1. 1 AARC Legislative Update Federal and State Regulatory Activities Ohio Society for Respiratory Care, Columbus, OH – September 28, 2009

2. 2 Federal Legislative and Regulatory Update

3. 3 Medicare Respiratory Therapy Initiative – HR 1107 and S 343 Amends Medicare Part B to recognize respiratory therapy services as a separate benefit HR 1107-House Sponsor Mike Ross (D- AK) 23 Co-Sponsors S 343-Senate Sponsors Blanche Lincoln (D-AK) and Mike Crapo (R-ID) 8 Co- sponsors

4. 4 What It Does and Doesn’t Do Adds RT services among other recognized medical and health care services, e.g., PAs, NPs Permits RRTs with a bachelor’s degree to work under a physician’s “general” supervision RRTs can provide services within their scope of work w/o physician being on site

5. 5 What It Does and Doesn’t Do It does not permit independent practice RRTs cannot bill Medicare directly The physician bills Medicare and receives the payment Payment is based on the same formula used to pay physician assistants and nurse practitioners

6. 6 Why Not All RTs? Need to set an education level consistent with other Part B providers Need to keep costs minimal Need to keep it a small benefit Objective is to get “toe in the door”

7. 7 What Are the Advantages? Opens opportunities for RTs to work in a physician’s office Patients have greater access to RTs Smoking cessation Disease Management Asthma Management MDI/DPI Device selection & patient education

8. 8 What Are the Advantages? (cont.) Physicians can be out of the office while the RT is furnishing a service Physician’s payment is less than 100% of fee schedule BUT It allows the physician to bill for two services while only performing one directly

9. 9 Support for RT Part B Initiative American College of Chest Physicians National Association for Medical Direction of Respiratory Care American Thoracic Society Alpha One Foundation COPD Coalition

10. 10 Medicare Oxygen Reform – HR 3220 Establishes a new Medicare home oxygen services benefit Eliminates the 36-month CAP Keeps competitive bidding Creates a Home Oxygen Services Advisory Committee (HOSAC) Mandates Certain Patient Protections and Rights

11. 11 Medicare Oxygen Reform – HR 3220 Revamps how Medicare pays and views oxygen equipment Stakeholders, DMEs, patients, Docs, RTs in coalition to hammer out acceptable details AARC was instrumental in advocating for patient protections in the bill

12. 12 Medicare Oxygen Reform – HR 3220 Introduced by Ross before Aug. recess Opposition from small and independent suppliers Major compromises were recently negotiated HME industry still at odds on interim payment policy

13. 13 Medicare Oxygen Reform – HR 3220 Likelihood of success is questionable Senate Finance wants to eliminate 36-month cap reduce payments for stationary equipment increase payments for portable equipment propose $1 billion cut Further cuts are needed to pay for eliminating the 36-month cap

14. 14 Quit Smoking for Life Act of 2009 HR 1850 and S 770 Creates specific smoking cessation counseling benefit – Medicare/Medicaid Eliminates patient deductible Adds coverage of OTC smoking cessation products if prescribed by physician Establishes therapeutic class under Medicare Part D

15. 15 Family Smoking Prevention and Tobacco Control Act – HR 1256 Signed into law by President Obama on June 22, 2009 AARC has been actively involved in tobacco control and smoking cessation for over 2 decades Part of Coalition that lobbied Congress for passage

16. 16 Family Smoking Prevention and Tobacco Control Act – HR 1256 Gives FDA authority to regulate marketing and promotion of tobacco products Will set performance standards in order to protect public health Phase-in of provisions between October 2009 and October 2012 FDA asked for public input

17. 17 Family Smoking Prevention and Tobacco Control Act – HR 1256 AARC commented on the on-going activities of its Tobacco Roundtable Creation of pocket guides Teaching modules for RT educators AARC stressed need for FDA to promote smoking cessation counseling AARC offered to work with FDA on setting up web-based training

18. 18 Access to Frontline Health Care Act of 2009 – HR 2891 Creates a student loan repayment program Graduate must agree to 2-year full-time service in health shortage areas Interdisciplinary studies given preference Frontline care services include respiratory therapy

19. 19 CDC Program Appropriations Request COPD 4 th leading cause of death Currently no targeted program at CDC Congress asked to appropriate $1M to CDC for a COPD Action Plan AARC partnered with US COPD Coalition Activated 435 Plan to gain support CDC COPD “Czar” named to begin development of national plan

20. 20 PACT Representatives’ Success PACT reps are the cornerstone of AARC success Annual D.C. Hill Lobby Day 2009: 103 RTs from 46 states and DC Over 300 scheduled meetings Lobbied: RT Medicare Initiative, CDC funding for COPD Joe Huff is Ohio’s representative

21. 21 National Health Care Reform Contentious debate – far from over Big Issues: public option; insurance industry reform, mandated coverage, independent commission Senate trying to gain bipartisan support Too soon to know where it will all come out

22. 22 RT Initiative Not Part of HCR Each year Congress’ passes one big bill Health Care reform is this year’s “must pass” bill RT Initiative is a separate part that gets tacked on to the larger piece – not part of the overall debate AARC not involved in health care debate

23. 23 Pulmonary Rehab (PR) CMS has proposed coverage criteria and payment for PR to implement new law Limits coverage to patients with moderate to severe COPD Sets payment through creation of a single new HCPCS Code Only allows 36 sessions – billable as 1- hour per session

24. 24 PR Workgroup Advises CMS AARC was part of multi-society workgroup to advise CMS on implementation What were they thinking? -- the question we keep asking ourselves Proposed policy is detrimental to patients Would deny access to many Would close most programs due to 78% reduction in current payments

