Why the requirement?
Given that the AHA explicitly calls the requirement “clinically unnecessary,” I was interested to know CMS’ rationale for enacting it.
I reached out to a CMS spokesperson and was provided the following explanation, which is generally attributable to CMS:
“The requirement for direct supervision stems from a longstanding statutory provision that therapeutic services furnished to hospital outpatients are furnished ‘incident to’ physicians’ services. That is, as a condition of Medicare payment, an appropriate physician or non-physician practitioner must be involved in the care and this is reflected in the direct supervision standard. In addition to the payment rule, there is a safety and quality of care concern. Most hospital outpatient therapeutic services must be furnished directly (are not delegable), or require an appropriate physician or non-physician practitioner nearby who is able to direct the services and intervene if necessary. We implemented the non-enforcement instruction in 2010 to allow time to establish an independent advisory review entity composed of the various stakeholders that could make recommendations to CMS for exceptions to this general rule. The independent review process has been in place since 2012 and exceptions have been established, so we believe we should reinstate enforcement of the supervision rules.”
CMS’ first rationale seems, to me, a technicality. And, while I understand the concern around quality, I haven’t seem any research suggesting that outpatient care provided when physicians are onsite is of significantly higher quality than when the care is provided under general supervision. (I didn’t yet do exhaustive research, however, so if studies like this exist, I’d love for a reader to point me in the right direction.)
Why it matters for rural America
The issue of direct vs. general supervision is of particular interest to me because I grew up in a very small town, home to its own critical access hospital, Memorial Hospital. The hospital is a major institution in our community, despite its small size. I recently heard from friends that it stopped offering obstetric services, likely because the volume wasn’t high enough to cover the costs of continuing the service line. Women in the community now travel around 30 miles to another critical access facility to give birth; the closest non CAH hospital is at least 45 minutes away. This is certainly not convenient, but childbirth isn’t something most women go through more than a few times in their lives.
Imagine, though, you were a patient with cancer undergoing chemotherapy multiple times a week — 45 minutes each way, three or four times a week, would make for a lot of driving. If a patient couldn’t drive herself, the driver certainly couldn’t be someone with a 9-5 job.
Luckily, my hometown hospital has a healthy medical staff, and I imagine it will be able to meet the challenges that direct supervision creates for small facilities. However, I certainly worry about other CAHs. Rural communities are special places with tight-knit connections and a powerful sense of community. However, many people living in rural communities are less wealthy, and less healthy, than those living in more metropolitan areas. If anything, they need policy that leads to more access to care, not policy that threatens it. Can the cancer patient afford the cost of driving 270+ miles a week for dialysis? What happens if she can’t?
Small towns aren’t the most attractive places for physicians, many who have trained in urban areas who are used to communities with more people and more things to do. HHS has certainly created many programs and policies to improve access to care for rural communities, and that should be lauded, but the recent decision to plow ahead with direct supervision requirements seems contrary to many of its other programs to protect rural healthcare in America.
Will the direct supervision requirement impact your hospital? Share your story with us; contact me at ldunn@beckershealthcare.com.
