Dr. George Waldmann's
Transcript of Dr. George Waldmann's
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Carrier Advisory Committee Carrier Advisory Committee (CAC)(CAC)
HistoryFunctionValueFuture
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George Waldmann, M.D.George Waldmann, M.D.
Contractor Medical Director
Carrier Advisory Committee
February 2006
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CMD Initial HistoryCMD Initial History
HCFA ordered each state to have Carrier Medical Director (CMD) in 1987
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CAC Initial HistoryCAC Initial History
HCFA ordered formation of Carrier Advisory Committees (CAC) in 1992
Defined members, chairpersons, functions
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CAC Initial HistoryCAC Initial History
Mission to foster better relations & trust between carriers and providers
Advisory capacity only
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CAC Initial HistoryCAC Initial History
Influence policy development at the
local level
No funds allocated by HCFA for CAC
Standardized format
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CAC EvolutionCAC Evolution
Provide local “flavor” to policy
developmentPublishing of Draft LCD/LMRP
Draft LCD/LMRP now available on websiteOpen or “pre-CAC” meeting available
for non CAC members
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CAC EvolutionCAC Evolution
Now more effectiveInformational vehicleVenting of frustrations with MedicareChannel meaningful comments from
constituents
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CAC EvolutionCAC Evolution
Disseminate information to medical
societies and specialties Carrier has opened up information such as
utilization, statistical data, program integrity, planned future changes
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CMD EvolutionCMD Evolution
CMD initially only reviewed complex claims
Some Fraud and Abuse examination
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CMD EvolutionCMD Evolution
Internal HCFA battle occurred between civil servants who felt that CMDs
were a nuisance to be tolerated versus those who thought they could be an asset to HCFA. This battle continues at CMS today. (HCFA changed to CMS 2001)
2000 suggestion to do away with CMDs
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CAC DescriptionCAC Description
Carrier Advisory Committee
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Number of CACsNumber of CACs
One CAC per state except New England
New England has only a single CAC for four states (MA, VT, NH, MA)
Could become the norm under
new contracting rules and budgets
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Purpose of CACPurpose of CAC
Three CACs per year (previously four)
Discussion of Local Medical Review Policies (LMRP) and Administrative Policies
Local Coverage Determinations (LCD) have replaced LMRPs
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Purpose of CACPurpose of CAC
Formal mechanism for physicians to be informed of and participate in the development of LCDs in advisory capacity
Mechanism to discuss and improve administrative policies that are
within carrier discretion
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Purpose of CACPurpose of CAC
Forum of information exchange between carriers and physicians
Not a forum for peer review, discussion of individual cases, or individual
providers
Final implementation of policies rests with CMD in conjunction with Carrier and CMS policies
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Role of CAC MembersRole of CAC Members
Disseminate proposed LCDs to colleagues in state and specialty societies to
solicit comments
Disseminate information about Medicare program obtained at CAC meetings to state and specialty societies
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Role of CAC MembersRole of CAC Members
Point out inconsistent or conflicting medical review policies
Point out items that conflict with community standard of practice
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CAC StructureCAC Structure
Each specialty and discipline shall have
at least one member
CMS defined specialties and disciplines
Non CAC members may attend as guests
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CAC StructureCAC Structure
Industry has attempted to infiltrate CACs
Pre CAC “Open meeting” is available to industry and non CAC members
Anyone may attend and comment at “Open Meeting”
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CAC StructureCAC Structure
Tenure at discretion of carriers
Co-Chairs are Medical Director and one other physician selected by committee
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CAC StructureCAC Structure
Carrier and CMS Participation is variable
Reports & Updates from-
CMS Regional Office representative
Medicare Part A Medical Director
Medicaid Medical Director
PRO/QIO representative
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CAC ProcessCAC Process
Minimum of three meetings per year
Data relating to LCDs must be presented
No payment allowed for CAC participation
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CAC ProcessCAC Process
Agenda and minutes will be sent to CMS
Discussion of LCDs is primary
defined CAC function
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CAC MembershipCAC Membership
State medical and osteopathic societies
Managed care organizations
Chiropractic
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CAC MembershipCAC Membership
Maxillofacial/Oral surgery
