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October 20, 2013 Maryland Association of Nurse Anesthetists. Reimbursement The Impact of Health Care Reform and Federal Issues. Christine S. Zambricki DNAP, CRNA, FAAN. Our Agenda. Context Economic, health policy and political contexts Federal health programs CRNA Issues

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Reimbursement the impact of health care reform and federal issues

October 20, 2013

Maryland Association of Nurse Anesthetists

ReimbursementThe Impact of Health Care Reform and Federal Issues

Christine S. Zambricki DNAP, CRNA, FAAN

Our agenda

Our Agenda


  • Economic, health policy and political contexts

  • Federal health programs

    CRNA Issues

  • Legislative and regulatory issues

  • Affordable Care Act

  • Advocacy programs

Federal policy environment

Federal policy environment

  • Economic

  • Health

  • Political

Economic factors shaping health

Economic Factors Shaping Health

Is it about the money

Is It About the Money?

Health spending in the u s www cms gov

Health spending in the

  • $2.7 T in 2011, up 3.9% in 2011, about 18% of U.S. economy, average $8,680 per person

  • Three years in a row of stable growth

  • Economic downturn

    • Demand

    • Supply

    • Technology

Political forces shaping the 113 th congress

Political Forces shaping the 113th Congress

  • 58.7% of vote eligible citizens, 10% latino, 13% black, 19% young voters

  • 65.9M to 60.9M votes, 51-47%, 332-206

  • Continuing divided government

  • House

  • Senate

  • 114th Congress?

Political forces shaping the 113 th congress1

Political Forces shaping the113th Congress

  • Considerable change beneath the surface

    • 12 new Senators of 100, 67 new Representatives of 435. Most of Congress is new since 2006

    • New leaders in some key health positions

    • Freshman class

Iom the future of nursing

IOM: The Future of Nursing

  • The Need to Transform Practice

    • Key Message #1: Nurses should practice to the full extent of their education and training.

  • The Need to Transform Education

    • Key Message #2: Nurses should achieve higher levels of education and training through improved education system that promotes seamless academic progression.

Iom the future of nursing1

IOM: The Future of Nursing

  • The Need to Transform Leadership

    • Key Message #3: Nurses should be full partners, with physicians and other health professionals, in redesigning health care

  • The Need for Better Data on the Health Care Workforce

    • Key Message #4: Effective workforce planning and policy making require better data collection and an improved information infrastructure

Health programs and crna practice

Health Programs and CRNA Practice

Medicare crnas

Medicare & CRNAs

  • Part A: Hospital insurance

    • Conditions of participation

      • Physician supervision

    • Pass-through program

  • Part B: Physician services

    • Anesthesia payment

      • Medical Direction

      • Medical Supervision

    • Teaching rules

    • Reimbursement for other services

  • Parts C & D: Managed care, prescription drugs

Part a for crnas

Part A for CRNAs

  • Conditions of participation & of coverage

    • Anesthesia services

    • ASC surgical services

  • Reasonable cost pass-through

    • Certain qualifying rural and critical access hospitals

    • <800 cases or less

    • CRNA services as a hospital service, no Part B



  • It is a Medicare requirement, a portion of a regulation, 42 CFR §482.52(a)(4)

Anesthesia must be administered only by … (4) A certified registered nurse anesthetist (CRNA), as defined in 410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c)of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed ….

Historical context

Historical Context

Part of the Medicare conditions for participation

  • 1997: Proposed to be repealed

  • 1/2001: Repealed in a final rule

  • 2/2001: Suspended

  • 11/2001: Finalized as an opt-out process

  • 11/2001 to today: 17states have opted out

  • 2013: No rule regarding supervision but good CMS precedents

Part b for crnas

Part B for CRNAs

  • Anesthesia payment

    • Medical direction

    • Pain care

    • Teaching rules

  • Payment for other services

Fee for service


  • (Base + time) x ($CF) = anesthesia fee

  • (Relative value) x ($CF) = physician fee

  • Pays for a thing

  • Does not necessarily pay for

    • Quality

    • The right thing

    • Care coordination

    • Optimal efficiency

Medicare anesthesia payment

Medicare anesthesia payment

  • (Base + time units) x (anesthesia CF)

  • Rules determined by:

    • Statutes enacted by Congress

    • Regulations adopted by Medicare agency (CMS)

    • Sub-regulatory policy adopted by Medicare

    • Medicare Administrative Contractor that operates Medicare in each state, regionally

Most common anesthesia services

Most common anesthesia services

  • QZ, CRNA non-medically directed (NOT AA!)

