In 2011, President Obama issued an Executive Order (No. 13563) directing each agency of the federal government to review its existing regulations and repeal or modify regulations that are “outmoded, ineffective, insufficient or excessively burdensome.”
The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services responded with revised regulations on multiple issues. The new regulations affecting physicians reflect changes in the way medicine is practiced and an increased use of technology.
Credentialing for telemedicine
Telemedicine is a method of providing clinical services to patients from a distance. It can include communication and examination of patients by audio-visual electronic communication as well as non-simultaneous services such as teleradiology. Telemedicine facilitates providing services to rural locations and giving prompt access to experts in a variety of settings.
Under old CMS rules, a provider of telemedicine services (who often was affiliated with a major hospital) had to be credentialed not only at his or her home hospital, but also at any hospital at which the patient was being treated.
CMS concluded “that our present requirement is a duplicative and burdensome process for physicians, practitioners, and the hospitals involved in this process, particularly small hospitals….” CMS also noted that small hospitals may not have the expertise to evaluate physicians in a wide range of specialties.
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A new final rule, issued in 2011, allows hospitals obtaining telemedicine services to rely on the credentialing process of the provider’s home institution rather than go through its own credentialing process.
Under the rule, the hospital at which the physician is based must provide the hospital at which the patient is located with evidence of the internal review of the physician’s credentials.
The rule provides “[a]t minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital’s patients and all complaints the hospital has received about the distant-site physician or practitioner.”
CMS estimates that the streamlined credentialing process will save approximately $1,500 per physician credentialed in time spent by physicians, hospital administrators and attorneys.
Hospital privileges to non-physicians
CMS issued a proposed rule in October 2011 to allow more flexibility for hospitals to grant privileges to non-physicians.
Under the proposed rule, if state law allows certain categories of non-physician practitioners, those practitioners also may obtain privileges to work at hospitals within the scope of their practices. Examples of such practitioners include advance practice registered nurses, physician assistants, physical therapists, speech language pathologists and doctors of pharmacy.
The proposed rule states that being a member of the medical staff is not a prerequisite to being granted privileges. The hospital may treat the non-physicians as members of the medical staff, but is not required to do so. Another option for hospitals is to have additional categories of staff membership such as “associate” or “limited” memberships for non-physicians.
For multi-hospital systems, CMS said it did not believe that a separate medical staff is necessary for each hospital within the system. Instead, multi-hospital systems, if they wish, could grant practitioners privileges which would encompass more than one hospital.
CMS has sought comments about whether clarification of the rules on this issue was necessary. Under a related proposal, systems with more than one hospital will have the option of having a single governing body for all the hospitals in the system rather than separate governing bodies for each hospital.
Other efficiency initiatives
Other proposed regulations to streamline procedures and save costs include:
• Increased use of pre-printed and electronic standing orders.
Hospitals may use such orders as long as they “have been reviewed and approved by the medical staff in consultation with the hospital’s nursing and pharmacy leadership” and “are consistent with nationally recognized and evidence-based guidelines.”
• Patient self-administration of medications.
Hospitals will have the option of allowing patients (or caregivers) to self-administer medications issued by the hospital as well as medications the patient has brought to the hospital. The practitioner responsible for the patient’s care will have to approve the arrangement, and procedures will need to be in place to ensure the safety of the administration of medications.
• Interdisciplinary care plans.
Instead of having a patient’s nursing care plan be separate from other parts of the patient’s record, hospitals may use interdisciplinary care plans that incorporate a nursing plan.
• Revising HIPAA rules.
While maintaining privacy rights for health care records, the Department of Health and Human Services plans to reduce the burden associated with distributing notices of privacy practices under the Health Insurance Portability and Accountability Act (HIPAA). In addition, the department plans to make it easier to distribute students’ immunization records to schools. The department estimates the changes in rules could save up to 2 million “burden hours” and $120 million.
• Uniform ID number for health plans.
The Department of Health and Human Services plans to establish “unique health plan identifiers” of a standard length and format for each health plan. Currently, a wide range of identifiers are used, and this results in misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty in determining patient eligibility. The department estimates this change will save providers and health plans $4.6 billion over the next 10 years.
For reasons of pragmatics as well as politics, the administration directed CMS and the Department of Health and Human Services to pause and consider how existing regulations can be made more efficient.
The most recent round of CMS rules and proposed rules should indeed save time and money, although there also will be costs in implementing the new rules.