New RAC Rules for Document Request Limits

Yesterday, CMS updated its rules regarding limits on the number of additional documentation requests. Excerpts from the document has been cut and pasted below.

You can download the original document at:http://www.cms.hhs.gov/RAC/Downloads/DRGvalidationADRlimitforFY2010.pdf

You can find the RAC homepage at: http://www.cms.hhs.gov/RAC/


Additional Documentation Limits for FY 2010 for DRG Validation
as of December 1, 2009 (Excerpts)

• CMS has modified the additional documentation request limits for the RAC program in FY 2010. These limits will be set by each RAC (CMS) on an annual basis to establish a cap per campus on the maximum number of medical records that may be requested per 45-day period.
• A campus unit (defined below) may consist of one or more separate facilities/practices under a single organizational umbrella; each limit will be based on that unit’s prior fiscal year Medicare claims volume.
• Limits will be based on the servicing provider/supplier’s Tax Identification Number (TIN) and the first three positions of the ZIP code where they are physically located.
• Limits will be set at 1% of all claims submitted for the previous calendar year (2008), divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days. A provider’s limit will be applied across all claim types, including professional services. Note: FY 2010 limits are based on submitted claims, irrespective of paid/denied status and/or individual lines, although interim/final bills and RAPs/final claims shall be considered as a unit.
• While respecting a provider’s overall limit, the RAC may exercise discretion in the exact composition of an additional documentation request. For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may only be a small portion of their total claim volume.
• Two caps will exist in FY 2010: Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare (per TIN, across all claims processing contractors) will have a cap of 300 additional documentation requests per campus unit, per 45 days.
• In addition, in FY 2010 CMS will allow the RACs to request permission to exceed the cap. Permission to exceed the cap cannot be requested in the first six (6) months of the fiscal year. The expanded cap will not be automatic; the RACs must request approval from CMS on a case-by-case basis and affected providers will be notified prior to receiving additional requests.

Leadership in Healthcare Organizations

Yesterday the Joint Commission posted this monograph from the Governance Institute regarding healthcare organization leadership. You can download the 44 page white paper here.

The paper is divided into the following chapters:
Part 1 - Introduction and Background
Chapter 1: Leaders and Systems
Chapter 2: What Leaders Do

Part 2 - Joint Commission Leadership Standards
Chapter 3: Leadership Structure
Chapter 4. Leadership Relationships
Chapter 5. Hospital Culture and System Performance
Chapter 6. Leadership Operations

Every quarter, along with updating the hospital compare website, CMS also makes the flat files available for download. With the flat files, anyone can compare any combination of CMS performance measures. Below is the performance of HF-1 for all Indiana hospitals that submitted data.

Note the following:

• Caution when looking at Hospitals with n<=25
• National Top 10% of hospitals submitting data was 99%
• Indiana Average of hospitals submitting data was 77%
• National Average of hospitals submitting data was 76%
• This is based on data submitted to CMS from Jan 08 to Dec 08
• Some hospitals sampled. Other Hospitals reported on all eligible patients

