Carrier Advisory Committee CAC

1. Carrier Advisory Committee (CAC) History Function Value Future

2. George Waldmann, M.D. Contractor Medical Director Carrier Advisory Committee February 2006

3. CMD Initial History HCFA ordered each state to have Carrier Medical Director (CMD) in 1987

4. CAC Initial History HCFA ordered formation of Carrier Advisory Committees (CAC) in 1992   Defined members, chairpersons, functions

5. CAC Initial History Mission to foster better relations & trust between carriers and providers   Advisory capacity only

6. CAC Initial History Influence policy development at the local level No funds allocated by HCFA for CAC Standardized format

7. CAC Evolution Provide local “flavor” to policy development Publishing of Draft LCD/LMRP Draft LCD/LMRP now available on website Open or “pre-CAC” meeting available for non CAC members  

8. CAC Evolution Now more effective Informational vehicle Venting of frustrations with Medicare Channel meaningful comments from constituents

9. CAC Evolution    Disseminate information to medical societies and specialties Carrier has opened up information such as utilization, statistical data, program integrity, planned future changes

10. CMD Evolution CMD initially only reviewed complex claims Some Fraud and Abuse examination

11. CMD Evolution Internal HCFA battle occurred between civil servants who felt that CMDs were a nuisance to be tolerated versus those who thought they could be an asset to HCFA. This battle continues at CMS today. (HCFA changed to CMS 2001) 2000 suggestion to do away with CMDs

12. CAC Description Carrier Advisory Committee

13. Number of CACs One CAC per state except New England New England has only a single CAC for four states (MA, VT, NH, MA) Could become the norm under new contracting rules and budgets

14. Purpose of CAC Three CACs per year (previously four) Discussion of Local Medical Review Policies (LMRP) and Administrative Policies Local Coverage Determinations (LCD) have replaced LMRPs

15. Purpose of CAC Formal mechanism for physicians to be informed of and participate in the development of LCDs in advisory capacity Mechanism to discuss and improve administrative policies that are within carrier discretion

16. Purpose of CAC Forum of information exchange between carriers and physicians Not a forum for peer review, discussion of individual cases, or individual providers Final implementation of policies rests with CMD in conjunction with Carrier and CMS policies

17. Role of CAC Members Disseminate proposed LCDs to colleagues in state and specialty societies to solicit comments Disseminate information about Medicare program obtained at CAC meetings to state and specialty societies

18. Role of CAC Members Point out inconsistent or conflicting medical review policies Point out items that conflict with community standard of practice

19. CAC Structure Each specialty and discipline shall have at least one member CMS defined specialties and disciplines Non CAC members may attend as guests

20. CAC Structure Industry has attempted to infiltrate CACs Pre CAC “Open meeting” is available to industry and non CAC members Anyone may attend and comment at “Open Meeting”

21. CAC Structure Tenure at discretion of carriers Co-Chairs are Medical Director and one other physician selected by committee

22. CAC Structure Carrier and CMS Participation is variable Reports & Updates from- CMS Regional Office representative Medicare Part A Medical Director Medicaid Medical Director PRO/QIO representative

23. CAC Process Minimum of three meetings per year Data relating to LCDs must be presented No payment allowed for CAC participation

24. CAC Process Agenda and minutes will be sent to CMS Discussion of LCDs is primary defined CAC function

25. CAC Membership State medical and osteopathic societies Managed care organizations Chiropractic

26. CAC Membership Maxillofacial/Oral surgery Optometry Podiatry

27. CAC Membership Defined Medical Specialties--- Allergy Anesthesia Cardiology Cardiovascular/Thoracic surgery Dermatology Emergency Medicine

28. CAC Membership Family Practice Gastroenterology Gerontology General Surgery Hematology Internal Medicine Infectious Disease

29. CAC Membership Medical Oncology Nephrology Neurology Neurosurgery Nuclear Medicine Obstetrics/Gynecology Ophthalmology

30. CAC Membership Orthopedic Surgery Otolaryngology Pain Medicine Pathology Pediatrics Peripheral Vascular Surgery Physical Medicine and Rehabilitation

31. CAC Membership Plastic and Reconstructive Surgery Psychiatry Pulmonary Medicine Radiation Oncology Radiology Rheumatology Urology

32. CAC Membership Clinical Laboratory Beneficiary Disabled Beneficiary State Hospital Organization

33. CAC Membership PRO/QIO Fiscal Intermediary Medical Director Medicaid Medical Director Medical Group Management Association

34. Other CAC Invitees Congressional Staff CMS Regional Office Staff Others at discretion of Co-Chairs

35. Membership List Availability CMS Regional Office CMS Central Office Provider Community (Single name or entire list) FOIA Requests Other Groups (Drug and Device Manufacturers) are attempting to access

36. CAC Value to Practicing Physicians Provide input into LCDs Be informed of changes by their CAC representatives Any physician can request LCD reconsideration Any physician can request new LCD

37. National Coverage Determination (NCD) Anyone may request NCD by CMS CMS scientific panel evaluates NCD request and makes decision to cover, decision not to cover, or leaves to discretion of local carriers

38. National Coverage Determination (NCD) CACs and physicians have no input into NCDs NCDs generally take longer than LCDs to implement

39. NCD May be more NCDs (national) and less LCDs (local) If more NCDs the need for local CMDs in present form may decrease

40. LCD LMRPs are both Regulatory and Educational LCDs are Regulatory only

41. LCD LCDs require supplementary educational articles LCD can be challenged same as LMRP Net effect of LMRP to LCD change is minimal

42. Contracting New Medicare Administrative Contracts (MAC) Combined Part A and Part B contracts Completed by 2008

43. Contracting 15 Combined Part A & Part B contracts Will there be a single CAC and single CMD for each jurisdiction? Current New England model of single Part B CMD and CAC for 4 States may become the norm?

44. Contracting

45. Contracting Jurisdiction 3 will be awarded in June 2006 (ND, SD, MT, WY, UT, AZ) Jurisdiction 2 will be awarded June 2007 (AK. WA, OR, ID)

46. Contracting

47. The Future What happens if CMDs and CACs disappear? Will all LCDs be replaced by NCDs?

48. MedPAC The Medicare Payment Advisory Commission is an independent federal body established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.

49. MedPAC In addition to advising the Congress on payments to health plans participating in the Medicare+Choice and providers in Medicare's traditional fee-for-service program, MedPAC is also charged with analyzing access to care, quality of care, and other issues affecting Medicare.

50. AdvaMed The Advanced Medical Technology Association represents more than 1,100 innovators and manufacturers of medical devices, diagnostic products and medical information systems.

51. AdvaMed Members produce nearly 90 percent of the $71 billion health care technology products consumed annually in the United States, and nearly 50 percent of $169 billion purchased around the world annually.

52. NCD vs LCD MedPAC calls for more NCD and elimination of local policies (LCD) AdvaMed calls for keeping status quo (prefer LCD to NCD)

53. NCD vs LCD Advantages and disadvantages either way Mix of policies will probably persist although the mix between NCD and LCD may change

54. Questions ???