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The fourth meeting of the HCFA Negotiated Rulemaking Advisory Committee on Medicare Ambulance Fee Schedule began at 9:00a.m. June 28 at the above address. The meeting was facilitated by Commissioners Elayne Tempel and Lynn Sylvester.
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 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 - Steve Ennis
Member(s) Absent
American Health Care Association (AHCA) - Robert T. Deane, Ph.D.
Administrative Matters:
| Next Meeting: | August 2-3, 1999 Phoenix Park Hotel 520 North Capitol St., N.W. Washington, D.C. 20001 (202)638-6900 |
The minutes from the May 24-25, 199 were adopted with modifications. Elayne Tempel announced to the Committee that American Health Care Association was no longer a member of the Committee, and would not be attending any future meetings.
Bob Niemann (HCFA) presented an update of prevailing charge data. He presented a handout and explained the contents. He interrupted his discussion upon the arrival of Chris Molling, the HCFA Actuary, in order for Mr. Molling to address the Committee.
Mr. Molling reviewed the Committee's May 25, 1999 letter to the Actuary. He addressed their concerns regarding the "pot" of money and explained that he is not directly involved in this issue. He advised the Committee that once they have a model or models ready to present, HCFA will prepare an impact analysis for their consideration.
Dr. Bass ( ACEP/NAEMSP) discussed the Medical Issues Group meeting held in Baltimore. The next meeting for this group will be July 15, 1999 in Baltimore.
Darryl Grinstead (AAA) distributed a draft matrix that could be used in a possible fee schedule model. The Committee discussed this draft.
The Committee prefers to create the model using additional data that Project Hope is currently collecting. Nancy Edwards (HCFA) explained the time constraints for the Committee to construct a model and that if the Committee does not come to a timely conclusion, HCFA will construct the fee schedule. She explained the need for the structure for a model no later than the August meeting. The Committee discussed sending a letter to Congress requesting an extension of the current deadline. HCFA advised the Committee to proceed as though there would be no further extension. The Committee should prepare a model without the Project HOPE data. Discussion centered on one or two models to which the data from Project Hope (if it becomes available) could be applied. The Committee is concerned that HCFA's data is not adequate, but there is no certainty that the data from Project Hope will be better.
The Committee tried to define the terms needed to construct the model for the fee schedule.
The discussion centered on the differences in ground ambulance services supplied by advanced life support (ALS) versus basic life support (BLS), and emergency versus non-emergency.
Next the Committee discussed ground transportation. There were two possible approaches:
a) Two separate rates: 1) ALS base rate; and 2) BLS base rate;
or
b) Base charge with an ALS service component add-on.
It was decided that ALS and BLS require further definition. The structure cannot
be based solely on transport of the patient. Services furnished to the patient
must be distinguished. The following questions arose:
1) What service delivery costs are included in ALS and BLS rates?
2) What costs are included in base rate and ALS service component charges?
After discussion and caucus the Committee agreed that:
1) simplicity is essential; and 2) the proposal must support emergency medical
care and quality care given to the patient.
They also agreed that the service delivery costs that are included in the ALS base rate are whatever clinical costs are associated with the delivery of advanced care. Furthermore, costs such as fuel and vehicle depreciation are included in the mileage code and not included in base rates.
IAFC presented a Proposed Structure for Ambulance Reimbursement (Attachment 4-2).
The following is a synopsis of the charges chart (Attachment 4-3):
Charge 1 - Fixed costs of scheduled BLS transport and care including 2 personnel, operating expenses, infrastructure
Charge 2 - Fixed costs of unscheduled BLS transport and care including 2 personnel, operating expenses, and infrastructure
Charge 3 - Fixed costs of scheduled ALS transport and care including 2 people at least 1 of whom is ALS, operating expenses, infrastructure, for non- complex routine ALS patient
Charge 4 - Fixed costs of unscheduled simple ALS including assessment and/or simple ALS intervention including IV, monitor, including 2 people at least 1 of whom is an ALS person, operating expenses, infrastructure (Question raised - does an ALS person need to accompany the patient during the transport?)