HF-1 n Hospital Name
100 303 PORTER, VALPARAISO HOSPITAL
100 60 MORGAN HOSPITAL AND MEDICAL CENTER
100 41 BLUFFTON REGIONAL MEDICAL CENTER
100 22 DUPONT HOSPITAL LLC
100 9 COMMUNITY HOSPITAL OF BREMEN INC
100 38 ST VINCENT WILLIAMSPORT HOSPITAL INC
100 33 TIPTON HOSPITAL
100 27 JASPER COUNTY HOSPITAL
100 25 ST MARY'S WARRICK HOSPITAL INC
99 250 ST MARGARET MERCY HEALTHCARE CENTERS
99 327 ST CATHERINE HOSPITAL INC
99 169 ST JOSEPH HOSPITAL
99 101 RIVERVIEW HOSPITAL
99 296 INDIANA HEART HOSPITAL, THE
98 102 HOWARD REGIONAL HEALTH SYSTEM
97 252 ST MARY MEDICAL CENTER INC
96 251 CLARK MEMORIAL HOSPITAL
96 49 MEMORIAL HOSPITAL
96 191 COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY
95 751 CLARIAN HEALTH PARTNERS INC D/B/A METHODIST IUU
95 111 KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICES,THE
95 188 ST MARGARET MERCY HEALTHCARE CENTERS
95 42 DUNN MEMORIAL HOSPITAL
94 80 JOHNSON MEMORIAL HOSPITAL
94 358 WILLIAM N WISHARD MEMORIAL HOSPITAL
94 98 GOSHEN GENERAL HOSPITAL
94 49 HENRY COUNTY MEMORIAL HOSPITAL
94 291 REID HOSPITAL & HEALTH CARE SERVICES INC
94 363 BALL MEMORIAL HOSPITAL INC
92 218 GOOD SAMARITAN HOSPITAL
92 64 GREENE COUNTY GENERAL HOSPITAL
91 180 ST ANTHONY MEMORIAL HEALTH CENTERS
91 264 COMMUNITY HOSPITAL
91 91 CLARIAN WEST MEDICAL CENTER
91 23 MONROE HOSPITAL
90 331 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC
90 52 KOSCIUSKO COMMUNITY HOSPITAL
90 10 WABASH COUNTY HOSPITAL
89 160 MARION GENERAL HOSPITAL
89 55 DECATUR COUNTY MEMORIAL HOSPITAL
88 267 FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES
88 319 MEMORIAL HOSPITAL OF SOUTH BEND
88 56 WITHAM HEALTH SERVICES
88 26 ST VINCENT FRANKFORT HOSPITAL INC
87 231 METHODIST HOSPITALS, INC
87 223 TERRE HAUTE REGIONAL HOSPITAL
87 45 PARKVIEW HUNTINGTON HOSPITAL
87 54 MAJOR HOSPITAL
85 119 HENDRICKS REGIONAL HEALTH
85 13 GIBSON GENERAL HOSPITAL
85 33 ADAMS MEMORIAL HOSPITAL
84 318 ST VINCENT HEART CENTER OF INDIANA LLC
84 38 DUKES MEMORIAL HOSPITAL
82 131 COLUMBUS REGIONAL HOSPITAL
82 55 WESTVIEW HOSPITAL
81 412 UNION HOSPITAL, INC
81 37 DEKALB MEMORIAL HOSPITAL INC
81 42 SCOTT COUNTY MEMORIAL HOSPITAL AKA SCOTT MEMORIAL
80 185 BLOOMINGTON HOSPITAL
80 258 SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND
80 465 LUTHERAN HOSPITAL OF INDIANA
80 25 CAMERON MEMORIAL COMMUNITY HOSPITAL INC
79 19 WHITE COUNTY MEMORIAL HOSPITAL
78 153 LAPORTE HOSPITAL AND HEALTH SERVICES
78 67 SCHNECK MEDICAL CENTER
76 46 SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH
76 144 SAINT JOHN'S HEALTH SYSTEM
74 563 DEACONESS HOSPITAL INC
74 31 ST VINCENT CARMEL HOSPITAL INC
73 210 ST ELIZABETH CENTRAL
73 56 ST CLARE MEDICAL CENTER
73 33 PERRY COUNTY MEMORIAL HOSPITAL
72 576 ST VINCENT HOSPITAL & HEALTH SERVICES
72 18 PARKVIEW WHITLEY HOSPITAL
72 36 SAINT CATHERINE REGIONAL HOSPITAL
72 40 BEDFORD REGIONAL MEDICAL CENTER
71 245 COMMUNITY HOSPITALS OF INDIANA INC (EAST)
70 80 ST JOSEPH HOSPITAL & HEALTH CENTER INC
70 100 ST FRANCIS HOSPITAL AND HEALTH CENTERS
70 47 CLARIAN NORTH MEDICAL CENTER
69 227 PARKVIEW HOSPITAL
69 32 MARGARET MARY COMMUNITY HOSPITAL INC
68 44 PARKVIEW LAGRANGE HOSPITAL
67 420 ST FRANCIS HOSPITAL AND HEALTH CENTERS-INDIANAPOLI
66 228 ST ANTHONY MEDICAL CENTER OF CROWN POINT
64 164 COMMUNITY HOSPITAL SOUTH
63 27 DAVIESS COMMUNITY HOSPITAL
60 53 LAFAYETTE HOME HOSPITAL
60 65 COMMUNITY HOSPITAL NORTH
59 29 SULLIVAN COUNTY COMMUNITY HOSPITAL
59 27 HARRISON COUNTY HOSPITAL
56 27 STARKE MEMORIAL HOSPITAL
52 98 DEARBORN COUNTY HOSPITAL
52 149 MEMORIAL HOSPITAL AND HEALTH CARE CENTER
50 36 WEST CENTRAL COMMUNITY HOSPITAL
50 12 PUTNAM COUNTY HOSPITAL
48 62 FRANCISCAN PHYSICIANS HOSPITAL LLC
48 21 ST VINCENT CLAY HOSPITAL INC
45 304 ELKHART GENERAL HOSPITAL
42 86 HANCOCK REGIONAL HOSPITAL
41 46 PARKVIEW NOBLE HOSPITAL
41 44 ST VINCENT RANDOLPH HOSPITAL INC
34 90 FAYETTE REGIONAL HEALTH SYSTEM
33 21 PINNACLE HOSPITAL
25 4 ST FRANCIS HOSPITAL MOORESVILLE
23 13 JAY COUNTY HOSPITAL
11 9 ST VINCENT MERCY HOSPITAL
10 10 ST VINCENT JENNINGS HOSPITAL INC

Commonwealth Fund Highlights Accomplishments of Reid Hospital

Last week the Commonwealth Fund highlighted the SCIP achievements of Reid Hospital (Richmond, IN) by publishing a case study on both the Commonwealth Fund's website
as well as their http://www.whynotthebest.org/ website.

