Congressional Action on the ACA

As our government transitions to a new administration, the following question has become increasingly common:

Would amendments to or repeal of the Affordable Care Act (ACA) affect medical assistants’ scope of practice?

The answer? Almost certainly not.  The scope of practice of medical assistants is determined primarily by state law.  An exception is the meaningful use order entry requirements of the Medicaid Electronic Health Record Incentive Program.  The Medicaid Incentive Program was not created by the ACA and would not be impacted by any amendments to or repeal of the Affordable Care Act.  Consequently, it is highly unlikely that the scope of practice for medical assistants will be impacted by congressional action on the ACA.

AAMA Submits Comments on Stage 3 Final Rule

In its efforts to stay abreast of state and federal laws pertaining to the medical assisting profession, the AAMA recently submitted comments to the Centers for Medicare and Medicaid Services regarding some specific language from the October 16, 2015 Federal Register. What follows are those comments.

…

The following comments are being submitted on behalf of the American Association of Medical Assistants (AAMA), the national organization representing the medical assisting profession at the federal and state levels.

There appears to be an accidental inconsistency between the following language on page 62944 of the final rule, and the following language on pages 62949 and 62950 of the final rule:

Page 62944, third column:

(3) Computerized provider order entry. (i) Objective. Use computerized provider order entry for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.

Page 62949, third column, and page 62950, first column:

(4) Computerized provider order entry (CPOE).—(i) EP CPOE—(A) Objective. Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant, who can enter orders into the medical record per state, local, and professional guidelines. …

(ii) Eligible hospital and CAH CPOE—(A) Objective. Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.

The American Association of Medical Assistants believes that there is an inconsistency between the above excerpts because of the following language in the analysis of, and responses to, public comments:

Page 62798, second column:

Response: In the Stage 2 final rule (77 FR 53986) and in subsequent guidance in FAQ 9058,6 we explained for Stage 2 that a licensed health care provider or a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant may enter orders. We maintain our position that medical staff must have at least a certain level of medical training in order to execute the related CDS for a CPOE order entry. We defer to the provider to determine the proper credentialing, training, and duties of the medical staff entering the orders as long as they fit within the guidelines we have proscribed. We believe that interns who have completed their medical training and are working toward appropriate licensure would fit within this definition. We maintain our position that, in general, scribes are not included as medical staff that may enter orders for purposes of the CPOE objective.

However, we note that this policy is not specific to a job title but to the appropriate medical training, knowledge, and experience.

Page 62839, first column:

Response: As noted in the Stage 3 proposed rule (80 FR 16751), we require that the person entering the orders be a licensed health care professional or credentialed medical assistant (or staff member credentialed to the equivalency and performing the duties equivalent to a medical assistant). We defer to the provider’s discretion to determine the appropriateness of the credentialing of staff to ensure that any staff entering orders have the clinical training and knowledge required to enter orders for CPOE.

The American Association of Medical Assistants therefore recommends that the above language on page 62944, third column, be expanded to include “credentialed medical assistants,” as do the above excerpts from page 62949, third column, and page 62950, first column.

Addressing Recent Concerns About Order Entry

The Centers for Medicare and Medicaid Services (CMS) Blog recently posted these articles dealing with forthcoming changes to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs:

EHR Incentive Programs: Where We Go Next

Comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Care Conference, Jan. 11, 2016

In the wake of these pieces, there has been some concern about the potential effects on medical assistants’ ability to enter orders into the computerized provider order entry (CPOE) system for meaningful use purposes. I have addressed these concerns in a memorandum to AAMA leaders. The body of this message is as follows:

January 22, 2016

Within the last 10 days the Centers for Medicare and Medicaid Services (CMS) has issued statements about forthcoming changes in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Incentive Programs) required by the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015, referred to as “MACRA.”

Congress enacted MACRA on April 16, 2015.  This legislation replaces the current meaningful use (MU) payment adjustment provisions with the Merit-Based Incentive Payment System (MIPS), effective January 1, 2019.  According to CMS, MIPS will incorporate some meaningful use elements of the current program and will introduce new elements.

There has been a groundswell of concern that MACRA will do away with the requirement that only third-party-credentialed medical assistants, licensed health care professionals, and third-party-credentialed individuals “who hold a more specific title than ‘medical assistant’ because their duties include only parts of the medical assisting scope of practice, or because of the specialization of the overseeing eligible professional (EP),” are permitted to enter medication, laboratory, and diagnostic imaging orders into the computerized provider order entry (CPOE) system for meaningful use calculation purposes under the Incentive Programs.

In my legal opinion, this concern is not warranted because of the following:

1. The order entry credentialing requirement of the Incentive Programs was established by CMS rule, not by federal statute.
2. No provisions of MACRA impact the CMS order entry credentialing requirement.
3. The legislative history of MACRA does not indicate that Congress was concerned about the CMS order entry credentialing requirement.

CMS regulations implementing MACRA and MIPS are scheduled to be published for comment in 2016.  I do not anticipate that these forthcoming regulations will include any changes to the credentialing requirement of the CMS MU order entry rule.  However, if changes are proposed that could potentially harm patients by lowering the credentialing requirement for medical assistants who enter orders into a CPOE system, the American Association of Medical Assistants will be quick to point this out to CMS decision makers, and to persuade them to maintain or increase the current requirement.

CMS Final Rule Reaffirms Credentialing Requirement for Medical Assistants

On October 6, 2015, the Centers for Medicare and Medicaid Services (CMS) issued its final rule for the Electronic Health Record (EHR) Incentive Programs. In responding to comments urging that the “credentialed medical assistant” requirement be made less stringent, CMS reaffirmed that medical assistants must have a third-party credential (such as the CMA (AAMA)), and must have sufficient knowledge to handle properly clinical decision support (CDS) alerts.

One party commenting on the CMS notice of proposed rulemaking for the EHR Incentive Programs made the suggestion “that if a standard for medical assistant CPOE [computerized provider order entry] is required, then the standard should be that the medical assistant must be appropriately trained for CEHRT [certified electronic health record technology] use (including CPOE) by the employer or CEHRT vendor in order to be counted [toward meeting the meaningful use requirements of the Incentive Programs].” (page 322 of the attached document)

CMS responded as follows:

We [CMS] disagree that the training on the use of CEHRT is adequate for the purposes of entering an order under CPOE and executing any relevant action related to a CDS. We believe CPOE and CDS duties should be considered clinical in nature, not clerical.  Therefore, CPOE and CDS duties, as noted, should be viewed in the same category as any other clinical task, which may only be performed by a qualified medical or clinical staff. (page 323 of the attached document)

This position of CMS is a resounding affirmation of the fact that only professionally-credentialed medical assistants (such as CMAs (AAMA)) are qualified to enter orders safely into the CPOE system.

More information about the CMS final rule will be forthcoming in Legal Eye: On Medical Assisting and CMA Today.

CMS Final Rule (10/6/15), pages 322-323

Video: “How Medical Assistants Can Meet the CMS Meaningful Use Requirement”

Below is a video of my presentation at the AAMA 58th Annual Conference in St. Louis, in which I discussed order entry into the computerized provider order entry (CPOE) system and answered questions about the Centers for Medicare and Medicaid (CMS) Stage 2 Meaningful Use requirements.

The video can also be accessed through the AAMA YouTube channel: https://www.youtube.com/watch?v=Hz4avFT3XZE