  • QX, CRNA medically directed by an anesthesiologist

  • QK, anesthesiologist medically directing 2, 3 or 4 concurrent CRNA cases

  • AA, personally performed by an anesthesiologist

Tefra medical direction rules

TEFRA medical direction rules

  • Anesthesiologist performs all seven tasks in each of up to four concurrent cases provided by a CRNA

  • Fee split 50/50 between CRNA and medically directing anesthesiologist

  • A payment model not a standard of care

  • Encourages higher-cost anesthesia delivery without demonstrated quality improvement

What are the tefra rules

What are the TEFRA rules?

  • Performs a pre-anesthetic examination and evaluation;

  • Prescribes the anesthesia plan;

  • Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;

  • Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;

  • Monitors the course of anesthesia administration at frequent intervals;

  • Remains physically present and available for immediate diagnosis and treatment of emergencies; and

  • Provides indicated-post-anesthesia care.

MCM Ch 12 Sec 50G

Medical direction undermined

Medical Direction Undermined

Anesthesiology 2012; 116:683-91.

Reimbursement the impact of health care reform and federal issues

Of the anesthetics you personally administer, how often is an anesthesiologist involved in the following activities?

AANA 2011 member survey, unpublished.



Anesthesiologist supervision often lapses

Anesthesiologist Supervision Often Lapses

Anesthesiology 2012; 116:683-91.

Part b medical direction vs part a supervision

Part B Medical Direction vsPart A Supervision

Part b medical supervision

Part B Medical Supervision

  • MDA supervises 5 or more CRNAs

  • MDA bills 3 base units + 1 base unit

  • CRNA bills QX (50%)


  • Failed medical direction: CRNA bills QZ and MDA bills “0” per CMS

Aana action on crna reimbursement

AANA action on CRNA reimbursement

  • Anesthesia payment panels

  • Summit on Anesthesia Reimbursement

  • Member education on Business of Anesthesia

  • Building relationships with key payer leaders

  • Comment on changes impacting CRNA reimbursement

  • Development and support of State Reimbursement Director

Reimbursement the impact of health care reform and federal issues


  • Reporting program that uses incentive payments and payment adjustments to promote reporting of quality info by eligible professionals (EPs)

  • CRNAs are EPs

  • Report on 50% of Medicare patients by the end of 2013, get a .5% incentive payment

  • In 2015, not reporting results in a 1.5% "adjustment" (meaning reduction).

  • If not reporting, 1.5% cut in your Medicare payments in 2015, which will go to 2% in 2016.

  • CMS proposed rules: 9 measures, registries only

Reimbursement the impact of health care reform and federal issues


  • CMS cannot accept data codes for reprocessing on a claim that has already been submitted. Providers have until Dec 31 2013 services to add the appropriate code to the claim.

  • There are also registry options.

  • Additional options for avoiding the negative adjustment: reporting one data code for one Medicare patient for one measure in CY13 would help avoid the ding in CY15. If they want a bump in CY15 they have to report 50% plus one.

  • CMS calculate administrative claims for incentives – deadline October 15. (Requires an Individual Access to CMS (IACs) Account). It can take more than a day to calculate.

Reimbursement the impact of health care reform and federal issues


  • Payment adjustment information:

  • 2013-2015 tip sheet:

Provider nondiscrimination

Provider Nondiscrimination

  • Part of the Affordable Care Act (Sec. 1206)

  • Promotes consumer choice and cost savings, by prohibiting health plans from discriminating against qualified healthcare providers by licensure

  • Takes effect 2014, subject to notice-and-comment rulemaking

  • Attempts to amend to weaken or strike it

Asa on nondiscrimination

ASA on nondiscrimination

  • “(T)he Senate bill also includes gratuitous so-called “non-discrimination" language (Sec. 2706).  The intentionally vague language, inserted by supporters of paraprofessionals, seeks to prevent health insurers from "discriminating" against non-physician providers in deciding who may participate in their plans.  Its practical implications are to open the doors to various disruptive tactics within the insurance marketplace by paraprofessionals, putting Federal law on a collision course with each state’s scope of practice law.”

