are. HCFA will consider different
base rates for certain things like services or drugs. Somewhere between a Band-Aid and a
$1,000 drug there is some wiggle room. All fees are subject to the fixed pot,
however."
Member: "Is the base rate open to discussion?"
HCFA: "Yes. The Committee must define items and services in the base rate versus
mileage plus number of base rates, e.g., for expensive drugs."
Member: "Then HCFA’s goal is to move to commonality and administrative
simplicity?"
HCFA: "Yes."
Member: "As we go forward [with this process], several examples of having HCFA data
[available] would be useful. What can we expect in terms of information support from
HCFA?"
HCFA: "Obtaining hard data for a year isn’t difficult. The effect of the Y2K
pressures from the people who generate HCFA data are an unknown factor. HCFA will
determine how much data is available, and in what form."
Member: "Is trend data captured? How many unique providers have been billing? Is the
BESS (Part B Extract and Summary System) report available?"
HCFA: Provider numbers are not available in BESS.
Member: "Can the Committee hear from actuaries about nuances?"
HCFA: "We will have an actuary at the next meeting; Members should give the HCFA
Member any questions ASAP so that complete responses or handouts can be prepared."
Member: "Is there a system for describing level of service for transport? [The
industry has a] great deal of anxiety with use of ICD-9-CM coding system. Perhaps there is
a way to make the ICD-9-CM more useful."
HCFA: "There are HIPAA (Health Insurance Portability and Accountability Act of 1996)
issues regarding the use of code sets. It would be possible to bring a data person to the
next meeting to describe these issues. However, we need to be finished with this topic for
now."
ISSUES
The Facilitator pointed out the need to reach a consensus that the headings on page 19 are
in fact the issues before the Committee. Are there other topics that need to be added?
Member suggestion: We should add types of service as its own category. Another
Member mentioned that he thought types of service would come under
"definitions." A Member mentioned (1) provider, (2) service, and (3) level of
care.
There were no more comments about the headings. The Committee agreed that the issues
identified are before the Committee.
Housekeeping
WEDNESDAY, FEBRUARY 24, 1999
Housekeeping:
Project Hope Discussion:
Attachment 1-8 AAA made available the language changes on the Proposed Agreement on
use of Project HOPE National Survey of Ambulance Providers Study. AAA said that they are
now prepared to go forward with contract modifications.
A Member noted that the decision that the Committee makes is contingent on seeing a final copy of the contract. The Committee agreed that AAA will incorporate the language changes in a contract modification with Project HOPE, and will create a subsequent agreement to go ahead with Phase 2 as modified in this Committee discussion. AAA said they would make sure the language is appropriate for the amendment, and will proceed from there.
A Member asked why data for the National Volunteer Fire
Council was restricted to volunteer Fire Departments? AAA responded that this restriction
would keep them separate from data collected by the International Associations of Fire
Chief and Fire Fighters.
AAA mentioned the need for access to "ground critical care" information. There
is no Committee representation for non-volunteer fire-based rescue. This level of rescue
is an Independent third service, which is significant in the south. They will have a
private study, per AAA. AAA will send the revised contract to the Committee.
Quality questions for the survey
The topic of quality service was readdressed with a Member report. Quality is perceived as
a subjective rating which is difficult to define. Exactly what does quality consist of,
and is it measurable? Response time could be considered as a quality factor. After
consideration, it is not clear that any of the indicators are adequate to define quality.
Factors can range from simple to complex, and are not always objective. The reporting
Member suggested that the whole section on quality be deleted, citing that there is no
relevance in coordinating cost with quality.
The content of the survey tool was revisited, with recommended changes made by Members. The survey will not be part of the attachments. The comment was made that bad debt is not an expenditure, and will therefore not be figured in a base rate. One Member brought up volunteer services. As the survey will only have three groups broken out, the only way to find Counties will be to look in the private sector. The question was raised that as counties often support volunteers, can counties be broken out separately? A suggestion was made that the National Association of Counties should have access to all pertinent information. AAA noted that ownership will fall into four categories, with breakdowns below that.
The public utility model service is unique. They are clearly a private company, but where will their performance be included -- with private companies or government? AAA will redraft the language of the survey to reflect the comments made at today’s meeting. The Committee recommended that a page of definitions go with the survey. The Members were informed that Project HOPE will include definitions in the final survey.
Discussion was held on the process of the distribution of
minutes. The Recorder will send draft minutes to principal members, who will send them to
alternates. Members will review the draft, and send corrections back to the Recorder.
Corrections/suggestions will be italicized, original language will be lined-out,
and at the subsequent meeting, minutes will be approved by consensus. The corrected
minutes will be posted on HCFA’s web page as soon as possible. There will be a
1-week deadline for review and return of the minutes, per the Committee’s suggestion.
