US – The Centers for Medicare & Medicaid Services (CMS) has backed off an earlier proposal regarding use of nonphysicians to perform inpatient rehabilitation services that could have a set a dangerous precedent for getting rid of physician supervision requirements across a wide swath of health care.
In the 2021 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) proposed rule, CMS wanted to change regulations to allow the use of nonphysician practitioners (NPPs) to perform the IRF services and documentation requirements that now must be done by rehabilitation physicians. The CMS proposal arrived on the heels of a 2019 presidential executive order that could undermine well-established Medicare supervision requirements for nonphysician professionals.
But, following unified opposition from the AMA, American Academy of Physical Medicine and Rehabilitation, and more than 120 health care organizations and state and specialty medical associations, CMS opoted not finalize their proposal.
In the final version of the rule, CMS instead allowed that a nurse practitioner, physician assistant, or clinical nurse specialist may perform one of the three required face-to-face visits in lieu of the rehabilitation physician in the second and later weeks of a patient’s IRF stay, when consistent with scope of practice requirements under applicable state law. CMS is maintaining the leadership responsibilities of the rehabilitation physician including the requirements to establish and implement the overall plan of care and lead the weekly conferences of the interdisciplinary care team.
CMS heeded stakeholders’ caution that undermining access to physician-led, patient-centered, team-based care in the rehabilitation setting would jeopardize the care for the extremely vulnerable patients receiving care in the IRF setting. AMA is grateful to CMS for acknowledging the critical role that physicians have in leading patient care and the vital role that other health care professionals have in supporting the provisions of patient care.
While the nonphysicians who help deliver inpatient rehab care are a valuable part of the physician-led team, their skill set is not interchangeable with that of fully trained rehabilitation physicians.
Rehab physicians’ many key responsibilities include:
- Evaluating and managing patients’ conditions, not only with respect to medical status but also to functional status, as well as assessing changes in status and adjusting treatment consistent with patients’ goals of care.
- Managing medication changes that must be made to accommodate exercise, including anti-hypertensive and diabetic medications.
- Managing the use of psychoactive medications including anxiolytics and anti-depressants.
- Managing complex care for high-acuity patients that includes medical management of changes in neurological status that may warrant imaging or transfer to an alternative level of care; cardiovascular changes that occur with exercise; neurogenic bowel and bladder management; and coordinating pain management interventions.
- Reviewing and concurring with findings of a comprehensive preadmission screening, which requires medical knowledge of the patient’s principal diagnosis in conjunction with their co-morbidities and biopsychosocial factors to determine prognosis for recovery.
- Prescribing durable medical equipment.
- Engaging in complex medical decision-making.
- Advocating for the many unforeseen needs newly disabled patients may have.
Rehabilitation physicians’ extensive training often includes more than 11 years of undergraduate education and medical training and over 10,000 hours of clinical experience. NPPs get much less training. Nurse practitioners, for example, must only complete two to three years of graduate-level education and between 500 and 720 hours of clinical training. Physician assistant programs are two years long and require 2,000 hours of clinical care.
The CMS proposal could have reduced the standard and quality of care IRF patients receive.