Non discrimination


  • The Obama Administration will not issue regulations interpreting the AANA-backed provider nondiscrimination provision of the Affordable Care Act before it takes effect Jan. 1, 2014

  • FAQ document issued by Medicare, IRS-Treasury and the Department of Labor

  • Non-grandfathered group health plans and health insurance issuers offering group or individual coverage are expected to implement the provision starting on January 1, 2014, using a good faith, reasonable interpretation of the law.

Non discrimination1


  • Rep. Andy Harris (R-MD), the only anesthesiologist in Congress, introduced HR 2817, on July 24 with the backing of the American Society of Anesthesiologists (ASA).

  • “We are deeply concerned that for certain covered services in a number of states, this new part of the Public Health Service Act will be interpreted to provide that all health professional groups be considered as if their education, skills and training were equal even if their state-based medical and healthcare professional licenses or certifications are very different…. This ACA [Affordable Care Act] provision disrupts over a century and a half of dynamic state-based licensure and certification, interjecting the federal government into interpreting the limits of scope of practice and procedure.” The letter was co-signed by medical societies representing dermatologists, family practice physicians, otolaryngologists, ophthalmologists, OB/GYNs and plastic surgeons.

  • Rep. Harris’ legislation was referred to the House Energy and Commerce Committee where he does not serve, and has no cosponsors and no Senate companion bill at this date.

Aana supports direct reimbursement to crnas providing pain management services

AANA supports direct reimbursement to CRNAs providing pain management services

Crna direct reimbursement for chronic pain management

CRNA direct reimbursement for chronic pain management

Medicare has paid CRNAs directly for chronic pain management services

The AMA and the ASA oppose CRNAs providing chronic pain management

Two Medicare contractors stopped paying CRNAs directly for chronic pain management services

These two contractors required that a physician bill for the CRNA chronic pain management services. This is called “incident-to” billing.

Reimbursement the impact of health care reform and federal issues

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Physician resistance

Physician Resistance

  • American Medical Association

  • Consistently issued resolutions, petitions, and position papers opposing scope of practice

  • AMA Citizens Petition to HCFA (2000)

  • AMA Scope of Practice Partnership (2006)

  • AMA Resolution “Independent Practice of Medicine by Nurse Practitioners” (2006)

  • AMA Scope of Practice Data Series (2009)

  • Health Care Truth and Transparency Act (2011)

  • CMS and CSA sued the State of California (2010)

Political reality

Political Reality


Institute of Medicine Report

Continued challenges imaging macs

Continued challenges: Imaging, MACs

What medicare ruled on pain care

What Medicare Ruled on Pain Care

What does the pain care rule say

What Does the Pain Care Rule Say

  • Medicare will cover services within CRNA scope of practice in a state

  • “The primary responsibility for establishing the scope of services CRNAs are sufficiently trained and, thus, should be authorized to furnish, resides with the states.”

Where they stood

Where They Stood

For CRNA Pain Care

  • AARP

  • American Hospital Association and select State Hospital Associations

  • National Rural Health Association

  • Nursing Associations

Opposed to CRNA Pain Care

  • AMA

  • “ASA Rebukes CMS Rule for Jeopardizing Patient Safety and Quality Health Care”

    Source: Comments at, and

Noridian lcds

Noridian - LCDs

  • Epidural Steroid Injections:

  • Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy:



  • HHS charged IPRCC to create a comprehensive population health level strategy for pain prevention, treatment, management, and research.

  • Structure includes 5 Working Panels

    • Professional Education and Training

      • Margaret Faut- Callahan, PhD, CRNA, FAAN

    • Public Health: Care, Prevention, and Disparities

      • Jackie Rowles, CRNA, MS

Iprcc structure

IPRCC Structure

Vha nursing handbook update

VHA Nursing Handbook Update

  • APRNs as LIPs – Cathy Rick, CNO

  • IOM “Future of Nursing”

  • Consistent with current anesthesia handbook

  • Dear Colleague Letter: The Honorable Eric Shinseki. Secretary of Veterans Affairs

  • ASA Campaign

  • Over 40 nursing groups co-signed letter to Shinseki this week

  • Met with Interim CNO – Christine Engstrom

Asa message and response

ASA message and response

  • ASA said CRNA LIPs would be “required” to function without physician oversight. In response, the AANA-AVANA letter stated that “the truth is that neither the VHA draft Nursing Handbook nor the term ‘Licensed Independent Practitioner’ suggest that CRNAs and other APRNs would be ‘required’ to function without physician involvement should the VHA designate APRNs as LIP.”

