Should CMS Expand Use of NPs, PAs for Inpatient Rehab?

The agency wants to know whether it should reduce a face-to-face requirement currently imposed on inpatient rehabilitation physicians.

The use of nurse practitioners and physician assistants in providing inpatient rehabilitation services could expand dramatically if the Centers for Medicare & Medicaid Services reduces the number of face-to-face visits it requires physicians to document.

The agency floated the idea Friday, when it announced $1.3 billion in proposed rate increases and several operational tweaks for four post-acute programs in fiscal year 2019, including an estimated $75 million increase for the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS).

Related: Post-Acute Providers Slated for $1.3B Raise in 2019

Under the proposed changes, rehabilitation physicians would no longer be required to perform one post-admission evaluation plus three face-to-face visits per week for each patient. Instead, each patient's initial evaluation would count toward the three face-to-face visits, beginning October 1.

"While we continue to believe that the post-admission physician evaluation and the face-to-face physician visits are two different types of assessments," the CMS proposal states, "after reevaluating these coverage criteria, we believe that the rehabilitation physician should have the flexibility to assess the patient and conduct the post-admission physician evaluation during one of the three face-to-face physician visits required in the first week of the IRF admission."

The change, which is part of an effort to reduce certain documentation requirements CMS officials believe to be overly burdensome, could foretell even more dramatic changes to come.

Officials are asking stakeholders whether they should allow non-physicians, such as NPs and PAs, to fulfill some of the requirements currently being imposed exclusively on physicians. To this end, the CMS proposal includes four specific questions:

1. Do non-physician practitioners have the specialized training in rehabilitation that they need to have to assess IRF patients both medically and functionally?
    
2. How would the non-physician practitioner’s credentials be documented and monitored to ensure that IRF patients are receiving high quality care?
    
3. Are non-physician practitioners required to do rotations in inpatient rehabilitation facilities as part of their training, or could this be added to their training programs in the future?
    
4. Do stakeholders believe that utilizing non-physician practitioners to fulfill some of the requirements that are currently required to be completed by a rehabilitation physician would have an impact of the quality of care for IRF patients?

In addition to floating the idea of permitting NPs and PAs to step into the physician's current role, CMS is also seeking feedback on the possibility of allowing rehabilitation physicians to do their work remotely, such as via videoconferencing. To this end, the CMS proposal includes six specific questions:

1. Do stakeholders believe that the rehabilitation physician would be able to fully assess both the medical and functional needs and progress of the patient remotely?
    
2. Would this assist facilities in rural areas where it may be difficult to employ an abundance of physicians?
    
3. Do stakeholders believe that assessing the patient remotely would affect the quality or intensity of the physician visit in any way?
    
4. How many and what types of visits do stakeholders believe should be able to be performed remotely?
    
5. From an operational standpoint, how would the remote visit work?
    
6. What type of clinician would need to be present in the room with the patient while the rehabilitation physician was in a remote location?

"Given the level of complexity of IRF patients, we have some concerns about whether this approach would have an impact on the quality of care provided to IRF patients," the CMS proposal notes.

"To maintain the hospital level of care that IRF patients require, we would continue to expect that the majority of IRF physician visits would continue to be performed face-to-face," it adds. "However, we are interested in feedback from stakeholders on whether we should allow a limited number of visits to be conducted remotely."

Comments on the proposal, which is slated for publication May 8 in the Federal Register, will be accepted through June 26.