The case study can be download here: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Nov/1338_Edwards_Reid_Hospital_case_study.pdf

The following is the summary section of the case study with sections of interest in red.

Reid Hospital and Health Care Services is a high performer on process-of-care, or “core” measures. The measures, developed by the Hospital Quality Alliance (HQA), relate to achievement of recommended care in four clinical areas: heart attack, heart failure, pneumonia, and surgical care. This case study focuses on Reid’s achievement in providing recommended care to surgical patients in order to reduce the risk of a hospital-acquired infection.

Quality of care has been high on Reid’s agenda since the late 1990s, when the hospital began using a report card to track health care processes and outcomes. In 2004, the multidisciplinary Surgical Care Improvement Project Quality Action Team was formed, which hospital leaders’ credit with helping to achieve high performance on the surgical measures. The team is supported by:

• a strong board, administrators, and clinical leaders;
• a clinical information system that aligns physicians’ orders with hospital standards, and alerts nurses about the timing of critical care;
• physician and nurse champions;
• performance data analysis and feedback; and
• a "just do it" approach to quality improvement.
  

CDC Updates CA-UTI Prevention Guidelines

Last week the CDC released its updated CA-UTI Prevention Guidelines - last published in 1981.

The guidelines can be found here.

The following is an excerpt from the document's executive summary with sections of interest in red:

This guideline updates and expands the original Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTI) published in 1981. Several developments necessitated revision of the 1981 guideline, including new research and technological advancements for preventing CAUTI, increasing need to address patients in non-acute care settings and patients requiring long-term urinary catheterization, and greater emphasis on prevention initiatives as well as better defined goals and metrics for outcomes and process measures. In addition to updating the previous guideline, this revised guideline reviews the available evidence on CAUTI prevention for patients requiring chronic indwelling catheters and individuals who can be managed with alternative methods of urinary drainage (e.g., intermittent catheterization). The revised guideline also includes specific recommendations for implementation, performance measurement, and surveillance. Although the general principles of CAUTI prevention have not changed from the previous version, the revised guideline provides clarification and more specific guidance based on a defined, systematic review of the literature through July 2007. For areas where knowledge gaps exist, recommendations for further research are listed. Finally, the revised guideline outlines high-priority recommendations for CAUTI prevention in order to offer guidance for implementation.

This document is intended for use by infection prevention staff, healthcare epidemiologists, healthcare
administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for healthcare settings across the continuum of care. The guideline can also be used as a resource for societies or organizations that wish to develop more detailed implementation guidance for prevention of CAUTI.

Our goal was to develop a guideline based on a targeted systematic review of the best available evidence, with explicit links between the evidence and recommendations. To accomplish this, we used an adapted GRADE system approach for evaluating quality of evidence and determining strength of recommendations. The methodology, structure, and components of this guideline are approved by HICPAC and will be used for subsequent guidelines issued by HICPAC. A more detailed description of our approach is available in the Methods section.

Healthy People 2020 - Review Draft Objectives

Early last week the US Dept of Health and Human Services released the draft Healthy People 2020 objectives for public comments via the internet.

Historically, federal agencies have been guided somewhat by the objectives set in Healthy People. Every 10 years, the objectives are developed, reviewed, updated, and/or archived.

You can download the draft objectives here: http://www.healthypeople.gov/hp2020/Objectives/files/Draft2009Objectives.pdf

Or,...you can go to the following webpage to review the objectives and comment directly:
http://www.healthypeople.gov/hp2020/Objectives/TopicAreas.aspx

Note that Healthcare IT and Hospital Aquired Infections are established objectives in Healthy People 2020.

The entire press release from the AHRQ is below:

Opportunity for public comment on draft Healthy People 2020 objectives

The U.S. Department of Health and Human Services invites you to comment on the DRAFT set of objectives for Healthy People 2020. For three decades, Healthy People has provided a set of national 10-year health promotion and disease prevention objectives aimed at improving the health of all Americans.