Optometry
Podiatry
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CAC MembershipCAC Membership
Defined Medical Specialties--- Allergy Anesthesia Cardiology Cardiovascular/Thoracic surgery Dermatology Emergency Medicine
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CAC MembershipCAC Membership
Family Practice Gastroenterology Gerontology General Surgery Hematology Internal Medicine Infectious Disease
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CAC MembershipCAC Membership
Medical Oncology Nephrology Neurology Neurosurgery Nuclear Medicine Obstetrics/Gynecology Ophthalmology
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CAC MembershipCAC Membership
Orthopedic Surgery Otolaryngology Pain Medicine Pathology Pediatrics Peripheral Vascular Surgery Physical Medicine and
Rehabilitation
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CAC MembershipCAC Membership
Plastic and Reconstructive Surgery Psychiatry Pulmonary Medicine Radiation Oncology Radiology Rheumatology Urology
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CAC MembershipCAC Membership
Clinical Laboratory
Beneficiary
Disabled Beneficiary
State Hospital Organization
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CAC MembershipCAC Membership
PRO/QIO
Fiscal Intermediary Medical Director
Medicaid Medical Director
Medical Group Management Association
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Other CAC InviteesOther CAC Invitees
Congressional Staff
CMS Regional Office Staff
Others at discretion of Co-Chairs
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Membership List AvailabilityMembership List Availability
CMS Regional OfficeCMS Central OfficeProvider Community (Single name or
entire list) FOIA RequestsOther Groups (Drug and Device
Manufacturers) are attempting to access
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CAC Value to Practicing CAC Value to Practicing PhysiciansPhysicians
Provide input into LCDsBe informed of changes by their CAC
representativesAny physician can request LCD
reconsideration Any physician can request new LCD
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National Coverage National Coverage Determination (NCD)Determination (NCD)
Anyone may request NCD by CMS
CMS scientific panel evaluates NCD request and makes decision to cover, decision not to cover, or leaves to discretion of local carriers
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National Coverage National Coverage Determination (NCD)Determination (NCD)
CACs and physicians have no input
into NCDs
NCDs generally take longer than
LCDs to implement
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NCDNCD
May be more NCDs (national) and less
LCDs (local)
If more NCDs the need for local CMDs in present form may decrease
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LCDLCD
LMRPs are both
Regulatory and Educational
LCDs are Regulatory only
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LCDLCD
LCDs require supplementary
educational articlesLCD can be challenged same as LMRPNet effect of LMRP to LCD change
is minimal
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ContractingContracting
New Medicare Administrative Contracts (MAC)
Combined Part A and Part B contracts
Completed by 2008
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ContractingContracting
15 Combined Part A & Part B contracts
Will there be a single CAC and single CMD for each jurisdiction?
Current New England model of single Part B CMD and CAC for 4 States
may become the norm?
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ContractingContracting
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ContractingContracting
Jurisdiction 3 will be awarded in June 2006
(ND, SD, MT, WY, UT, AZ)
Jurisdiction 2 will be awarded June 2007
(AK. WA, OR, ID)
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ContractingContracting
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The FutureThe Future
What happens if CMDs and
CACs disappear?
Will all LCDs be replaced by NCDs?
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MedPACMedPAC
The Medicare Payment Advisory Commission is an independent federal body established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.
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MedPACMedPAC
In addition to advising the Congress on payments to health plans participating
in the Medicare+Choice and providers in Medicare's traditional fee-for-service program, MedPAC is also charged
with analyzing access to care, quality of care, and other issues affecting Medicare.
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AdvaMedAdvaMed
The Advanced Medical Technology Association represents more than 1,100
innovators and manufacturers of medical devices, diagnostic products and
medical information systems.
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AdvaMedAdvaMed
Members produce nearly 90 percent of the $71 billion health care technology products consumed annually in the United States, and nearly 50 percent
of $169 billion purchased around the world annually.
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NCD vs LCDNCD vs LCD
MedPAC calls for more NCD and elimination of local policies (LCD)
AdvaMed calls for keeping status quo
(prefer LCD to NCD)
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NCD vs LCDNCD vs LCD
Advantages and disadvantages either way
Mix of policies will probably persist although the mix between NCD and LCD may change
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QuestionsQuestions
???