MEDICARE AMBULANCE FEE SCHEDULE NEGOTIATED RULEMAKING
Turf Valley Hotel & Conference Center
2700 Turf Valley Road
Ellicott City, Maryland 21042
October 4 - 5, 1999

The sixth meeting of the HCFA NEGOTIATED Rulemaking Advisory Committee on Medicare Ambulance Fee Schedule began at 9:10 a.m. October 4, 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) - Dan Manz
National Volunteer Fire Council (NVFC) - Steve Ennis

General Administrative Matters - Handout 6-1, Agenda

Handout 6-2: Medical Necessity Workgroup Report
Medical issues workgroup presentation. See handout 6-2.

Dr. Robert Bass reported that the workgroup met September 22, 1999. The report is a compilation of the issues and recommendations they sought to bring to the attention of the Committee.
COMMENTS
Workgroup met Sept 22, 1999: 4 items to report

1. The work group has completed the first draft of the list of conditions encountered by pre-hospital providers and the appropriate level of service that should be reimbursed for those conditions. He distributed this list to the Committee (attached). The conditions are categorized as follows:

• Emergency Conditions (ALS and BLS)
• Emergency Conditions—Trauma (ALS and BLS)
• Non-Emergency Transports (ALS and BLS)
• Inter-facility Transports

  The conditions list included the following:

• differences by diagnosis (i.e., the condition of the patient whether it was relevant or irrelevant)
• if a patient was ALS or BLS
• mobility of the patient and whether additional services were needed, i.e., oxygen

Question:
AHA wanted to know how this fit in with the current coding systems used by HCFA. It was decided that the word coding should be eliminated.

3. Dr. Bass then reviewed the work group’s discussion of the definition of Specialty Care Transport (SCT) (page one (1) of the work group report). He reported that they recommend the following definition:

Comments: Questions were raised regarding the lists of medications within states. The group concluded there was nothing consistent about the way this was done.

Some of the procedures and qualification discussed were defibrillation, the amount of medications required, and the assessment of the illness of the patient. The group will meet again on November 15 and 16.

What determinations are needed to assess the levels? Discussion included the inclusion of patients who are receiving in home treatment and where in the classification system they would fit. Also discussed was where levels that are defined on a state and local level would fit. Also questioned was whether the state or local levels defined the criteria for care. If ambulances are paid on a particular level, the burden of proof would rest on the ambulance carrier. It was believed that the common misconception will be the debate on what services the paramedics are trained and certified to provide. There also must be a formula used to determine a threshold for specialty care for paramedics with additional training. There are no national standards to define routine care of paramedics and what is determined to be specialty care.

The discussion resumed around the points the various groups want included in the definition of specialty care. These included the need to define specialty care with regard to area served, the drugs or procedures the carrier would be required to reimburse as well as the need for a national standard to define what procedures determine the level of care a patient receives. The question arose as to what Medicare will reimburse with regard to certain levels under BLS and ALS services.

The group tried to reach a consensus on the definition of specialty care as reached by the workgroup. Some in the group were comfortable with the definition as reached; others felt there was a need to further elaborate on the definition including more specific determinations. It was determined that a particular stumbling block was the need to define what it takes to train a critical care paramedic on a national level. Also discussed was the transfer of some critical care patients because of EMTALA. The group decided to revisit the issue on Tuesday.

4. ALS2 Definition
Dr. Bass reported that the work group requested that the Committee think about and revisit on Tuesday the ALS2 definition.

Darrel Grinstead reported that the Modeling Work Group had met 3 times by teleconference since the last meeting. The Negotiating Committee then discussed the following issues:

1. Definition of application of Response Modifier
The modeling committee asked that the term Immediate in the definition of Response Modifier be defined. There were several proposals discussed including:

1. setting a time limit for the interval between receipt of a request for service and the actual wheels turning movement of the response vehicle;
2. allowing only a designated 9-1-1 provider to qualify for the response modifier;
3. allowing only a response that results from a call to 9-1-1 or the local equivalent emergency number to qualify for the response modifier.
   After HCFA made it clear that they did not support further definition of Immediate, they agreed to provide guidance to the carriers in how to determine an "immediate response," e.g., within 5 minutes.