Visit www.healthypeople.gov/hp2020 to
· View proposed draft objectives for Healthy People 2020
· Comment on the proposed objectives
· Comment on the topic areas
· Suggest additional objectives
· Suggest topic areas you feel are missing from the draft set

Your comments will help ensure issues important to you are included in Healthy People. Establishing objectives and providing benchmarks to track progress motivates, guides, and focuses action. Be part of the change. Comments will be accepted through December 31, 2009.

Visit www.healthypeople.gov/hp2020 today. Your feedback will help define the vision and strategy for building a healthier Nation.

CMS Releases Hospital Outpatient and Ambulatory Surgery Center Payment Update

Last week CMS released the CY2010 hospital outpatient payment update in a final rule with comment period. Hospitals will be getting a 2.1% increase in payments from Medicare, however, hospitals that are not participating in HOP QDRP will only be getting 0.1% increase.

The full text of the press release is below with items of interest to hospital quality professionals in Red.

The full text (1936 pages!) of the final rules (with comment period) can be downloaded at: http://federalregister.gov/OFRUpload/OFRData/2009-26499_PI.pdf
The HOP QDRP section starts on page 1135.

(Note! CY2012 HOP QDRP Measures under consideration can be found on page 1167.)



FINAL 2010 POLICY, PAYMENT CHANGES FOR HOSPITAL OUTPATIENT DEPARTMENTS AND AMBULATORY SURGICAL CENTERS‏

OVERVIEW

On Oct. 30, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period that updates payment policies and rates for both hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for calendar year (CY) 2010. The update to ASC rates constitutes the third year of a four-year transition to a revised payment system that aligns ASC payment rates with those paid to HOPDs for similar services. The final rule with comment period also seeks to promote higher quality, efficient services for Medicare beneficiaries by adopting improvements to the Hospital Outpatient Quality Data Reporting Program (HOP QDRP) and establishing procedures to make the data collected through the HOP QDRP publicly available.

CMS projects that total payments for services furnished to people with Medicare in HOPDs during CY 2010 under the Outpatient Prospective Payment System (OPPS) will be $32.2 billion, while total projected CY 2010 payments under the ASC payment system will be approximately $3.4 billion.

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM

Background:

Since August 2000, Medicare has paid hospitals for most services furnished in their outpatient departments under the OPPS. Medicare currently pays more than 4,000 hospitals ‑‑ including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities,
long-term acute care hospitals, children’s hospitals, and cancer hospitals ‑‑ for outpatient services under the OPPS. Medicare also pays community mental health centers (CMHCs) under the OPPS for partial hospitalization services. The OPPS payments cover facility resources including equipment, supplies, and hospital staff, but do not pay for the services of physicians and nonphysician practitioners who are paid separately under the Medicare Physician Fee Schedule (MPFS).

All services under the OPPS are classified into groups called Ambulatory Payment Classifications (APCs). Services in each APC are similar clinically and require the use of similar resources. A payment rate is established for each APC. The APC payment rates are adjusted for geographic cost differences, and payment rates and policies are updated annually through rulemaking. The final rule is generally issued by November 1 each year and, unless otherwise specified, becomes effective January 1 of the subsequent year.

Beneficiaries share in the cost of services under the OPPS by paying either a 20 percent coinsurance rate or, for certain services, a copayment required under the Medicare law not to exceed 40 percent of the total payment for the APC. The statutory copayment is gradually being replaced by the 20 percent coinsurance as the composition of APC groups is updated in response to policy changes or new cost data. CMS estimates that the overall beneficiary share of the total payments for Medicare covered outpatient services will be about 22.6 percent in CY 2010.

Significant Changes For Calendar Year 2010

CMS projects that the aggregate Medicare payments to providers under the OPPS in CY 2010 will be $32.2 billion, a $1.9 billion increase over projected payments in CY 2009.

Implementing New Coverage Authorized by MIPPA: The final rule with comment period implements several expansions of Medicare coverage that were required in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), including:

Kidney disease education –CMS is establishing payment to rural providers under the Medicare Physician Fee Schedule (MPFS) for kidney disease education services furnished on or after Jan. 1, 2010 for Medicare beneficiaries diagnosed with Stage IV chronic kidney disease.

Pulmonary and cardiac rehabilitation – CMS is establishing OPPS payment for new, comprehensive pulmonary and intensive cardiac rehabilitation services furnished to beneficiaries with chronic obstructive pulmonary disease, cardiovascular disease, and related conditions, effective Jan. 1, 2010.


Strengthening Ties between Payment and Quality:
Payment reduction for failure to report quality measures – As required by law, CMS will reduce the CY 2010 annual inflation update factor by two percentage points for most services furnished by hospitals that failed to meet the CY 2009 reporting requirements of the HOP QDRP. The reduction will not apply to payments for separately payable pass-through drugs, biologicals and devices, separately payable non-pass-through drugs and non-implantable biologicals, separately payable therapeutic radiopharmaceuticals, and services assigned to New Technology APCs.