Meeting time on the last day of each session will be 8:30 am to 3:30 pm.
Medicare’s ambulance fee web page address:
www.hcfa.gov/medicare/ambmain.htm
ISSUES
The Facilitators suggested that the Committee break up into subgroups to decide the draft
language for each of the five proposed issues. The Committee will not suggest resolutions
at this point. The suggestion was made that a Member and one alternate participate in the
process agreement. The process was explained -- the subgroups are charged with writing up
a description of the issue. Each subgroup will choose one spokesperson to explain how the
group reached their conclusions.
ISSUE #1, STRUCTURE - what will the fee schedule look like?
1. Should the fee schedule be based on a
‘matrix’?
2. Assume the matrix, then what should the components be?
3. What, if any, are the relationships of the matrix components?
4. Each component of the matrix will require a detailed definition.
5. A list of the possible matrix components and /or subcomponents:
‘Base service’ - irrespective of
anything else provided, a base level of service is given for patients who are transported.
What does it consist of - this is the issue? ‘Common denominators’. Some level
of care will be given, even if nothing else occurs.
‘Level of service provided’ - BLS,
ALS, critical care
‘Service delivery’ - air, ground,
boat, sled
‘Response demand’ - non-emergency,
emergency
‘Interventions provided’ - vitals,
bandaging, etc.
‘Adjustments’ - factors like mileage,
waiting time, etc.
‘Condition groups’ - cardiac, trauma,
other categories of presenting condition.
ISSUE #4, EXPENDITURE CONTROL
1. Should the number of trips by a beneficiary be limited?
HCFA: This is off the table. We will not permit this to happen.
2. Capitated agreements. This is also off the table.
A. Will there be a demonstration project with
EMS? HCFA responded that this is off the table for this group. It comes under a separate
section of the law, and cannot be decided by this group. The Committee is free to discuss
this topic, but there will be no conclusion. It is possible that there will be a
demonstration project, but this Committee, as a Committee, will not be involved. HCFA
noted that the law addressed expenditure control, inflation factors, etc. The kinds of
control one would adjust for in case the ‘pot’ is exceeded. Does HCFA cut
payment for the next year to keep spending within the total outlay? Any recommendations of
this nature go beyond the scope of this NPRM. This group is only charged with being an
advisory committee for an ambulance fee schedule. §4532 of the Balanced Budget Act was
discussed by an HCFA representative.
B. Will arrangements with Medicare+Choice
entities be addressed by the Committee?
HCFA: No, the ambulance
fee schedule is strictly fee-for-service.
3. Will unscheduled (emergency, non-emergency) transports to non-hospital facilities be covered? HCFA: This is also off the table - this NPRM will describe fee-for-service. This Committee can’t change that. There are no coverage issues on the table. There are definitions for transport from a residence to the hospital, interim stops, SNF, ESRD facility (scheduled) or hospital, or critical access facility (non-scheduled) which are in the regulation. There are guidelines for critical access hospitals - defined as rural, not more than 15 inpatient beds, in which the patients stay less than 96 hours. There is a presence of semi-hospitals in areas where hospitals are going out of business. There are landing zone issues - this can be considered a transfer, and both ambulances will bill. One way of identifying this type of service is use of the "I" modifier on a code. This coverage is a local decision, based on carrier discretion, and is occurring in California according to one Member. As this scenario concerns a coverage issue, another part of HCFA would issue any relevant instruction. One transport destination which is not an option is the "Doc-in-a-box." HCFA would question why transport to an outpatient clinic was medically necessary. An intermediate stop at a physician’s office is only billable if the ambulance stops to stabilize the patient, then continues on to the hospital. None of this is on the table, but is included in the minutes to reflect that these issues were brought before the Committee.
4. Is 100% prepayment review necessary for air/medical
services?
HCFA: This is an operational question, and is not on the table for purposes of this
discussion. Carriers may vary in their requirements for prepayment, and the Committee may
certainly give opinions on guidelines through this fee schedule.
5. What happens if ambulance reimbursements exceed estimated projections?
6. Should treatment without transport be covered?
HCFA: This question is not on the table. A decision such as this comes from Congress.
ISSUE #3, ADJUSTMENTS TO THE SCHEDULE
1. Questions: are these factors that:
Influence the base rate?
Are in addition to the base rate?
2. Mileage:
A) What factors included in mileage relate to
cost?
B) Should factors analogous to ground mileage
be applied to air, e.g., flight miles or flight time.
3. Regional
What regional differences should be considered?
A)
Wage rates (GPCI)
B)
Local mandates
4. Operational differences
What are the operational differences affecting
cost?
