What’s the news: A proposed Centers for Medicare & Medicaid Services rule regarding use of nonphysicians to perform inpatient rehabilitation services could “set a dangerous precedent for removing physician supervision requirements across all health care settings,” says a letter to CMS Administrator Seema Verma from the AMA, American Academy of Physical Medicine and Rehabilitation, and more than 120 health care organizations and state and specialty medical associations.

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The proposal is included in the 2021 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) proposed rule. CMS wants 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 comes on the heels of a 2019 presidential executive order that could undermine well-established Medicare supervision requirements for nonphysician professionals.

Why it’s important: 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,” says the letter to Administrator Verma.

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.

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Rehabilitation physicians’ extensive training gives them “a unique set of tools to use in treating IRF patients.” That often includes more than 11 years of undergraduate education and medical training and over 10,000 hours of clinical experience.

“By sharp contrast, the education and training of NPPs is significantly less,” the AMA and the other signatories to the letter noted. “For example, nurse practitioners must complete only 2-3 years of graduate level education and 500–720 hours of clinical training. Physician assistant programs are two-years in length and require 2,000 hours of clinical care.”

The CMS proposal “could reduce the standard and quality of care IRF patients receive,” says the letter. And while CMS officials say their proposal would cut costs, the AMA and others expressed concern “that the risks to patient care outlined above may even contribute to increased health care costs, rather than savings.”

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Learn more: Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.

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