Quality measures to be reported – CMS will continue to require hospitals subject to HOP QDRP requirements to provide quality data for the current 7 chart-abstracted emergency department and surgical care measures and 4 claims-based imaging efficiency measures for CY 2011 payment determinations.

Validation of quality reporting – CMS will be implementing a HOP QDRP validation requirement to ensure that hospitals are accurately reporting measures using chart-abstracted data. Under this requirement, CMS will select a sample of reported cases, request the corresponding medical records, re-abstract the HOP QDRP chart-abstracted measures, and compare the results with the measures reported by the hospital. Hospitals will be required to return paper copies of requested medical records for this CY 2011 requirement within a 45 calendar day timeframe. However, the validation results will not affect a hospital’s CY 2011 OPPS payment. This initial validation requirement for CY 2011 will provide hospitals an opportunity to become familiar with the process for future years.

Public reporting of quality data – CMS is establishing procedures to make HOP QDRP quality measure data publicly available as early as June 2010.

Supervision of Hospital Outpatient Services:
· Supervision requirements for outpatient services – In order to ensure that hospital outpatient services are appropriately supervised by qualified practitioners while not impeding beneficiary access to these services, and in response to concerns raised by the hospital community, CMS is revising or further defining several current policies for the supervision of outpatient services. First, in CY 2010, CMS will allow certain nonphysician practitioners ‑ specifically physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, and licensed clinical social workers ‑ to provide direct supervision for all hospital outpatient therapeutic services that they are authorized to personally perform according to their state scope of practice rules and hospital-granted privileges. Under current policy, only physicians may provide the direct supervision of these services.


For purposes of on-campus hospital outpatient therapeutic services, CMS is defining “direct supervision” to mean that the physician or nonphysician practitioner must be present anywhere on the hospital campus and immediately available to furnish assistance and direction throughout the performance of the procedure. For services furnished in an off-campus provider-based department, “direct supervision” would continue to mean that the physician or nonphysician practitioner must be present in the off-campus provider-based department and immediately available to furnish assistance and direction throughout the performance of the procedure.

CMS also will require that all hospital outpatient diagnostic services furnished directly or under arrangement, whether provided in the hospital, in a provider-based department, or at a nonhospital location, follow the MPFS physician supervision requirements for individual tests.

Payment for Drugs, Biologicals, and Radiopharmaceuticals:
Drugs and pharmacy overhead – CMS will pay for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals without pass-through status at the average sales price (ASP) plus 4 percent in CY 2010. The payment rate of ASP plus 4 percent is based upon the cost of separately payable drugs and biologicals calculated from hospital claims and cost reports (ASP minus 3 percent), with an adjustment for pharmacy overhead cost that reflects the redistribution of $200 million of the pharmacy overhead cost currently attributed to packaged drugs and biologicals (both coded and uncoded) to separately payable drugs and biologicals without pass-through status.

Pass-through implantable biologicals – Beginning in CY 2010, implantable biologicals that are surgically implanted (through a surgical incision or a natural orifice) and that are not receiving pass-through payment before Jan. 1, 2010 will be evaluated for pass-through status using the device category pass-through process rather than the drug and biological pass-through process. Implantable biologicals that initially qualify for device pass-through status beginning on or after Jan. 1, 2010 will be paid at hospitals’ charges adjusted to cost for the two to three year pass-through payment period.

Drug and biological pass-through payment eligibility period – Consistent with current policy, in CY 2010, CMS will continue to recognize the first date of OPPS pass-through payment of ASP plus 6 percent as the beginning of the two to three year pass-through payment eligibility period for a new drug or non-implantable biological.

· Therapeutic radiopharmaceuticals – Beginning Jan. 1, 2010, CMS will provide payment for separately payable therapeutic radiopharmaceuticals with ASP data at ASP plus 4 percent. If ASP data are not available, payment will be based upon mean unit cost from hospital claims data. Subregulatory guidance on submitting ASP for OPPS radiopharmaceutical payment based on ASP is available on the CMS Web site at: www.cms.hhs.gov/HospitalOutpatientPPS/.

Payment for Brachytherapy Sources:
CMS is adopting the proposal to pay for brachytherapy sources based on median unit costs in CY 2010, as calculated from claims data according to the standard OPPS ratesetting methodology.

Partial Hospitalization Services, including Services Provided by CMHCs:
CMS will continue paying two separate partial hospitalization program (PHP) per diem rates: one for days with three services ($150) and one for days with four or more services ($211). The CMHC multiple outlier threshold will continue to be set at 3.4 times the APC payment amount for the higher intensity partial hospitalization day for CY 2010.


