Extending access to coverage of audiology treatment services for more than 48 million Medicare beneficiaries is not only the right thing to do for patients, but also the right way to better position audiology for upcoming changes in health care. H.R. 2330, the Medicare Audiology Services Enhancement Act of 2013, accomplishes both goals. Here's how.
- The bill would allow audiologists the ability to demonstrate their full scope of practice and expertise within Medicare and the larger health care system. Audiologists are experts in the areas of hearing and balance treatment, but Medicare beneficiaries now must either receive these services from non-audiology providers or pay out-of-pocket for access to an audiologist's care and expertise.
- The bill helps audiology adapt to changes in the health care system, which continues to evolve with greater focus on outcomes and pay-for-performance. Improved Medicare coverage of audiology services is essential to aligning the profession with the needs and demands of health care consumers and third-party payers. To be an integrated part of the health care system, audiologists must be recognized at the federal level as health care providers working within their entire scope of practice.
- The bill recognizes that audiology is more than diagnostic services, it is more than dispensing hearing aids, and it is more than a treatment service for hearing and balance. Audiology is a dynamic profession that helps people improve their function and communication. Expanding the scope of practice recognized by Medicare helps define audiology by making our services more accessible and allowing those with expertise not only to diagnose, but also to treat patients and be recognized for doing so.
Under this bill, audiologists would have some additional responsibilities required of all non-physician providers. Collaboration and teaming with primary care and specialty physicians is a hallmark of Medicare policy, as is the establishment of a plan of care. As part of an integrated health care team, audiologists would be responsible for sharing their expertise through the plan of care, for example, so that care coordination captures the full range of the patient's condition and needs. In this system, audiology services are part of a comprehensive system increasingly focused on coordinated care and outcomes for patients.
Participation in Medicare programs such as the Physician Quality Reporting System, which requires outcome measures, proves difficult for services like audiology and radiology, considered exclusively diagnostic under Medicare. Expanding coverage to include treatment allows PQRS to measure audiology outcomes and demonstrate the absolute and relative value of audiology services.
Choosing a strategy
Other groups have proposed different Medicare initiatives to achieve direct access, comprehensive coverage and limited license practice. In fact, ASHA—in concert with all of the audiology groups—actively supported direct access (allowing beneficiaries to visit an audiologist without a physician referral) for several years. Several allied health organizations spent hundreds of thousands of dollars and countless hours of effort in attempts to pass this legislation, which stalled on Capitol Hill in response to stiff opposition from the American Medical Association and other physician specialty societies. The American Physical Therapy Association, with more than 80,000 members and more than 300,000 practicing physical therapists and assistants across the country, abandoned its direct access legislation efforts after determining it was not feasible in the current environment. No group has achieved direct access or limited-license practice in more than a decade.
So what was the next step? ASHA's staff and external consultants evaluated the challenges and opportunities facing the profession. After careful deliberation and consultation with members, volunteer councils and committees, and discussions with key policy makers and officials at the Centers for Medicare and Medicaid Services, we determined that comprehensive audiology legislation was the best alternative: It moves the profession forward and is politically feasible. Passage of the bill is possible, and with it:
- Audiology can move from diagnostics to diagnostics and treatment under Medicare.
- More than 48 million Medicare beneficiaries can gain access to the professional treatment services of audiologists.
- The profession can begin to demonstrate its value by collecting data related to treatment outcomes and can help patients achieve maximum function and independence.
Some audiologists are concerned that the legislation will reduce their reimbursement. The expanded services would be reimbursed at the rates established in the Medicare Physician Fee Schedule, as diagnostic procedures are now. Services such as vestibular and some audiologic rehabilitation, which are covered when performed by other professionals, would be subject to already-established Medicare rates. Uncovered services—such as hearing aids and related services—would still be paid by the patient.
Some existing audiologic rehabilitation codes that audiologists could use have never been valued for reimbursement. Under the bill, audiologists could lead the valuation process for these codes and ensure the values appropriately account for the work value of audiology services.
Although some audiologists charge out-of-pocket for audiologic and vestibular rehabilitation treatment services, these services more often are provided by other health care professionals or by audiologists who receive inconsistent reimbursement from any health insurance carrier. Under the comprehensive benefit legislation, Medicare beneficiaries would receive those covered services from audiologists.
Will adding audiology treatment services be too expensive for Medicare—resulting in overall payment reductions to keep total costs the same? We believe not. This bill would add roughly 16,000 new covered providers—to a system with millions already in it—for reimbursement of services that are already covered when provided by more than 430,000 physical therapists and speech-language pathologists. The idea that this change will cause a major increase in cost or trigger system-wide rebalancing doesn't stand up to scrutiny.
Yes, adding treatment services provided by audiologists will increase Medicare costs a bit. If, however, we believe—as ASHA does—that audiologists add value to the system, then the addition will demonstrate improved beneficiary outcomes and merit the investment. Any scrutiny of existing procedure codes that results from slightly increased utilization could provide an opportunity to increase the work value of those codes and their corresponding fees. ASHA continues to push for equitable payment and works collaboratively with all interested audiology organizations on coding and reimbursement issues, including the creation and valuation of audiology codes.
No therapy cap
Some audiologists are concerned that audiology services would be subject to the annual cap Medicare places on outpatient therapy services. This concern has no basis under the current Medicare statute, which limits therapy caps to occupational therapy, physical therapy and speech-language pathology services. Claims for these services include discipline-specific modifiers used to track the services back to the individual professions. Only those services determined by CMS as "always therapy services" and "sometimes therapy" are subject to the cap when provided by a therapist. Audiologists, like physicians, physician assistants and nurse practitioners, would fall into the category of professions outside the therapy cap when providing "sometimes therapy" services.
Developing a plan of care and continuing to have physician oversight do not constitute a step back for the profession, as some claim. Medicare already requires a physician order for an audiologist's diagnostic services, and some private insurers require some level of coordination of care and physician oversight. Current health care trends emphasize integrated and coordinated care—not isolated service provision—with the primary care physician's role including oversight of a patient's constellation of care to improve patient outcomes and efficiency. Each professional contributes his or her expertise in the best interest of the team and patient.
ASHA backs the comprehensive benefits legislation after long consultation with members, in the best interests of the overwhelming majority of members, and in the best interests of consumers. Expanding access to more than 48 million beneficiaries is clearly the right thing to do for consumers and is ultimately the best choice for the profession, both now and in the face of the changing American health care environment.