DRAFT SUMMARY MINUTES

The fifth meeting of the HCFA Negotiated Rulemaking Advisory Committee on Medicare Ambulance Fee Schedule began at 9:13 a.m. August 2, 1999 at the above address. Commissioners Elayne Tempel and Lynn Sylvester facilitated the meeting.

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 Krakeel
National Association of Counties (NAC) - C. Ronald Aycock
National Association of State Emerg. Medical Services Directors (NASEMSD) - Robert (Bob) Bailey, Alternate
National Volunteer Fire Council (NVFC) - Craig Sharman, Alternate

General Administrative Matters - Handout 5-1, Agenda
Two additional presentations were added.

Minutes
Consensus: Delete any specific references to the words Acost data@; use the word Aadditional@ instead. Page 4; delete #2 under Consensus of Committee. Consensus: The minutes are approved as amended.
Discussion of letter from HCFA
A letter from the Acting Administrator, Health Care Financing Administration, was faxed to each Committee representative on Friday, July 29. This letter explains that the Committee must conclude its business with a proposed fee schedule model by February 15, 2000.

Handout 5-2: Letter to Mr. Bill Archer, Chairman, Committee on Ways and Means, House of Representatives.
AAA had drafted the letter and sent it out electronically to Committee Members, asking for comments. Changes were made by AAA based on Member=s comments, and a final copy was circulated today. The purpose of this letter is to apprise the appropriate committee(s) in the House about the activities of the Ambulance Fee Schedule Negotiated Rulemaking Committee and request an extension of the deadline to have a finished product. In light of the HCFA Acting Administrator letter, above, discussion was held regarding the appropriateness of sending the letter. The Committee decided to send the letter anyway. Additional corrections were suggested, and discussion was held concerning to whom the letter should be sent. Consensus: Send the Archer letter to the Ways & Means Committee and Finance Committee, addressed to the ranking Majority and Minority members of each committee. HCFA abstained from this vote. There will be four letters for Committee signature after corrections.

Presentation on GCPI (Geographic Cost Practice Index) -- Handout 5-3
Robert (Bob) Ulikowski, HCFA, presented a report on GCPI (Geographic Cost Practice Index) for the physician fee schedule, which uses GCPI for reimbursement to physicians for their services. Mr. Ulikowski explained the process surrounding the development of this fee schedule.

The law requires that the GPCIs measure the resource cost differences in the over-7,000 services paid under the physician fee schedule among areas in the three components of the fee schedule -- physician work, practice expense (such as employee wages, rents, and medical equipment and supplies) and malpractice insurance. Uniform national relative value units (RVUs) were established for each of these three components. Data common to all geographic areas was needed. HUD data was used on fair-market rents for determination of practice expense (type of employees and rents). It was found that most supplies were sent from a central area, therefore differences in supply prices were tied to volume discounts, as opposed to geographical differences in supply costs. Data compiled by census on MSA and non-MSA levels was taken by HCFA and mapped to the county level to perform the calculations. This mapped data was adjusted to 89 localities in 1997, including DC and Puerto Rico. Mr. Ulikowski noted that the most relevance to the ambulance fee schedule process is probably the practice expense component of this model. When this Committee decides what data is needed, it should keep in mind that (1) data should reflect information available everywhere, and (2) data needs to be collected on an on-going basis for update purposes. The law requires review and revision of the physician fee schedule, if warranted, every 3 years.

HCFA collects MSA and non-MSA hospital cost report data on wages of each category of hospital worker. This information is approximately 3-4 years old by the time everything is collected, because validation is such a lengthy process. This is similar to the physician practice expense. The hospital wage index is used for other place of service reimbursements, i.e., SNFs. For the Ambulance Fee Schedule, Project Hope is collecting data on wages, including rural indicators, and differences between the costs of providing services between rural & urban areas. Non-MSA data is by state, except for New Jersey, which has no rural area. Market basket is an update factor, and is used instead of the consumer price index (CPI). The physician fee schedule is re-estimated every year.

Medical Workgroup Report -- Handout 5-4, Draft
Dr. Bass presented this topic. The Workgroup has met a total 3 times, for 1 day each time. Draft handout includes an overview of some of the issues the Workgroup was asked to review. They will meet again September 22-23, and will revise the draft handout, based on comments received from Members. Dr. Bass reviewed the draft, explaining the Workgroups decisions and language for the decisions made and information included. Service levels need to be added to the list of emergency conditions. Dr. Bass anticipates that this list is more or less the end product. In response to a Member comment, there was a clarification that the Workgroup=s work is to be considered a recommendation to HCFA. Dr. Bass requested that any comments be e-mailed or telephoned to him.

HCFA Data Presentation -- Handout 5-5
In response to requests from Members, Bob Nieman compiled statistics, which he presented to the Committee. Mr. Nieman explained that the data represented a 5% sample of carrier information, and described the information presented in each of the runs. HCFA is working on matching ICD-9-CM codes to services.