AMBULATORY SURGICAL CENTERS

Background:

There are approximately 5,000 Medicare-participating ASCs. Since Jan. 1, 2008, ASCs have been paid under a revised ASC payment system that both aligns payment in ASCs and hospital outpatient settings by basing ASC payment rates on the APC relative weights for similar services and extends payment to more surgical services in ASCs than under the prior payment system. To minimize the impact of the revised payment system, the ASC payment rates calculated under the new ratesetting methodology are being phased in over four years. CY 2010 is the third year of the transition. In general, the revised ASC payment rate for a surgical procedure is a percentage of the payment rate for the same procedure under the OPPS; however, there are a few exceptions. For device-intensive procedures (assigned to a subset of the OPPS device-dependent APCs where device costs account for more than 50 percent of the total cost of the service), ASCs receive the same payment for the device cost as under the OPPS. For new ASC procedures that are predominantly performed in physicians’ offices, the ASC payment is capped at the amount the physician is paid under the MPFS for practice expenses for providing the same procedure in an office.

In the CY 2008 final rule that revised the ASC payment system, CMS added approximately 800 procedures to the list of ASC procedures for which payment could be made. Only those surgical procedures that would be expected to pose a significant safety risk to beneficiaries or that would be expected to require an overnight stay following the procedure are excluded from the ASC list. These changes in payment policies for ASCs give patients broader access to surgical services in settings that are clinically appropriate.

Significant Changes For Calendar Year 2010:

ASC Payment Rate Updates: The revised ASC payment rates were established to reflect the same relativity of resource use among procedures as under the OPPS, taking into consideration the lower costs of surgical procedures performed in ASCs and maintaining budget neutrality in the payment system. By law, CY 2010 is the first year that CMS may provide an inflation update under the revised ASC payment system. The percentage increase in the Consumer Price Index for All Urban Consumers that updates the ASC conversion factor for CY 2010 is 1.2 percent.

Changes to ASC Covered Surgical Procedures and Covered Ancillary Services: CMS is adding 26 surgical procedures to the list of procedures for which Medicare would pay when performed in an ASC. CMS also is newly designating 6 procedures as office-based procedures (subject to payment at the lesser of the national office practice expense payment to the physician or the national ASC rate), and temporarily designating an additional 16 procedures as office-based procedures based on coding changes for CY 2010. The final rule with comment period also updates the list of device-intensive procedures and covered ancillary services and their rates, consistent with the OPPS update.

The CY 2010 OPPS/ASC final rule with comment period will appear in the Nov. 20 Federal Register. Comments on designated provisions are due by 5:00 p.m. Eastern time on Dec. 29, 2009. CMS will respond to comments in the CY 2011 OPPS/ASC final rule.
For more information on the CY 2010 final rule with comment period for the OPPS and ASC payment system, please see the CMS Web site at:
OPPS: http://www.cms.hhs.gov/HospitalOutpatientPPS/
ASC payment system: http://www.cms.hhs.gov/ASCPayment/

IHI Assembles Leadership Resources to Assist with Crisis Management

The Institute for Healthcare Improvement (http://www.ihi.org/) recently assembled a set of resources to assist hospital executives with effective crisis management.

At the core of the resources page is a power point presentation (and soon to be publication) from Jim Conway, Senior VP of IHI, summarizing what a well coordinated crisis management plan would look like when put into action. The page is then peppered with a series of resources and links to other sites describing recent adverse events and how they were handled.

The Jim Conway presentaton is here.

The IHI resource site is here.

AHRQ Tools and Resources to Prevent HAIs.

In early September, the AHRQ released a webpage highlighting research and resources related to the prevention of hospital acquired infections. This is an excellent site that links to tools and resources for both healthcare providers as well as healthcare consumers.

You can find the website here.

ThedaCare - "No Medication Errors in 2 years"??? via Lean

Fox News in Wisconsin recently interviewed the CEO of ThedaCare and discussed their Lean journey.

http://www.foxnews.com/search-results/m/25995300/what-is-thedacare.htm#q=thedacare

http://www.foxnews.com/search-results/m/25995305/what-works-what-doesn-t.htm#q=thedacare

http://www.foxnews.com/search-results/m/25995515/collaborative-care.htm#q=thedacare

Specifically, in these videos, you will hear the CEO talk about the Lean tools, the control boards, the improvement methodology, and the fact that their staff are empowered to solve the problems themselves rather than wait for a manager to solve the problem for them.

...a very interesting discussion.

Joint Commission issues Sentinel Event Alert Regarding Leadership

On 8-27-09, the Joint Commission released a Sentinel Event Alert regarding leadership and its commitment to safety.

