Reimbursement, Legislation, Regulation and Advancing Your CRNA Practice Frank Purcell, AANA Senior Director Federal Government Affairs Your Money and Your Life:

Our Agenda Today What shapes health policy? What are some current health policy issues affecting CRNAs? What is AANA working to address?

What Shapes Health Policy Ideas Economic, financial and political markets Legislative and Regulatory Processes

Economic Factors Shaping Health Going UpGoing Down Elderly as a share of the population Workers / retiree Per-capita health spending, more slowly U.S. health compared with industrialized world U.S. debt, >$17TNU.S. deficits annually Economic growth Public coveragePrivate coverage

Health Spending in America $2.8 TN in 2012, up 3.9% over 2011, about 1/6 of U.S. economy – 3d year of reduced growth Economic downturn Cuckler et al. National health expenditures Health Affairs 32(10) 09/13/hlthaff full.pdf/ 09/13/hlthaff full.pdf/. Wang, S. US health spending. Wall Street Journal 7/23/13, health-spending-one-of-these-things-not-like- others/ health-spending-one-of-these-things-not-like- others/

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 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

Legislative & Regulatory Processes Make rules Enforce rules Pay for things 1.Constitution 2.Public laws enacted by a legislature and signed by an executive 3.Regulations for carrying out the public laws 4.Subregulatory guidance

Utah Congressional Delegation, 2015 Sen. Orrin Hatch Sen. Mike Lee, 1.Rep. Rob Bishop, Brigham City 2.Rep. Chris Stewart, Farmington 3.Rep. Jason Chaffetz, Provo 4.Rep. Mia Love, Saratoga Springs

Regulatory Process 1.Congress enacts a law 2.Agency considers an idea to implement it 3.Agency publishes Notice of Proposed Rulemaking in Federal Register 4.60-day public comment 5.60-day agency consideration 6.Agency publishes final rule in Federal Register 7.60 days until the regulation is effective

Health Programs and CRNA Practice Public benefit programs  Medicare, Medicaid, CHIP  Veterans Administration  Affordable Care Act Private coverage Nurse workforce development  Title 8  Graduate Nursing Education

Medicare & CRNAs Part A: Hospital insurance  Conditions of participation  Pass-through program Part B: Physician services  Anesthesia payment  Teaching rules  Reimbursement for other services Parts C & D: Managed care, prescription drugs

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

Alternative Payment Models With quality reporting Bundled payment models Community or population payment

Medicare anesthesia payment (Base + time units) x (anesthesia CF) Rules determined by:  Statutes enacted by Congress  Regulations adopted by Medicare agency (CMS)  Subregulatory policy adopted by Medicare  Medicare Administrative Contractor that operates Medicare in each state, regionally

Most common anesthesia services QZ, CRNA nonmedically directed QX, CRNA medically directed by an anesthesiologist QK, anesthesiologist medically directing 2, 3 or 4 concurrent CRNA cases AA, personally performed by an anesthesiologist

CRNA Issues in Washington Protecting and advancing CRNA practice and patient safety Protecting and advancing coverage and markets for CRNA services Promoting nurse anesthesia workforce development

VA updating Nursing Handbook to recognize CRNAs & other APRNs to “full practice authority” Supported by AANA, AVANA, APRNs, AARP Opposed by ASA Helping the VA to finish this important work in time of change Caring for America’s Veterans

Protecting & Advancing Practice Provider Nondiscrimination provision prohibits health plans from discriminating against qualified licensed providers solely on the basis of licensure Effective for plan years Jan. 1, 2014, and after Rep. Harris Introduces Legislation to Repeal the Non-Discrimination Provision of PPACA Friday, July 26, 2013 On July 24, Rep. Andy Harris, M.D., (R-MD), the first physician anesthesiologist ever elected to the U.S. House of Representatives, introduced H.R. 2817, the "Protect Patient Access to Quality Health Professionals Act of 2013.”

Protecting & Advancing Coverage Medicare recognition of all CRNA services within their state scope of practice Medicare clarification that AAs may not bill QZ (nonmedically directed) services Legislation in Congress to permanently repeal SGR cuts and reform Medicare payment Health reform implementation Rural access to CRNA services

Promoting Workforce Development Title 8 funding FY14 slight boost over FY13 levels FY15 again a slight boost over FY14 Graduate Nursing Education (GNE) demonstration project Title 8 reauthorization

Within AANA, What’s Your Role? Membership AANA Mid-Year Assembly Coordinated Advocacy Programs: FPD, Key Contacts, SRS, CRNAdvocacy CRNA-PAC

AANA Mid-Year Assembly April 18-22, 2015, Washington, DC Learn the issues Hear from the experts and the leaders Practice effective advocacy with your colleagues Strengthen the profession with your own voice on Capitol Hill Build professional relationships that make a difference

Coordinated Advocacy Programs CRNAdvocacy, answering AANA alerts to contact Congress Key Contacts, a CRNA relationship with each federal lawmaker Federal Political Directors (FPDs), in each state to coordinate advocacy activity State Reimbursement Specialists (SRSs), in each state to promote value of CRNA services to health plans and payors

Protect. Advance. Commit Largest federal nursing PAC in the country. Top ten among all health professionals. New Advocacy Website – $1.8 million fundraising goal 8% of AANA membership donates. $20/member each year would total $940,000. >$1 million impact on the November elections – bipartisan support of congressional candidates. CRNA-PAC’s Mission Statement: Advancing the profession of nurse anesthesia through federal political advocacy.

Reimbursement Advocacy Medicare and Medicare Administrative Contractors Medicaid nationally and in each state Major plans like Blue Cross and United plans Health benefits administrators like Aetna Influential associations nationally and in each state like the American Hospital Association, National Rural Health Association, and America’s Health Insurance Plans

CRNAs’ Strong Voice in Washington

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 November 2012, effective January 2013

We’ve Learned About The environment Our issues And now it’s time for your questions

Thank You from Your AANA FGA Frank Purcell, Senior Director Federal Gov’t Affairs Kate Fry, Associate Director Political Affairs Emily Forrest, Assistant Director Federal Government 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 Octavia Thompson, Administrative Assistant AANA Division of Federal Government Affairs 25 Massachusetts Ave., Suite 550 Washington, DC // //