Presentation by AAA -- Handout 5-6
Daryl Grinsted presented a model fee schedule discussed at the last meeting, with the caveat that the numbers presented were for theory purposes only, and were not intended to reflect any real figures. The physician practice GPCI was used as a placeholder and actual mileage was used as the distance parameter. Ben Hinson put together a chart reflecting the work of the modeling workgroup, applying the imaginary numbers, and showing what it would look like when extrapolated. The worksheet was created to be budget neutral. The purpose of this chart and presentation is so that the Committee can finish this two-day meeting with a model, enabling HCFA to have a starting point for the fee schedule.

Presentation - Association of Air Medical Services-- Handout 5-7
Bill Bryant gave a PowerPoint presentation describing another methodology for determining the fee schedule. This presentation’s conclusion is similar to the AAA presentation, but with a slightly different approach. The numbers presented are used for illustration only. Consideration must be given in this model to the question of how to carve up the average total payment for each type of service. Geographic factors are not a problem. This presentation represents a mathematical formula, so it would be easy to plug into a model. The Committee needs to agree on the numbers that will go in the blanks. The relative values cannot be determined until the Project Hope data is received, but the Committee can plug in numbers into the formula to see what the schedule could look like. Missing from this model: (1) Service levels, (2) Relative value units, (3) Rural issue, (4) any other potential modifiers, such as emergency, non-emergency.

Definitions developed by the modeling workgroup that would justify a modifier:
Scheduled: For purposes of this part, an ambulance trip is considered to be scheduled if the request for the service was made to the ambulance supplier at least 24 hours prior to the time requested for the patient to be transported. Repetitive transportation of an individual for treatment for the same condition is always considered to be scheduled regardless of when the actual arrangements for the transportation are made.

Unscheduled: For the purposes of this part, an ambulance trip is considered to be unscheduled if the request for the service is based on an emergency or 911 call or if the request for the service is made to the ambulance supplier less than 24 hours prior to the time requested for the ambulance transportation to be made available.

1. Volume (Handout 5-8, Effect of Volume on Cost/Transport)
2. MSA/non-MSA
3. Census Tract
                   Sole Community Provider
4. Garage vs. Scene
5. Emergency vs. Non-emergency
6. Apply to base mileage

HCFA can easily determine the following information: beneficiary address, garage location, and Medicare volume.

Identifying future tasks:

1. Rural adjuster. Whether there is one; what it is. Waiting for HCFA to come back with what can be determined for a location adjuster
2. Wage/geographic adjuster
3. Define levels of service
4. Medical conditions associated with levels of service
5. Relative value units
                 Plan AB@ - back-up plan if project Hope data doesn=t serve Committee=s needs
6. Paramedic intercept
7. Implementation/transition
Consensus: Discussion on expenditure control will not be a future task, but the Committee is not relinquishing input into this topic. The regulation will contain information about expenditure control, and comments on the proposed notice will be considered.

Discussion was held about adjustments to be made for providers who will not bill the fee schedule amount. HCFA will handle this issue.

The Committee would like to consider a wage adjuster or cost of living adjuster. The warning is that when February 15th comes, the regulation negotiation process is over, whether or not these types of issues have been discussed.
In HCFA=s modeling options, there are choices between GPCI and hospital wage index (HWI), as well as other configurations of this data.

Service levels
Discussion concerned the starting an IV, and whether it should be considered an ALS service? The suggestion was made to leave BLS as its defined. Define level of service by what is delivered, rather than the National standard curriculum (credentials) of the provider. IV is invasive procedure, therefore should be considered ALS. There are variations state-to-state in the requirements of the providers, so services performed seems like the best way to go.
Consensus: level of service is defined by skill provided (intervention), assuming there is medical necessity.
Consensus: BLS service is defined as the National Core Content and Practice Blueprint for EMT-B.
Consensus: ALS-1 is defined as AWhere medically necessary, an ALS assessment done by an ALS provider and/or the provision of ALS intervention@.

A lengthy discussion was centered on IV insertion, and some Members expressed concern that ALS would be equated with EMT-B. One option is to say that IV insertion is a BLS procedure, and then IV insertion could be rolled into the base rate. This Committee is charged with deciding what constitutes ALS/BLS services. Option: Redefine BLS service as the National Core Content and Practice Blueprint for EMT-B, including starting an IV where medically necessary. The service is defined as ALS when the assessment is provided, which makes the service beyond the basic standard. The AAA suggested that a system be built on intervention and assessment, and place IV in ALS.

 * Must address these at the next meeting; HCFA would like to be able to start modeling after the October meeting.

 December: Paramedic intercept - already defined, establish the RVUs.

Dates for next meetings: