Update Supervision Rule to Advance Rural Care, AAFP Advises

Specifically, the AAFP wrote, the agency should revise the National Coverage Determination for Cardiac Rehabilitation Programs for Chronic Heart Failure to allow such programs to operate under a physician's "general supervision" -- without requiring the physician to be immediately accessible -- as long as an automated external defibrillator is immediately available and the patient is attended by nursing staff trained in basic life support and AED use.

The July 29 letter was sent to CMS Administrator Seema Verma, M.P.H., and signed by Board Chair John Cullen, M.D., of Valdez, Alaska.

The correspondence reflects advocacy called for in a resolution the Missouri AFP submitted during the 2019 Congress of Delegates titled "Eliminating Barriers in Rural Communities for Cardiac Rehabilitation." The Board of Directors referred the resolution to the Commission on Federal and State Policy.

Heart disease is the leading cause of death for Americans, and the letter noted that cardiac rehabilitation "can reduce cardiovascular risk, improve the health and quality of life, enhance emotional well-being and improve other outcomes." It cited HHS' Million Hearts 2022 program and its goal of 70% national participation in cardiac rehabilitation by eligible patients.

The AAFP's letter, like the resolution, pointed to a July 2016 American Family Physician article titled "Cardiac Rehabilitation: Improving Function and Reducing Risk." The article reported that patients in rural areas were less likely to participate in cardiac rehabilitation because of the distance from their homes to sanctioned facilities.

"One of the barriers to cardiac rehabilitation, particularly in rural areas, is the CMS requirement for direct supervision by a physician," the letter said.

Since 1989, CMS has defined "direct supervision" in cardiac rehabilitation programs to mean that the physician "must be immediately available and accessible but (is) not required to be physically present."

"Unfortunately, even clarifying that a physician must be immediately available and accessible is an insurmountable barrier for cardiac rehabilitation facilities in rural communities," the AAFP told CMS.

The letter urged CMS to instead apply the definition of "general" physician supervision codified in the "Non-Surgical Extended Duration Therapeutic Services" section of the Hospital Outpatient Prospective Payment System policy. The policy calls for services to be performed "under the supervisory practitioner's overall direction and control" but notes that the practitioner's "presence is not required during the performance of the procedure."