  • ASA said the Nursing Handbook would result in “effectively eliminating physician-nurse team-based coordinated care. In response, the AANA-AVANA letter stated, “The ASA statement is false. While the VA Anesthesia Handbook supports care provided in teams, it does not require anesthesiologist supervision of CRNAs. Consistent with the Anesthesia Handbook, several VHAs are staffed solely by CRNAs working without anesthesiologist supervision…. Overall care of the patient remains a collaborative effort among physicians, APRNs, nurses and other healthcare professionals, as it should.”

  • ASA cited its long-discredited “Silber” study as justification for concluding “anesthesia care is improved with the involvement of a physician anesthesiologist in a team.” In response, the AANA-AVANA letter stated that “This ASA statement misrepresents the findings of a claims-data based study, the results of which have not been replicated and have been disregarded by Medicare.”

Anesthesia payment teaching rules

Anesthesia Payment Teaching Rules

  • What Medicare pays for services when education of anesthesia students or residents is involved

  • When it’s 1:1, payment is as though qualified provider (CRNA, anesthesiologist, or medically directed CRNA) is delivering the service

74 FR 61738, 61867. 11/25/2009.

Teaching rules 1 to 2

Teaching Rules: 1 to 2

  • CRNA uses QZ modifier, present during pre- and post-anesthesia care and during concurrent cases

  • Anesthesiologist uses AA + GC modifier, present during critical or key portions, immediately available

Teaching rules medically directed

Teaching rules: Medically directed

  • Medically directed CRNA gets 50% of a fee in one SRNA case, and discontinuous time in each of two concurrent SRNA cases

Teaching rules inequity issue md with resident vs md with srna

Teaching Rules inequity issue: MD with resident vs MD with SRNA

Medicaid and chip

Medicaid and CHIP

  • Federal-state program for indigent pregnant women or women with children, and for indigent seniors in post-acute nursing home settings

  • Covered services vary by state

  • Affordable Care Act expansion of Medicaid

Private coverage

Private coverage

  • Insurance

  • Self-administered plans

  • By type:

    • Fee for service

    • Preferred provider organization

    • Health maintenance organization

    • High deductible health plan

Comparing average 13 unit anesthesia fee

Comparing average 13-unit anesthesia fee

Reimbursement of crna services

Reimbursement of CRNA services

The affordable care act of 2010

The Affordable Care Act of 2010

  • Expansion of coverage

    • Medicaid expansion, subsidies in exchanges

  • Insurance reforms

    • State-based exchanges for marketing coverage

    • Nondiscrimination, consumer protections

  • Delivery system reforms

    • Accountable Care Organizations

    • Innovation Center

    • Independent Payment Advisory Board

  • Financing

Workforce provisions

Workforce Provisions

  • Title 8 Reauthorization

  • Graduate Nursing Education

  • National Healthcare Workforce Commission

Title 8 funding mm

Title 8 Funding, $MM

Graduate nursing education

Graduate Nursing Education

  • Part of ACA, funded through GME

  • Four-year, up to $200MM total to expand education of APRNs in five hospitals

    • Duke (Durham)

    • Memorial-Hermann Texas Medical Center (Houston)

    • Penn (Philadelphia)

    • Rush (Chicago)

    • Scottsdale Healthcare Medical Center (Scottsdale)

  • Evaluation

Coverage provisions

Coverage Provisions

  • Medicaid Expansion

    • Increase eligibility for Medicaid

    • Additional federal funding for new participants

  • Exchanges

    • A regulated means to market health plans

Supreme health reform decision

Supreme Health Reform Decision

  • Is requiring a person to purchase health coverage or pay a penalty constitutional?

  • Is expanding Medicaid, a state-run program with some federal funds, constitutional?

Medicaid expansion in the aca

Medicaid expansion in the ACA

  • For beneficiaries up to age 65 up to 138% FPL (FPL = $15,415 for an individual in 2012)

  • Starts in 2014, feds pay 100% of expansion, declining to 90% by 2020 and years thereafter

  • Supreme Court: Unconstitutional to take away a state’s Medicaid for refusing to expand it

  • Mississippi is rejecting Medicaid expansion (Gov. Bryant, 11/7/12)


Exchanges marketplaces and essential health benefits

Exchanges (Marketplaces) and Essential Health Benefits

  • Exchanges are for marketing health coverage in a state

    • State-based exchange (As of Oct. 1 working well)

    • Federally facilitated exchange (disaster so far)

    • Combination ( jury is out)

  • Essential Health Benefits link to benchmarks of small business plans in a state

Delivery system reforms

Delivery System Reforms

  • Accountable Care Organizations

  • Center for Medicare & Medicaid Innovation

  • Independent Payment Advisory Board (IPAB)

Implementation timeline

Implementation Timeline

  • 2011: Various pilot projects and advisory panels launch, Title 8 reauthorization, beginning of Medicaid expansion implementation

  • 2012: Graduate Nursing Education

  • 2012: Supremes decide constitutionality

  • 2013: Finalization of plans

  • 2014: Provider nondiscrimination, state based exchanges take effect

Budget sequestration

Budget Sequestration

  • Sequestration is $1.2 trillion in automatic spending cuts due to go into effect over the next 10 years

  • $85 billion 3/1/12

    • Half by dollar value from national security

    • Medicare, -2%

    • Other health and research, -8%

    • National security, -9%

    • Exempts Medicaid, Veterans benefits, most student aid

  • Agency flexibility in apportionment?

Pew increase decrease or same

Pew: Increase, decrease or same?

Pew Research Center, 2/13-18/2013.

Reimbursement the impact of health care reform and federal issues

AANA supports permanent repeal and replacement of the SGR formula with a payment system that accurately reflects the cost of providing anesthesia care.

Briefing sgr

Briefing: SGR

The Sustainable Growth Rate (SGR) is a Medicare Part B payment formula for CRNA and physician services

SGR is based on the economy

Reduced payment has been threatened since 2002

Every year Congress defers rather than repeals the SGR cuts

2012 CRNA payment will decrease by 26.2% in MARCH

What s a 26 2 medicare cut

What’s a 26.2% Medicare Cut?

  • If a CRNA performs 900 12-unit 100% Medicare cases, that yields $236,700 in fees

  • Minus 30% = $165,690

  • Difference of -$71,010 if 26.2% cuts hit 3/1/2012

  • Congress continues struggling with paying for relief from 26.2% Medicare Part B payment cuts scheduled for March 1. The AANA and CRNAs have weighed-in and continue to, but the outlook for long-term relief is dim and short-term relief appears more likely.

  • Approximately $365.00/week

What s new with sgr

What’s new with SGR

  • Energy and Commerce plan to replace SGR with a quality-based plan that would update payments by .5 – 1 % each year.

  • Update Medicare payment rates by 0.5 percent until 2019, until performance-based payment methods: the Quality Update Incentive Program and the Alternative Payment Model, which could increase doctors’ payments by as much as 1 percent.

  • The CBO scored the SGR reform bill $175.5 billion over 10 years.

  • Freezing SGR payments will cost $139.9 billion. $36 billion comes from the cost of replacing that system with a quality-based payment plan.

Sgr key talking points

SGR Key Talking Points

  • 4 years ago Medicare said anesthesia services were undervalued

  • CRNAs do not control service volume

  • CRNAs provide access to care in rural America

  • CRNAs are 25% more cost effective

  • Quality of CRNA care is equal

  • All barriers to the use of CRNAs should be eliminated

What can aana crnas do

What Can AANA & CRNAs Do?

  • Know the issues

  • Participate in AANA advocacy programs

    • Mid-Year Assembly

    • CRNA-PAC

    • FPDs & Key Contacts

    • CRNAdvocacy Email Alerts

    • Initiatives in reimbursement – SRS

    • State level GRC, PAC and BOD

Srs program

SRS Program

Srs background

SRS Background

  • AANA Anesthesia and Payment Policy Coordinating Panel (APPCP) recommendation to the AANA BOD

  • AANA BOD approved September 2012

  • Goal: reimbursement advocacy in each state

  • The SRD

    • repository of state reimbursement information

    • coordinator of state advocacy work.

State reimbursement specialist program

State Reimbursement Specialist program

  • At the direction of the Board

  • A focal point in each state for CRNA reimbursement knowledge, and for advocacy of CRNA reimbursement interests

  • Development of key relationships

    • Private payors – three largest health plans in state

    • Public payors – Medicaid, exchanges, MAC

    • Other interests – Hospital, rural health and health plan associations

  • Coordinated by your AANA FGA team



  • Monitor trends

  • Serve as a resource

  • Work with state association to establish key relationships

Srs position requirements

SRS Position Requirements

  • Keen interest in reimbursement

  • Willing to enhance knowledge

  • Represent with professionalism and enthusiasm

  • Willing to disclose conflicts of interest

Job description

Job Description

  • Coordinate and improve payment processes and reimbursement in your state

  • Accomplish this task by working with others based on state association’s needs and resources

Job description1

Job Description

Establish key contacts with

  • Top three health plans in your state

  • Exchange Boards

  • Medical Director for Medicare Administrative Contractor

  • Medicaid Director

  • Insurance Commissioner

  • State Hospital Association

  • State Ambulatory Surgery Center Association

  • State Rural Health Association

Job description2

Job Description

  • Serve as a repository of information by monitoring state reimbursement activities:

    • Medicare Local Coverage Determinations (LCDs)

    • Medicaid payment policy

    • Commercial insurance reimbursement

    • Accountable care organizations (ACOs)

    • State exchanges

Job description3

Job Description

  • Assist with state reimbursement issues as a first responder

  • Communication with state leaders

  • Enter state reimbursement information into special SharePoint site

  • Alert the AANA to any emerging issues

Reimbursement the impact of health care reform and federal issues


Volunteers who get others to volunteer or contribute

Volunteers - contributors


Everyone who voted for the candidate

Voters who voted for the wrong candidate

Registered voters who don’t vote

Voting age not registered to vote

Reimbursement the impact of health care reform and federal issues

What is CRNA-PAC?

  • Separate fund, 100% from CRNAs’ voluntary contributions, not dues

  • Ensures CRNAs have access to DC, where our issues are decided

  • Not partisan

  • Always working for the profession of nurse anesthesia

CRNA-PAC’s Mission Statement: Advancing the profession of nurse anesthesia

through federal political advocacy.

Stats that make us proud

Stats that Make Us Proud

  • Largest federal nursing PAC in the country

  • Top ten PAC nationwide for healthcare professionals

  • $1.1 million impact on the 2012 national elections with 94% of CRNA-PAC supported candidates elected to office.

2013 crna pac highlights

2013 CRNA-PAC Highlights

  • $1.75 million goal for 2013-2014

  • “CRNA-PAC Loves the 80’s” Party at Mid-Year Assembly

  • “Remember the RatPAC” Party at Annual Meeting

  • Refreshed Care to Be Counted website,

  • Student-specific engagement

  • New Incentive Club levels

Does this work a case study

Does This Work? A case study

  • Problem: Present threat to CRNA pain practice

  • Strategy: Research. Grassroots. Local & national allies. Advocacy. Response. Comments.

  • Outcome: Medicare rule covering all CRNA services within state scope of practice published 12/2012, effective 1/2013

Thank you from your aana fga

Thank You from Your AANA FGA

  • Frank Purcell, Senior Director Federal Goverment Affairs

  • Christine Zambricki, Senior Director Federal Affairs Strategies

  • Kate Fry, Associate Director Political Affairs

  • Romy Gelb-Zimmer,Associate Director Federal Regulatory and Payment Policy

  • Randi Gold, Associate Director Federal Regulatory and Payment Policy

  • Ralph Kohl, Associate Director Federal Government Affairs

  • Candida Richardson, Administrator

AANA Division of Federal Government Affairs

25 Massachusetts Ave., Suite 550

Washington, DC 20001-1450

202 484 8400 // //

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