Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs

Kerry Dooley Young

October 03, 2019

WASHINGTON — President Donald Trump today ordered federal officials to consider pegging Medicare reimbursement more closely to time spent with patients, seeking to address potential pay disparities between physicians and other healthcare professionals.

President Donald Trump

These directives are among the tasks Trump gave to the Department of Health and Human Services (HHS) in an executive order. The order also demanded HHS develop several proposals related to insurer-run Medicare Advantage, including one regarding payments for new technologies.

Trump signed the executive order after giving a speech at a rally in Florida.

The executive order gives HHS a 1-year deadline to propose a regulation that Trump describes as intended to let healthcare professionals spend more time with patients.

This regulation is meant to ensure that services, whether done by physicians, physician assistants (PAs), or nurse practitioners, "are appropriately reimbursed in accordance with the work performed rather than the clinician's occupation," the order said.

The order also tasks HHS with proposing a regulation to end what Trump called Medicare's "burdensome" requirements that are "more stringent" than federal and state laws require. The president intends to remove barriers that keep some personnel "from practicing at the top of their profession."

On a Thursday morning call with reporters, HHS Secretary Alex Azar said Medicare policies now sometimes "prevent people like nurse practitioners, PAs, et cetera from really maximizing the full value and training and licensure that they have through supervision requirements or other artificial limitations."

But it's unclear when and if the items listed in Trump's executive order will ever take effect.

In the order, Trump asked HHS to begin work on new regulations. There are many potential obstacles in attempts by any administration of any political party at promulgating rules. These include pushback from industry, congressional disapproval, and competing demands on the attention of leaders within an administration.

State or Federal?

Still, Trump's executive order serves as another example of what seems to be growing interest in Washington in examining how Medicare pays and regulates the practice of different kinds of healthcare professionals.

In the draft 2020 Medicare physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) included a proposal that would largely defer to state law and state scope of practice for PAs. States should have "the flexibility to develop requirements for PA services that are unique and appropriate for their respective state," CMS said in the draft rule, published in August in the Federal Register.

In a comment submitted to CMS in September, the American Medical Association (AMA) recommended Medicare instead maintain the current regulations on physician supervision for physician assistant services. If CMS does opt to finalize the proposed changes, AMA asked the agency to further revise the regulation to ensure physicians maintain the ultimate responsibility for coordinating and managing the patient's care.

In the letter, AMA also urged CMS to remove certain proposed regulatory language: "In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA's approach to working with physicians in furnishing their services."

"Some states require physician collaboration, which still requires that physicians maintain the ultimate responsibility for coordinating and managing the patient's care," wrote James L. Madara, AMA's chief executive officer, in a September 24 comment to CMS.

"Yet, this proposed language could be interpreted to preempt these state laws to, in effect, have the unintended consequence of eliminating any physician oversight of physician assistants, opening the door for independent practice of PAs," Madara added.

And, as Medscape Medical News previously reported, an influential panel in June recommended Medicare end a policy that lets medical practices bill at higher physician rates for services provided by certain other members of medical teams.

In a report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended eliminating "incident-to" billing for advanced practice registered nurses (APRNs) and PAs.

Instead, APRNs and PAs should consistently bill Medicare directly under their own national provider identifier for the services they provide, MedPAC said.

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