2. Mileage
The modeling group agrees that mileage should be paid. However, there is disagreement on what cost components should be included in mileage. The AAA believes that mileage should include the total vehicle costs, both fixed and variable divided by loaded miles plus the portion of personnel costs consumed on the transport. Others at the table felt that only vehicle costs should be included.

The committee was unable to reach consensus on this and asked the Modeling Work Group to continue work on this issue.

3. COLA Adjustment
The discussion has been whether to use the Practice Expense component of the Geographic Practice Cost Index (GPCI) used by the Medicare Physician Fee Schedule or the Hospital Wage Index. The work group was waiting to see a side-by-side comparison of the two to be presented by HCFA on the second day of this Committee meeting.

The Committee expects the Project HOPE study to be considered in determining the percentage of average costs that are allocated to labor.

4. Application of Rural Adjustment
The work group discussed the application of the rural adjustment. They have been waiting to see the Project HOPE data to determine the amount of the rural adjustment.

5. Modeling Cross-Walk
The work group has been providing input to HCFA on methods to crosswalk the 1998 claims data to the new service levels.

RURAL WORKGROUP
The workgroup determined that the modifier should be based on the population density, and the best way to look at the population density is by zip code. There are two suppliers of population date that is sorted by zip code, and they are The University of Kansas and Claritas. Both of the above would update the data by zip code to try to make the data more useful, would do it annually, and it would be updated periodically as specified by HCFA. The group wanted to know if this could be modeled and is it cost neutral.

Some questions that arose due to this are as follows:

A definition of population density was sought, it was determined that it is the simple calculation of the number of people in a square mile. There would also be a need o publish a list of eligible providers. The workgroup is willing to see if they can develop a model with and without the Project Hope data.

On the issue of the Fixed and Rotor wing, HCFA will try to run a model and get it out as soon as possible.

It was decided there was a need to reach a consensus on the remaining definitions and look over the grids. The Medical Workgroup will be meeting again in November, and if a consensus was reached on the grid they could bring it back after this meeting.

Is there a confirmed date for the Project Hope data? The only confirmation of Project Hope data was that it is to be available by December 1, 1999. They are also trying to get an analysis of the survey.

There will be a geographic presentation by HCFA tomorrow.

The meeting will resume at 8:30 a.m. on Tuesday.

Meeting adjourned at 3:00 P.M.

Meeting called to order at 8:30 a.m.

Project HOPE Status Report
AAA presented an interim report from Project Hope (6-3) describing the status of the report as of October 1, 1999. It included the refusal rate and the problems that developed in compiling the report. There was a list of one hundred cases that used actual data. The differences in the way the data was modified and used were discussed and presented.

Rural Modifier Report
AAMS handed out a Report on the Rural Modifier (6-4).

HCFA COLA Adjustment Report
HCFA handed out a report on data (6-2, 6-2A, 6-2B, 6-2C, & 6-2D). The data is by carrier and intermediary. This was 1998 data showing utilization and charges for ambulance services by county with the applicable GPCI. An explanation of the abbreviations used was given, however it was determined that the data did not reflect the correct GPCI (Geographic Cost Practice Index). Let the minutes reflect Handouts 6-2, 6-2A, 6-2B, 6-2C, and 6-2D were destroyed due to inaccurate collection of data.

There has been a run done using GPCIs, but the reaction of the group is the GPCI appears to be a combination of things. They need to review the corrected data and determine the percentage of the GPCI that is wages. HCFA will try to run a model by wage index and GPCI and post it on the web site with instructions on how to read it.

The issue of the definition of critical care was revisited as well as the possible need for a reference to pharmacology. HCFA will check on EMTALA rules to see what they require on the Federal level.

