Your company letterhead
September 4, 2015
Andrew Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Room 445–G
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
Re: CMS–1631–P: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Proposed Rule
Dear Acting Administrator Slavitt:
On behalf of insert your service name here, I want to thank you for the opportunity to provide comments on the proposed rule “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016” (Proposed Rule). We support the implementation of the extension of the ambulance payment add-ons, which we agree is self-implementing. We also support the modifications to the staffing requirements and the definition of Basic Life Support (BLS). However, as described in more detail below, we are concerned about the continued application of the CY 2015 modifications to the geographic area designations and offer recommendations as to how to address the problems it has created for some rural ambulance services categorized as urban.
In addition to the recommendations below, we ask that CMS issue an Advanced Notice of Proposed Rulemaking (ANPRM) prior to the CY 2017 rulemaking cycle to seek input from all interested stakeholders about whether a new urban-rural data set should be used or other policy modifications should be adopted to apply the Goldsmith Modification. The data to determine the levels for Rural Urban Commuting Areas (RUCAs) is no longer collected through the long-form census, which has a high response rate. The RUCA data is now based on a response rate in the single digits which is not high enough to accurately identify urban-rural areas when it comes to access to vital ambulance services. An ANPRM would allow CMS to hear from all interested parties at an early stage in the process and provide CMS with the information it needs to fully evaluate the current policy and to identify options for addressing the problems that have now been identified with RUCA being used as the data set for the Goldsmith Modification.
I.Given the critical importance of the rural add-on, it is imperative that CMS adjust the geographic area designations in an accurate manner.
We agree with CMS that it is appropriate to adjust the geographic area designations periodically so that the ambulance fee schedule reflects population shifts. We remain deeply concerned, however, because the modifications finalized last year have led to some truly rural ZIP codes being designated as urban. Changes to the geographic area designations have significant negative financial implications on ambulance service providers, which serve areas changing from rural to urban, both in terms of the rural adjuster as well as the 50 percent mileage rate increase. We strongly urge CMS to refine the modified geographic area designations to restore rural status to those ZIP codes improperly classified as urban last year.
In the Proposed Rule, CMS states that it cannot determine rural ZIP codes in RUCA 2 or 3 because it is not possible to split the ZIP codes. This policy leads to 132 Census tracts that are in urban counties, are 400 square miles or larger, and have 35 or fewer persons per square mile as being listed as RUCA levels 2 or 3. Thus, while these Census tracts are truly rural in every sense of the word, for purposes of the ambulance fee schedule they are designated as urban. For example, under the final rule a Census tract in Sequoia National Forest is now designated as urban, despite the fact that only 63 people live within the 90 square mile zip code.
The Health Services and Resources Administration (HRSA), which developed and continues to rely upon the RUCA policy for its programs as well, does not have the problem and has not split ZIP codes to apply rural designations. HRSA has designated these 132 Census tracts as rural in contrast to the Agency’s decision to designate them as urban.
The discrepancy in the application of RUCA appears to result from the fact that HRSA designates rural areas for its programs by focusing on the Census tract, while CMS focuses on a U.S. Department of Agriculture (USDA) ZIP code list. Thus, when HRSA applies the RUCAs, it works directly from the Census tract and assigns geographic designations accordingly. In contrast, it appears that CMS has skipped taking into account the Census tracks, which is a vital step in appropriately applying RUCA. Instead, it relies upon a ZIP code list created by the USDA. Because the USDA has not reassigned the ZIP codes associated with the 132 Census tracts to rural status before doing the crosswalk, these tracts are now designated as urban, when in fact, they should be designated as rural.
Given the importance of appropriately designating rural areas, we strongly urge CMS to adjust the ZIP code-RUCA file by flipping the 132 Census tracts recognized by HRSA as rural to RUCA status 4. Then, when the analysis is re-run, the resulting ZIP codes would be appropriately designated. This approach avoids the concerns that CMS has raised about splitting ZIP codes. There is simply no need to split ZIP codes. As HRSA has recognized, it is important for these 132 Census tract areas to be taken into account for making geographic designations. If CMS would adjust the RUCA status before cross walking the ZIP codes, it would align its policy with that of HRSA and address the concerns raised by ambulance services.
II.We support strengthening the staffing requirements for ambulance services.
We support the Agency’s proposal to require an ambulance to be staffed with at least two people, at least one of whom must be certified as an emergency medical technician (EMT), and who must be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. We also support the proposal that would require for all Advanced Life Support (ALS) vehicles that one of the two staff members to be certified as a paramedic or EMT to perform one or more ALS services, as well as the requirement that ambulance services meet all applicable state and local laws related to the staffing of vehicles.
These proposals are consistent with the efforts of the American Ambulance Association to strengthen the quality of services provided and to recognize that ambulance services are truly health care providers caring for patients on the front lines of our nation’s health care system. We encourage CMS to support efforts to designate ambulance services as providers (rather than having some described as suppliers).
The clear designation of all ambulance services as providers is an important step that would lead to establishing stronger national standards on which ambulance services would be evaluated through surveys or accreditation processes. Provider status would also set the stage for implementing a process to collect cost data through a national survey. As we have described previously, this data collection process could be staggered so that every ambulance service would be required to participate, but CMS would not have to review data from all 10,000 or more ambulance services annually. We support the AAA in their efforts to work with CMS to ensure that appropriate provider status is applied to all ambulance services in the Medicare program and that they are held to appropriate conditions of participation.
III.Wesupport removing the example from the definition of BLS to ensure that it remains consistent with varying state law requirements.
As CMS recognizes, States and local governments play a critically important role in defining the various levels of care ambulance services are expected to provide. Therefore, we agree that federal definitions should be written in a way that allows for State and local governments to retain appropriate flexibility. As CMS notes in the preamble to the Proposed Rule, the current definition of BLS includes the following example that could become inconsistent with State and local laws as care protocols change over time.
For example, only in some States is an EMT-Basic permitted to operate limited equipment on board the vehicle, assist personnel that are more qualified in performing assessments and interventions, and establish a peripheral intravenous (IV) line.
We support this modification.
IV.Conclusion
We appreciate the opportunity to provide you with our comments. Again, we support the continuation of the add-on payment, as well as the modifications to the staffing levels and the definition of BLS. We also strongly urge CMS to implement the recommendations outlined above to determine rural ZIP codes in RUCA levels 2 and 3. We also encourage CMS to issue in early 2016 an ANPRM to seek additional information about and policy options related to the application of the Goldsmith Modifier. Please do not hesitate to contact me at insert your phone number here if you have any questions.
Thank you for your consideration.
Sincerely,
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