The third meeting of the HCFA Negotiated Rulemaking Advisory Committee on Medicare Ambulance Fee Schedule began at 9:00a.m. May 24 at the above address. The meeting was facilitated by Commissioners Elayne Tempel and Pete Swanson.

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. 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
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) -
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 Emerg. Medical Services Directors (NASEMSD) - W. Dan Manz
National Volunteer Fire Council - Craig Sharman
Member(s) Absent
American Health Care Association (AHCA) - Robert T. Deane, Ph.D.
Association of Air Medical Services (AAMS) - Edward R. Marasco

American Hospital Association (AHA) - Bill Bryant (Alternate Attended)

Administrative Matters:

Next Meeting:

June 28-29, 1999 B.W.I. Marriott Hotel 1743 W. Nursery Road Baltimore, Maryland (410) 859-8300

John Brenan will be an alternate for ACEP

Lynn Sylvester couldn’t attend - Pete Swanson substituted for her.
Elayne Tempelintroduced the new members.
Comments about Minutes - It was recommended that the minutes be available no later than 10 days after the last session. It was suggested that a standard be set up. The discussion was halted until the recorder (Ann Fagan) arrived.

CONSENSUS -- The Reg/Neg minutes will be distributed 10 workdays after the meeting. Primary members will be faxed a copy. The E-Mail distribution will remain the same

Dr. Bass gave a status report on Medical issues work group. The membership was expanded from 12 to 14 to include a representative from AHA and AME. There were two groups formed. One group was to do the coding system, and the second group to develop conditions. The group was scheduled to meet again in Baltimore on June 17, 1999. AIMS wants to be in the subgroup, and Dr. Bass told them they were comfortable with the group the way it was, because it already included a nurse and physician from air ambulance groups. AAMS defended it position. AHA also wanted to be on a subgroup. They were interested in working on coding.
CONSENSUS -- AAMS & AHA will each have a member on the subgroup on medical conditions.

The issue was brought up of the proposed letter to Congress. AAA had drafted up a proposed letter, and had gotten a few comments.
CONSENSUS -- The Group is willing to hold up a Congressional letter unless and until Nancy Edwards says it is needed.
Nancy Edwards told them the Actuary would not meet with them. The committee wants a much more detailed presentation of how the Actuary arrived at his numbers. Nancy said she would see about Chris Molling attending the next meeting.

AAA wants to develop a uniform data request from the committee to HCFA. AAA said they would send out a draft request for the committee to review. A letter is being prepared for the committee to look at asking the HCFA Actuary the what they want to know. Representatives have authority to speak for their organizations. How HCFA figures out what part of money is available is not on the table.. Agreement around the room that actuaries need to listen to Organizations. HCFA - things that are of the table are subject to comment in the publication of NPRM. Actuary will consider all comments. Committee wants to know how calculations are made. Thumbs Up Consensus on: Open process. Organization should contact the Actuary and tell the Actuary what data is needed. Thumbs Up Consensus On: Committee draft shared letter to send to the Actuary concerns and data requests, to questions. Paragraph included which declares necessity for full disclosure. Looking for claims data and impact to ambulance payment.

Ann Fagan has arrived and the discussion returned to the minutes. Consensus was reached on the minutes at this time.

Bob Nieman of HCFA explained the data handouts. Also, OIG report “Medicare Payments for Ambulance Services: A Framework for Change,OEI-12-99-00280", Data Runs (requested last time), and the minutes were passed out. The minutes will be discussed tomorrow, May 25.

New standards: (list of reality checks)
14. Equity
      Horizontal - whatever we’re judging would be equal to all
            Example: fire & private. Same kind of parameters is a horizontal equalizer.
      Vertical - distribution of $$ to those who might not be in equal circumstances.
Consider rural providers. Gets to the modifier.
      Transitional - understanding that this will cause a hardship to some
      Inter-generational - Long term effects, way into the future.

15. Enhance integrity of medical transport system
      Emergency
      Scheduled

Proposed standards:
#4. Is it legal? Removed by the committee
#3. Modified to read more uniformity and predictability in carrier...

One member issued a handout as follows:
1. Is it effective as a solution?
2. Is it cost effective?
3. Can it be implemented operationally?
4. Does it promote uniformity, simplicity and predictability in administration?
5. Is it equitable to all participants?
6. Does it preserve appropriate beneficiary access?
Thumbs Up Consensus Agreement on the standards listed above.

Next item of business: ideas on the options themselves.
Issue #1 - Structure
There is some semblance of a matrix on the structure right now:
      Emergency/Non-emergency....mileage
ALS......./......../........
BLS......../......../........
Fixed Wing......../....na..../........
Roter......../....na..../........
Marine......../....na..../........

The option above is a matrix. Emergency/non-emergency may be better described as scheduled, non-scheduled.

Option 1: Multiple matrices
Option 2: Technical component with one single rate, professional component (based on rates delivered to the patient), with an adjustment factor HCFA doesn’t think splitting things out is a problem, just probable complicated.
Option 3: OIG report - 2 box matrix with emergency and non-emergency with additional payment for mileage > 10 miles.
Option 3b. 2 - Box matrix with scheduled and non-scheduled, with adjustment for mileage > 10 miles.
Option 4 - Eliminated
Option 5. Identify low volume, rural, sole provider (isolated essential), and make special payment (exemption) for them in addition to regular fee schedule. ADD THIS TO THE LIST OF PARKING LOT ISSUES - EXEMPTIONS FROM FEE SCHEDULE.
Option 6. Series of lists, like base rate, mileage, with a list of modifiers.
Option 7. Similar to above with 1 base rate, adjusted for BLS, ALS, rural, etc.
Option 8: Base fee, with adjustments based on the prospective condition of the patient.
Option 9: Per-capita reimbursement to local government. Let members figure it out at the local level.
Option 10: Status-quo matrix.
Option 11: capitate model. Predictive model of expected services.