ALS2 Definition
Dr. Bass presented a proposed revision to the definition of ALS2 from the medical work group:

• An ALS assessment plus at least 3 medications and/or one of the following ALS procedures: defibrillation/cardioversion, endotracheal intubation, central line, pacing, chest decompression, surgical airway, advanced invasive airway (e.g., PTL, Combitube), interosseous access.

After some discussion, the committee adopted the following revision for the criteria for the ALS2 service level:

• At least 3 medications and/or one of the following ALS procedures: manual defibrillation/cardioversion, endotracheal intubation, central line, pacing, chest decompression, surgical airway, interosseous access.

Further discussion continued on the levels of care as defined now with respect to how they will be in the future if not as a national standard.

Air Ambulance Service Levels
The medical work group agreed to go back and look at air ambulance as examined by the Medical Issues work group and further agreed the same matrix could apply to air and that language could be included for this. Cost efficiency can be determined by examining the difference in cost for land and air transport, and it appears the trend is moving more toward air transport.

CONSENSUS WAS REACHED ON THE FOLLOWING:
The definition of air ambulance in Section 2120.4 of the Carriers manual will be reviewed by the Medical issues work group.

The Committee asked AAMS and AAA to bring their data contractors together to determine a method to assure that the relative value units that will be developed from their data are based on a common approach. The two organizations agreed to proceed with this approach.

Specialty care definition
Medical conditions (include air ambulance code 2120.4 preview)
Rural modifier
Geographic modifier - GPCI % how applied (location)
Mileage add-on (including helicopter & fixed wing) role mileage plays as a component with the rural modifier
{Data from Project Hope/HCFA air med data}
Assign relative values to service levels Report from he Model Workgroup

Discussion of removing things from the list

HCFA will let the group know what they can use on the bill and get back with the information.

Paramedic Intercept
HCFA asked that the Committee determine how to determine the fee for Paramedic Intercept.

The fee for paramedic intercept should be the difference between BLS and ALS2 when either ALS1 or ALS2 is medically necessary.

1. Review consensus items
The Committee asked HCFA to compile a list of all of the items the Committee has achieved Consensus on that are relevant to the Fee Schedule. HCFA agreed.
2. Continue discussion of relative values.

If the data that is received from Project Hope is what the group hopes for it will only involve "plugging in" numbers into a working model, because the model would already be prepared by the model workgroup. The Committee discussed what they would do if for some reason the Project HOPE data was not useful to the Committee.

Is there any discussion of future technology and how it will be addressed in the future?

• There will be updates from time to time in the future.
• American Heart Association will have a meeting in February to discuss new treatments.

If there are new and stronger technological advances in the future what will HCFA do?

• HCFA indicated that the issue of Medicare medication reimbursement for drugs is not on the table. Comments may be made in the proposed rule about medications used. There will be no change in the amount of money paid for medications because medications are not part of the fee schedule, but it can be used as a comment in the rule in the future. Comments can be made and taken to Congress in the future. Heart medications were used as an example.

There is a limited amount of funding to be used in the calculation of these services and if more money is needed they will have to go to Congress.

Meeting Adjourned at 1:15 P.M.

Dates for next meetings:
December 6, 7 & 8, 1999, (Confirmed: Doyle’s Hotel—202-483-6000)
January 24, 25 & 26, 2000, in Baltimore
February 14-15, 2000, HCFA’s Central Office, Baltimore

List of Consensus items from this meeting:
*Consensus: The minutes are approved as written.
*Consensus: General Consensus reached with regard to EMT to decide the relevance of treatment
*Consensus: The group decided to use the term "immediate response" without any reference to response time (minutes of response).
*Consensus: Forgo the Definition of Specialty Care until the December meeting.
*Consensus: Consensus was reached on the definition of ALS2
*Consensus: Medical issues group 2120.4 Carrier manual definition will be looked at by the Medical issues workgroup
*Consensus: Reached on the issues that still needed to be decided in the next meeting.
*Consensus: To use GPCI and the 89 localities.
*Consensus: Reached on paramedic intercept.
*Consensus: Agenda for the December meeting.
*Consensus: To Discuss the relative values.

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Last Updated January 14, 2000