A)
Air: (Instrument Flight Rules vs. Visual Flight Rules, etc.)
B)
Ground Type of vehicle, Etc.
C)
Government mandates (local, state, federal, etc.)
D)
Water
5. Rural/Urban
What factors affect cost?
Rural
Urban
Isolated
essential service
Wilderness
Adjustments
for low volume.
Housekeeping:
Q: What data is contained in the BESS report?
A: BESS is aggregated claims detail, which can be sorted by HCPCS code, including
modifiers. HCFA has information from 1995 forward; the 1997 report is complete. Obtaining
information about hospital billing data from Intermediaries (MedPAR - Medicare Provider
Analysis & Review) is more difficult. If we want to look at prevailing Part B charges,
we would have to collect these from each carrier, as it is not collected centrally.
Q: Is there a list of any provider that has billed an ambulance code?
HCFA: The information is collected, it’s just a question of getting it.
Member: The current time frame is adequate for our purposes.
Q: "Is there growth in the number of providers who are
making claims on HCFA for reimbursement?"
HCFA: We will do the best we can to obtain historical data, prior to 1995. The easiest
breakout will be by Carrier.
How will attachments to the minutes be kept, and how will
they be available?
HCFA will establish a folder where attachments are maintained. Members of the public who
need a copy can contact HCFA; the Committee minutes will contain attachment numbers.
Committee members will have the handouts from the meetings.
Signed copies of the Committee’s Ground Rules were distributed.
ISSUE #2, DEFINITIONS
ISSUE #5, IMPLEMENTATION
1. Should the fee schedule be phased in?
Time frames?
Methodology, e.g., blended rates
2. Should mandatory assignment be phased in with the fee schedule?
Is advanced telemetry notice an issue?
3. Carrier & FI needs uniform administration of a fee schedule. HCFA’s
contractors will need education and training in interpreting rules
The criterion for reviews needs to be
established
4. Instructions to providers on changes in billing methods.
PARKING LOT ISSUES
There are some issues that cannot be decided by this Committee. They are listed in this
section as "parking lot" issues, meaning that the Committee has talked about
them:
Capitated agreements
Alternate ambulance destinations - landing
zones, "Doc-in-a-Box," clinics
Clarification of Air/Ground medical transfer
Is 100% prepayment review necessary for
Air/Medical services?
Should treatment without transport be a covered
service?
Project HOPE
To bring this discussion to a conclusion, AAA said that if the circulated language
(attachment 1-8) is acceptable to the Committee, they will advise Project HOPE to start on
the data project. The Committee concurred on the revised language for the
"Project Hope National Survey of Ambulance Providers Study Data" with a
"thumbs up" agreement. AAA will make the contract revision available to
the Committee by next week. Project HOPE will begin pretesting immediately.
AGENDA FOR NEXT MEETING
The Facilitator will be e-mailing this out to committee members prior to the meeting. The
agenda will include, but not be limited to:
After discussion, the Committee decided it doesn’t need systems people to discuss data at the next meeting. It also decides that actuaries aren’t needed at the next meeting. The Committee will address reimbursement issues at the third meeting.
The meeting was concluded at approximately 3:40 p.m.
The March and April meetings will be combined and held at:
Doyle’s Hotel
1500 New Hampshire Avenue, NW
Washington, D.C. 20036
Phone: 202-483-6000 - reservations
Fax: 202-328-3265
Additionally, the dates have been changed for the April meeting. It has been extended by one day, and will now be held from Monday, April 12 through Wednesday, April 14, 1999.
The following list is a summary of the Committee’s consensus items from this meeting:
APPENDIX A
Attachment to the Minutes
MEDICARE AMBULANCE FEE SCHEDULE NEGOTIATED RULEMAKING
February 22 - 24, 1999
1 - 1 Committee Representatives and Alternates
1 - 2 Agenda
1 - 3 Negotiated Rulemaking Orientation
1 - 4.1 Draft Negotiated Rulemaking Committee Ground Rules
1 - 4.2 Sample Negotiated Rulemaking Committee Ground Rules
& Protocols
1 - 4.3 Negotiated Rulemaking Committee Ground Rules
1 - 5 Compilation of Background Documents
-
Legislative History
-
Section 1861(s)(7) of the Social Security Act
-
Balanced Budget Act of 1997, Chapter 3, Section 4531
-
HCFA Final Rule: Ambulance Services
-
HCFA Notice of Intent to Form Negotiated Rulemaking Committee
1 - 6 Project HOPE - slide presentation
1 - 7 Letter, Office of the Mayor, City of
New York
1 - 8 Draft, Proposed Agreement on use of
Project HOPE National Survey of Ambulance Providers Study Data
#
Last Updated May 3. 1999
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