You can find the entire alert here.
The press release can be found here.

Within the alert are 14 recommendations for the governing body, CEO, and senior managers:

1. Define and establish an organization-wide safety culture that includes a code of conduct for all employees, including contract workers.
2. Institute an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
3. Make the organization’s overall safety performance a key, measurable part of the evaluation of the CEO and all leadership.
4. Ensure that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive and timely. Also, make sure they have the opportunity to fully participate in the investigation, risk identification and mitigation activities that will prevent future adverse events.
5. Create and communicate a policy that defines behaviors that are to be referred for disciplinary action; include the timeframe that the disciplinary action should take place.
6. Regularly monitor and analyze adverse events and close calls quantitatively and communicate findings and recommendations to leadership, the board and staff. Conduct root cause analyses of adverse events. Look for patterns in root causes that identify latent hazards and weaknesses in the defenses against errors—the holes in the slices of cheese—and make sure they are addressed.
7. Regularly hold open discussions with risk management, performance improvement, physician, nursing and pharmacy leaders, and with physicians and staff caring for patients, to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care could provide the ideal opportunity for these discussions, which should focus on learning and improvement, not blame or retribution.
8. Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention. Make a visible commitment of time and money to improve the systems and processes needed to defend against hazards and minimize unsafe acts. For example, some organizations create an emergency patient safety fund.
9. Establish partnerships with physicians and align their incentives to improving safety and using evidence-based medicine.
10. Add a human element and a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to board members, executive leadership, medical staff, and other key leadership groups; also solicit patient input into safety design.
11. When planning and implementing safety improvements, use the expertise of front-line staff who understand the risks to patients and how processes really work.
12. Regularly measure leadership’s commitment to safety using climate surveys and upward appraisal techniques (in which staff review or appraise their managers and leaders).
13. When leaders assess managers during the annual performance review, make sure they ask about the safety issues the manager encountered, how they were handled, and the impact their actions had on reducing unsafe conditions.
14. Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety.

Personal Opinion: Although senior leadership has the responsibility for creating a structure that is conducive to improving patient safety, senior leadership is also the least effective group to actually improve patient safety. It is the bedside staff that can impact patient safety the most - if allowed to by senior leadership. Maybe this list should have included more recommendations for senior leadership to empower the bedside staff to proactively assess and redesign their work flow to minimize risk factors?

2008 Indiana Medical Errors Report Released

On 8-20-09 the Indiana State Dept. of Health released its 2008 report on medical errors reported by hospitals, ambulatory surgery centers, and abortion clinics via the reporting system mandated by the Governor in 2005 to start CY2006.

The State's Medical Error Reporting System webpage is here: http://www.in.gov/isdh/23433.htm (Note: The State frequently changes its webpage urls and thus the link may become useless at any time. It was working this morning.)

The 2008 report itself can be found here: http://www.in.gov/isdh/files/2008_MERS_Report.pdf
Data Tables: http://www.in.gov/isdh/files/2008_MERS_Data_Tables.pdf
Appendix: http://www.in.gov/isdh/files/2008_MERS_Appendices.pdf

The 2008 Report also contains descriptions of patient safety improvements efforts and activities that are ongoing throughout the state.

Note that the reporting rules have changed for CY2009. Prior to 1-1-09, 27 events had to be reported. Twenty-Eight events are now covered by the reporting system. The new list is here: http://www.in.gov/isdh/files/28_REPORTABLE_EVENTS.pdf

The release of the report has been lightly covered by local media:
IndyStar: http://www.indystar.com/apps/pbcs.dll/article?AID=2009908210343
WTHR: http://www.wthr.com/Global/story.asp?s=10964770

Three Indiana Regions Identified as "Low-Cost, High Quality".

The Institute for Healthcare Improvement recently concluded a "How did they do that?" conference where invited healthcare leaders from regions around the US identified as "Low-Cost, High Quality" met in Washington, DC to talk about their experiences.

Although no region from Indiana participated in this meeting, the IHI did publish their methodology in identifying eligible regions. You can find that document here.

Based on their methodology, approximately 70 regions were identified as "Low-Cost, High Quality". The list of regions can be found here.

Three Indiana regions were named in this document. They are:

• Fort Wayne
• Muncie
• South Bend

Opening slides that compare "Low-Cost, High Quality" regions to "all others" from this meeting can be found here.

Maybe the three large Central Indiana health systems can learn a thing or two from the the three Indiana regions above?

CMS Announces New IPPS Quality Measures for FY2010

On Firday afternoon, CMS released the final rules for FY2010 IPPS. You can find the federal register entry here.

Ther press release from CMS is as follows. Areas of interest to acute care healthcare professionals are in red.


