CMS final rule clarifies that medical staff can extend beyond physicians
In May, CMS released a final rule that aims to "allow flexibility and eliminate burdensome Conditions of Participation (CoP)." As part of the final rule, CMS will now include podiatrists among those allowed to organize and lead the medical staff, a role formerly reserved for doctors of medicine (MD), doctors of osteopathy (DO), doctors of dental surgery, and doctors of dental medicine. CMS also expanded the definition of medical staff to include other practitioners such as advanced practice registered nurses (APRN) and physician assistants (PA), a decision that garnered mixed reviews from healthcare organizations as well as medical associations and boards.
The decision to include nonphysicians on the medical staff is not a huge change from the previous CoPs, says Carol S. Cairns, CPMSM, CPCS, senior consultant at The Greeley Company, a division of HCPro, Inc., in Danvers, Mass., and founder of the consulting firm PRO-CON. She notes that CMS has always allowed the governing body to appoint nonphysician practitioners as members of the medical staff in accordance with state law, and that the most recent update reflects a change in the language of the document rather than a change in the rule itself.
The preexisting language of § 482.22 (a) reads, "The medical staff must be composed of doctors of medicine or osteopathy and, in accordance with State law, may also be composed of other practitioners appointed by the governing body."
The Regulations and Interpretive Guidelines for Hospitals §482.22(a) indicates that these other practitioners eligible for appointment to the medical staff are defined in Section 1842(b)(18)(C) of the Social Security Act as:
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Certified nurse-midwives
- Clinical social workers
- Clinical psychologists
- Registered dietitians or nutrition professionals
Meanwhile, the revised text of CoP § 482.22 (a), effective as of July 16, reads, "The medical staff must include doctors of medicine or osteopathy. In accordance with State law, including scope-of-practice laws, the medical staff may also include other categories of non-physician practitioners determined as eligible for appointment by the governing body."
The changes to § 482.22 (a) do not alter the practitioners who are eligible for the medical staff, but rather streamline the language to make it clearer that the medical staff can include other categories of nonphysician practitioners, says Cairns.
"I think CMS wanted to simplify the language and didn't want to limit the disciplines that could be included," says Cairns. "In other words, there might be other categories of advanced practice professionals that a governing body wants to include and CMS is not going to exclude them if in fact state law permits it."
CMS' recommendations show an awareness of the increasing role of nonphysician practitioners in the hospital setting, according to Tricia Marriott, PA-C, MPAS, staff liaison to The Joint Commission and a member of the advocacy team for of the American Academy of Physician Assistants. Marriott, who maintains medical staff privileges and continues to practice on a part-time basis, points out that PAs and other nonphysician practitioners, in accordance with state law, were eligible for medical staff membership prior to the most recent revisions to the CoPs.
"Over the past decade, PAs have been granted medical staff committee seats and membership to the medical staff in hospitals, to varying degrees," says Marriott. "It is allowed by state law in many states. The [CMS] rule has not really changed that."
Marriott adds that in her experience, medical staffs that have allowed PAs to be members/sit on committees have found the PAs to be helpful and productive contributors.
Despite the fact that hospitals in many states could already appoint nonphysician practitioners to the medical staff, it remains rare at many hospitals, and CMS' reiteration of which practitioners can be appointed to the medical staff may meet opposition. CMS published the proposed changes in October 2011 and opened them to public comment; in December 2011, the AMA, along with 81 additional state and national specialty societies, issued formal comments in opposition of many of the proposed changes.
According to the AMA, CMS' revisions regarding the medical staff "would cause serious harm to patients by diluting the authority of the medical staff to set professional and clinical standards for patient care." With regard to nonphysician practitioners, the AMA objects to what it views as CMS' encouragement throughout the rule to replace physicians with nonphysicians.
"While we recognize that non-physician practitioners are a valuable component of a health care team, physicians are best qualified to lead that team," says the AMA statement. "The sweeping replacement of physicians with non-physicians that CMS advances in the proposed rule is especially troubling in the hospital setting, where patients are treated for complex and critical illnesses and injuries."
The AMA also opposes the proposal to allow podiatrists to hold leadership positions at any hospital, since podiatrists are not MDs or DOs.
The credentials of a practitioner, whether the practitioner is a physician or nonphysician, often seem to be at odds with the participation of the practitioner within his or her organization. Nonphysicians might be highly active in the hospital, attending meetings and other hospital activities, but may not be recognized for these efforts by being appointed to the medical staff. Kim Everett, medical staff coordinator at Good Samaritan Hospital in Vincennes, Ind., says she is pleased to see that CMS expanded the rule to include podiatrists among the hospital leadership, but acknowledges that adding nonphysicians to the medical staff may cause some ripples in the medical staff culture.
"The podiatrists already have a foot in the door, so to speak, because they already attend section and service meetings along with other activities," says Everett. "The allied health professionals do not, and it's going to be a bigger change for them."
Despite her concerns of potential cultural issues stemming from appointing nonphysicians to the medical staff, Everett feels they do serve a valuable role in the hospital setting by keeping a closer watch on patients so that physicians can spend additional time with serious cases. "It frees up the physician to concentrate on other patients who may be more at risk," she says.
Everett notes that although her organization already credentials AHPs who work alongside the medical staff, to her knowledge no AHPs have previously requested to join the medical staff at Good Samaritan Hospital. She does not know whether that will change with CMS' final rule.
Cairns cites change and loss of control as the biggest reasons for opposition to CMS' revisions. "People tend to not like change," she says. "Physicians may feel that they are clinically in a better place to hold positions of officer and department chair and they feel that they are better prepared and more clinically knowledgeable."
Individual hospitals should examine their structure and determine the best approach based on the composition of the practitioners, says Cairns. She offers the example of the psychiatric hospital, where a psychiatrist may be the only physician treating patients, and nonphysicians such as psychologists, social workers, and addictionologists may be providing the majority of the care. In instances such as this, it may be a logical and fundamental decision to allow nonphysicians to join the medical staff. Cairns also points to the critical role that advanced practice professionals (APP) have in patient care and patient satisfaction.
"These individuals tend to spend more time with the patient and provide more patient education," she says. "The physician outlines the scope of what he or she wants and then the APP provides education related to upcoming therapies, medications, or discharge instructions and so on."
This not only makes the patients happy, but also makes physicians happy as they are able to get more done without bringing another physician into their practice, says Cairns. She stresses, however, that patients should clearly understand who they are talking to and what each practitioners' credentials are, to eliminate any confusion for the patient.
Despite the previous existence of wording in the CoP allowing PAs and APRNs to join the medical staff, and the newest revisions to that language becoming finalized in July, it may take a while for many hospitals to appoint nonphysicians to the medical staff. Some concerns about the latest CMS final rule remain among both healthcare organizations and medical associations, and this could impede the expansion of the medical staff. However, the changes do reflect the growing role of nonphysician practitioners in healthcare. As these practitioners continue to take a more active role in providing patient care, more hospitals and other organizations may consider extending medical staff appointments to them.