Keep Options: 1, 2, 3a. & 3b (4 eliminated), 6, 7, 8, 9, 10.

1. AAA - four box matrix: Scheduled.../...non-scheduled
            ALS......../........
            BLS......../........
      Above is prospectively determined
      Additional 8 categories of breakout could be added

2. Other option:
            Base rate./.Loaded mileage./.scheduled./.non-scheduled.
      BLS......../......../......../........
      ALS......../......../
      CRITICAL CARE......../......../
      FIXED WING......../......../
      ROTOR WING......../......../
      MARINE......../......../

Comment: change base rate & loaded rate to fixed costs and incremental costs. Or: get rid of base rate, add other variables.

            ALS../..cc../..non-scheduled../..rural../..regular..
      Ground......../....../......../......../......../
      Fixed
      Rotor
      Marine......../....../......../......../......../

Level of detail - Members want to caucus with their groups.

Use the matrix model to guide considerations. Agree that the matrix issues might be the relative issues, and then decide whether they’re to be kept or not.

Groups will make presentations tomorrow.

Tuesday May 25 Agenda:
      April minutes approved
      AHA presentation of draft letter for the Actuary, or data the Committee wants.
      AAA - gave handout; it’s not in final form
Adjourned at 4:00 PM
Meet tomorrow at 8:30 AM.

On Tuesday, May 25, 1999 the minutes were read and corrected. Thumbs Up Consensus - minutes be adopted as corrected.

Letter to Rick Foster - Attachment 3-1 - Modifications made, changes to be given to recorder on disk. Procedural - need signatures? Yes.

Membership -American Health Care, an organization that is officially part of the committee, hasn’t been able to attend. Check with them, see if they want to be dropped. Elayne (Facilitator) will contact them to check.

Very close on many of the key issues. (1) Closing in on consensus that a matrix is the right way to do this. (2) some concept of simplicity, with conciseness and tightness.
Question: how will the model be founded? Committee should spend some time talking about differences between rates for BLS/ALS and Base rate + ALS service. Need to solve this, or else we’re stuck.
Comment - how ever we decide, there’s still a difference between BLS & ALS.
Comment - isn’t the difference between ALS & BLS marginal?
HCFA - neutral on either way the Committee decides to go.
Is the concept of paying for an ALS service fee legal? Truly paying for ALS, because you start with the base. ALS extra only paid to the transporting provider.
HCFA - ALS doesn’t have a life of its own, it’s a construct.
Further discussion was then held on the formation of a matrix.

Corrected letter to Rick Foster w/original to be signed by Committee. Attachment 3-2. Letter to Ambulance Service Provider - Attachment 3-3. Cover letter for the questionnaire. Has the Committee’s phone #s on it, which will be public domain when it is listed as an attachment. Changes made.

June 28 - 29 meeting at BWI Marriott. Federal Register announcement already made, as well as room deposit has been made.

HCFA agreement with any of the proposed models. Urge to think to the future, and make the schedule flexible enough to account for changes in practice.

Facilitator: ideas given that will help other ideas come out when this topic is taken back.
The proposed ideas will be attached to the minutes in additional appendices.
Discussion tabled until June, 1999. Not too many ideas about modifiers/adjustments - they’re similar.

ISSUE #3: Modifiers/adjustments:
Mileage (loaded)
      3rd leg mileage
Regional - Can HCFA describe GPCI? HCFA - way to describe labor costs. Based on state-wide geographic practice costs. Concern: get below the state level.
      Wage index
      Fuel
      Insurance
      Facility costs
Urban/Rural/Wilderness
      Topography
      Population density
      Volume Density
      Distance per trip
      Availability

Consecutive multiple providers on the same call (i.e. air to ground)
Federal Taxes/Mandates - federal excise taxes on fuel have been exempted on air ambulances
Want to guarantee that any future taxes will be covered by HCFA.
J-codes for medications
Speciality services, i.e., neonatal

Comment: Inflation index? HCFA: it’s in the law
Comment: Can HCFA provide current adjustments? HCFA: other than wage related adjustments, the rest are specific to the kind of payment
HCFA: Consensus region differences - see regional, above.

Agenda for June 28, 29 Meeting:
      Presentation from Actuary
      Implementation issues
      Structure
      Adjustments (wage related adjustments)
      Minutes of May meeting

Thumbs Up Consensus - Establish ground rules for public comment - 5 minutes. Identify self and Organization.

Comments: Implementation will not happen on Jan 1, 2000.
HCFA clarified that the requirement for providers to take assignment will be tied to the actual implementation of the fee schedule, not the calendar date.

PUBLIC COMMENT PERIOD:
Comment: The GAO representative in the audience was asked to comment. GAO here as observers. Looking at current system. Asked by Senator Dashiell to look at current system. Issues raised by South Dakota. Looked at less densely populated states. Looked at Carrier - Meridian. Met providers; discussed their concerns.
Complaints: (1) Low reimbursement. (2) High denial rates
The meeting was adjourned at approximately 2:30 pm.

3-1      Agenda
3-2      Rick Foster letter to be signed by the Committee
3-3      Letter to Ambulance Service Provider

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Last Updated July 19, 1999