25. 25 AARC Comments on PR Must add “very severe” COPD to criteria At minimum, include patients covered now by local policies Scientific literature supports other conditions Continue use of current G codes 0237-39

26. 26 AARC Comments on PR Permit separate billing for other services Allow the physician to submit appropriate E&M code Permit programs to be shaped based on individual need Cap number of billable hours per day at 3 or 4 – each hr. must have exercise component

27. 27 Other Strategies for PR Requested meeting with Deputy Sec. of DHHS May engage Congress to write to CMS insisting on changes to final rule Final rules expected in next couple of months Program becomes effective January 1, 2010

28. 28 Definition of RT in CORFs Currently limits services to those of RRT AARC worked diligently with CMS to change – misunderstood profession today New proposal reverts back to longstanding policy Includes CRTs that are registry eligible or have comparable experience/training

29. 29 Medicare Policy on Sleep Coverage Policies on sleep testing in labs and at home don’t define “qualified” personnel Local Coverage Decisions – some are more detailed policies Some require only AASM accreditation, leaves Joint Commission out=monopoly AASM personnel qualifications restrictive AARC working with CMS to urge changes

30. 30 State Legislative and Regulatory Update

31. 31 Economy Driving State Programs Economic downturn severely impacting state budgets and demands on services Lose job= lose employer health insurance increase in Medicaid claims increase in unemployment claims Little room for expansion of services

32. 32 Overall State Legislative Picture Less legislation on disease management: COPD (CO & IL enacted), pulmonary, asthma Some bills to track hospital acquired infections: VAP Some expansion of smoking cessation and prevention programs Many bills to increase tobacco taxes

33. 33 RT Licensure Law Changes MN upgraded RT registration law (i.e., “title protection”) to full RT licensure law HI came close to enacting a RT licensure law; will try again in 2010 FYI: Only Alaska and Hawaii do not regulate the RT profession

34. 34 Examples of State Legislation Impacting RT NV exempt US military from RT licensure law CT & KS to raise (significantly) RT licensure fees GA - Tightens timeframe for temp licenses; also bill to permit the Lic. Bd. to require a mental or physical exam

35. 35 Examples of State Legislation Impacting RT (cont.) VT appropriations to support state colleges with programs for health professionals – includes RT schools MS has Volunteer Health Care Practitioners Registry (OK similar law) IA Consumer protection bill against fraudulent actions by health professionals – including RTs

36. 36 Ohio Bills and Regulations HR 127 – amends disciplinary criteria in the RC Act – must have committed an RT-related offense Regulations – new rules relating to personal information systems; renewal of license or permits, general respiratory care requirements and reporting mechanisms

37. 37 Stay on Top of Changes Bookmark: RC Licensure Board Bookmark: Ohio Society for Respiratory Care www.respiratorycare.ohio.gov www.osrc.org

38. 38 Challenges from Other Disciplines or Professions Leg or Regs can negatively impact the RT profession, intentional or not Diminishes RTs scope of practice Additional Education and/or Additional Tests or Credentials you pay for All to continue services legally permitted to do under scope of practice

39. 39 Other Disciplines (cont.) Perfusionists: Licensure bills: MN, FL bill explicitly exempts RTs, some RTs do ECMO Paramedics & EMTs - IN, ID, MT AND

40. 40 State Polysomnograhy Bills/Laws – Impacting RTs Oklahoma Georgia North Carolina Kentucky Virginia Minnesota Hawaii Maryland California Tennessee

41. 41 Polysomnography AAST Model Practice Act is detrimental to RT profession Requires RTs to be credentialed by the BRPT or other nationally recognized body for services already in scope of practice Calls for disciplinary action if RTs don’t adhere to standards

42. 42 AAST Model Practice Act Recommended in states as legislative wording “A respiratory therapist licensed under Section___ may provide sleep-related services under the general supervision of a licensed physician if the licensed respiratory therapist is credentialed by the Board of Registered Polysomnographic Technologists or other nationally recognized body.”

43. 43 AAST Model Practice Act (cont.) “Respiratory therapists performing sleep- related services shall be subject to disciplinary action by the Board of Respiratory Care if they fail to adhere to the standards established under this chapter.”

44. 44 Polysomnography in TN Licensure law follows AAST model practice act (perhaps other way around) TN State Society actually supported additional testing of RTs AARC had to hire TN lobbyist to fight sleep industry and our own society leadership

45. 45 Polysomnography in TN (cont.) Legislative compromise was finally reached –much time and $$ RTs engaged in sleep can either: Take RPSGT exam Take NBRC’s SDS exam Document competency through standardized check-off created by TN RC Licensure Board

46. 46 The Way it Should Be Iowa Board of RC, Medicare & Nursing has it right Personnel who have specific training and competency testing in sleep are qualified Includes RTs, nurses, RGPSTs, other licensed health care professionals

47. 47 AARC Does Not Oppose Polysom Licensure Majority of polysomnography services include RT services RTs must be permitted to continue to provide sleep disorder services without additional requirements No justification to change or single out RT profession

48. 48 We Need to Work Together Polysom state legislation will continue to be a major focus for AARC, state societies and state licensure boards Clearly other changes on the state level impacting the provision of RT will result in the need for continuing joint efforts between RT Societies and the RT Licensure Boards/Councils/Committees

49. 49 Conclusion We have responsibility to continue to monitor, analyze and respond to good/not so good legislation and regulations/rules State Society first line of defense, but all RTs must step up and respond if needed If RTs won’t do it, no one else will…..

50. 50 Thank You