Dr. George Waldmann's

Carrier Advisory Committee Carrier Advisory Committee (CAC)(CAC)

HistoryFunctionValueFuture

George Waldmann, M.D.George Waldmann, M.D.

Contractor Medical Director

Carrier Advisory Committee

February 2006

CMD Initial HistoryCMD Initial History

HCFA ordered each state to have Carrier Medical Director (CMD) in 1987

CAC Initial HistoryCAC Initial History

HCFA ordered formation of Carrier Advisory Committees (CAC) in 1992

Defined members, chairpersons, functions


Mission to foster better relations & trust between carriers and providers

Advisory capacity only


Influence policy development at the

local level

No funds allocated by HCFA for CAC

Standardized format

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


Now more effectiveInformational vehicleVenting of frustrations with MedicareChannel meaningful comments from

constituents


Disseminate information to medical

societies and specialties Carrier has opened up information such as

utilization, statistical data, program integrity, planned future changes

CMD EvolutionCMD Evolution

CMD initially only reviewed complex claims

Some Fraud and Abuse examination

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

CAC DescriptionCAC Description

Carrier Advisory Committee

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

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


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


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

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

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

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


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”


Tenure at discretion of carriers

Co-Chairs are Medical Director and one other physician selected by committee


Carrier and CMS Participation is variable

Reports & Updates from-

CMS Regional Office representative

Medicare Part A Medical Director

Medicaid Medical Director

PRO/QIO representative

CAC ProcessCAC Process

Minimum of three meetings per year

Data relating to LCDs must be presented

No payment allowed for CAC participation

CAC ProcessCAC Process

Agenda and minutes will be sent to CMS

Discussion of LCDs is primary

defined CAC function

CAC MembershipCAC Membership

State medical and osteopathic societies

Managed care organizations

Chiropractic


Maxillofacial/Oral surgery

Optometry

Podiatry


Defined Medical Specialties--- Allergy Anesthesia Cardiology Cardiovascular/Thoracic surgery Dermatology Emergency Medicine


Family Practice Gastroenterology Gerontology General Surgery Hematology Internal Medicine Infectious Disease


Medical Oncology Nephrology Neurology Neurosurgery Nuclear Medicine Obstetrics/Gynecology Ophthalmology


Orthopedic Surgery Otolaryngology Pain Medicine Pathology Pediatrics Peripheral Vascular Surgery Physical Medicine and

Rehabilitation


Plastic and Reconstructive Surgery Psychiatry Pulmonary Medicine Radiation Oncology Radiology Rheumatology Urology


Clinical Laboratory

Beneficiary

Disabled Beneficiary

State Hospital Organization


PRO/QIO

Fiscal Intermediary Medical Director

Medicaid Medical Director

Medical Group Management Association

Other CAC InviteesOther CAC Invitees

Congressional Staff

CMS Regional Office Staff

Others at discretion of Co-Chairs

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

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

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

National Coverage National Coverage Determination (NCD)Determination (NCD)

CACs and physicians have no input

into NCDs

NCDs generally take longer than

LCDs to implement

NCDNCD

May be more NCDs (national) and less

LCDs (local)

If more NCDs the need for local CMDs in present form may decrease

LCDLCD

LMRPs are both

Regulatory and Educational

LCDs are Regulatory only

LCDLCD

LCDs require supplementary

educational articlesLCD can be challenged same as LMRPNet effect of LMRP to LCD change

is minimal

ContractingContracting

New Medicare Administrative Contracts (MAC)

Combined Part A and Part B contracts

Completed by 2008


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?



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)


The FutureThe Future

What happens if CMDs and

CACs disappear?

Will all LCDs be replaced by NCDs?

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.

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.

AdvaMedAdvaMed

The Advanced Medical Technology Association represents more than 1,100

innovators and manufacturers of medical devices, diagnostic products and

medical information systems.

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.

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)

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

QuestionsQuestions

???

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