Charge 5 - Fixed costs of a more complex ALS transporting care (e.g., cardiac arrest, pulmonary edema, major trauma) assessment and could include third person. (The medical issues group will clarify this)
Charge 6 - Fixed costs of critical care treatment and transport including 2 personnel, operating costs, infrastructure, including specialty personnel by local protocol or by state law (could be a third person). For example, CHAMIS standards for the care that is beyond the scope of practice of a paramedic (per the DOT national standard curriculum) in patients that are generally physiologically unstable.
The questions that remain unanswered are:
How do we handle scheduled versus unscheduled?
How do we handle other than ground transport (e.g., air, water)?
What about add-ons (in addition to the base rate)?
What about modifiers (multiply base rate)?
Can a modifier adjust an add-on as well as a base rate?
Modifiers are used in the creation of the fee schedule and add-ons are attached to the claim.
On Tuesday June 29, 1999 the meeting was called to order at 8:35am. Discussion began about the letter to Congress requesting an extension. The current law requires implementation by January 1, 2000.
The Project Hope data should be available by December 1, 1999. Forcing an earlier date may jeopardize the quality of the data.
The options now are:
The Committee believes it can complete its work by January 31, 2000. They believe the Project HOPE report will be thoroughly discussed in the December meeting. HCFA cannot commit the programmers who will work on the impacts of the proposals after the original deadline due to backlog created by Y2K constraints. The Committee must be willing to commit to a date to submit a model to HCFA and this must be contained in the letter requesting the extension, and they must also realize in asking for an extension this may be preempted by other work in HCFA. The letter will be addressed to the Committee on Ways and Means, Senate Finance Committee, the majority and minority leaders with a cc to the Administrator. The letter will be drafted and brought to the August meeting to be signed.
CONSENSUS OF COMMITTEE
The Committee reached a consensus (HCFA abstained from the vote) to draft
a letter to Congress requesting an extension of the deadline for this Committee
with the following stipulation:
A Subcommittee was formed to draft this letter.
Discussion returned to the chart that was developed late yesterday afternoon (Attachment 1).
There is no difference who provides the services to the patient, it is just the patient's condition and the service or services provided to the patient as to what is paid. It was decided that the structure and framework of the chart adhere to the beginning of the discussion model.
CONSENSUS - The chart is a basis to start work on the model with modifications to be made by the AAA.
Further Definitions:
Mileage is affected by geographic cost modifier; therefore, add mileage to base rate prior to application of geographic cost modifier. Whether high-cost drugs should be an add-on was discussed. There was informal agreement that this would not be an add-on.
Urban/Rural/Wilderness - there are some advantages to regionalizing ambulance services. Examples were given of small volunteer companies with regard to how they are formed and operated. Dan Manz (NASEMSD) agreed to form a subcommittee to address urban/rural/wilderness issues. It was agreed to change the issue to rural/wilderness because urban is already sufficiently being handled. Clarification was needed regarding multiple providers on the same call (i.e., air to ground). HCFA will work with carriers to determine who is billed for what "leg" of the trips
Need to be done for the next meeting
Prepare the drafts to focus Committee discussion on the following topics:
The term "emergency" has been defined by HCFA in regulations.
DEADLINE: To Lynn Sylvester by July 19, 1999. Ms. Sylvester will distribute the drafts to all Committee members prior to the next meeting.
Expenditure Controls
It is not clear what expenditure controls can be used, other than the inflation
factor required by the Law.
Paramedic Intercept
The relative value subgroup will consider this. This must be in the fee schedule
even though it affects only one small group.
Public Comment
There were no comments from the public.
General Impressions
All Committee members gave their impressions so far. Everyone felt the Committee
had begun to work together, but all were concerned about the time remaining
to resolve many details of the fee schedule. There was also concern that all
of the data needed for informed decisions may not be available.
Agenda items for the August 2, 3, 1999 Meeting:
Discussion of Service Levels
Discuss Issues:
Implementation
Expenditure Control
Minutes of June Meeting
The meeting adjourned at 3:30 pm.
Attachments to the Minutes
MEDICARE AMBULANCE FEE SCHEDULE NEGOTIATED RULEMAKING
June 28-29, 1999
4-1 Agenda
4-2 IAFC Proposed Structure for Ambulance Reimbursement
4-3 Service Level Chart
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Last Updated August 17, 1999
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