FOR IMMEDIATE RELEASE
July 31, 2009

MEDICARE ADDS QUALITY MEASURES FOR REPORTING BY ACUTE CARE HOSPITALS FOR INPATIENT STAYS IN FY 2010

OVERVIEW:
On July 31, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises policies and payment rates for general acute care hospitals that are paid for inpatient services under the Inpatient Prospective Payment System (IPPS), effective for discharges in fiscal year 2010 – that is, on or after October 1, 2009. In addition to promoting accurate payment for inpatient services to Medicare beneficiaries, the final rule strengthens the relationship between payment and quality of service, by expanding the quality measures that hospitals must report in order to receive the full market basket update in fiscal year 2011. Under the Medicare law, hospitals that choose not to participate in the voluntary reporting program or do not participate successfully will receive an inflation update equal to the hospital market basket less two percentage points The final rule sets the market basket at 2.1 percent, and, therefore, hospitals that do not successfully report the quality measures will receive updates of 0.1 percent.

The final rule does not change the list of hospital-acquired conditions (HACs) in FY 2010, but describes CMS’s plans to evaluate the impact of the existing policy on hospital practices and patient care.

This Fact Sheet discusses only the quality provisions of the IPPS FY 2010 final rule; separate fact sheets also issued today provide more detail on the payment and policy changes.

BACKGROUND: The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) and HACs initiatives represent significant steps toward implementing value-based purchasing (VBP) in Medicare. VBP is intended to transform Medicare from a passive payer for
services to a prudent purchaser of services, paying not just for quantity of services but for quality as well.

The RHQDAPU initiative grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups. Participation in the program is voluntary, but after initial levels of participation proved disappointing, Congress added a financial incentive to the program in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. Under the MMA, hospitals that chose not to participate or failed to meet the criteria for successful reporting in a given year received the annual payment update reduced by 0.4 percentage points. The Deficit Reduction Act of 2005 increased this reduction to 2.0 percentage points. Since the implementation of the financial incentive, hospital participation has increased to 99 percent and, of participating hospitals, 97 percent receive the full annual payment update in FY 2009.

In the meantime, the RHQDAPU measure set has grown from a starter set of 10 quality measures in 2004 to the current set of 43 quality measures. The 43 measures include 25 chart-abstracted measures (heart attack, heart failure, pneumonia, surgical care improvement), 16 claims-based measures (mortality and readmissions measures for heart attack, heart failure, pneumonia; AHRQ Patient Safety Indicators and Inpatient Quality Indicators; nursing sensitive care), 1 survey-based measure (patient satisfaction), and 1 structural measure (participation in a cardiac surgery registry).

CHANGES TO THE RHQDAPU PROGRAM FOR FY 2011:
Additions: The IPPS FY 2010 final rule adds four new measures and program requirements to the current measures for which hospitals must submit data under the RHQDAPU program to receive the full market basket update in FY 2011. This includes two new chart-abstracted measures for surgical care improvement and two structural measures. The new Surgical Care Improvement Project (SCIP) measures are additions to the existing SCIP measure set for which data elements are already being collected and submitted to CMS. Therefore, the additional chart abstraction burden for hospitals will be minimal. CMS believes that the two structural measures will promote hospital participation in nursing-sensitive care and stroke care registries that collect quality data.
The additions to the quality measures are summarized in the following table:

Surgical Care Improvement Project (SCIP) Measures
SCIP INF 9 - Urinary Catheter Removed on Postoperative Day 1 (POD1) or postoperative Day 2 (POD2)
SCIP INF 10 - Surgery Patients with Perioperative Temperature Management

Structural Measures
Participation in a Systematic Clinical Database Registry: Nursing Sensitive Care
Participation in a Systematic Clinical Database Registry: Stroke Care

Retirement of Measure: The final rule notes that CMS retired the Acute Myocardial Infarction (AMI)-6 – Beta-blocker at arrival measure. CMS took this action based on the evolving evidence for care of AMI patients and changes in the American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines. The new guidelines recommend that early beta-blockers should be avoided in certain patient populations due to increased mortality risk. Retirement of this measure is based on evidence that revision of the measure would be impractical and might cause unintended consequences, including harm to certain AMI patients.

Program Requirements: CMS currently provides hospitals that will not be receiving the full market basket update an opportunity to submit a RHQDAPU reconsideration request to CMS. The final rule now requires hospitals that are denied the full market basket update for FY 2010 because they fail to meet the RHQDAPU validation requirements to submit a copy of all the paper medical records that they submitted to the CMS contractor each quarter for purposes of the validation, along with a copy of the reconsideration request form. CMS believes this new process will streamline the reconsideration process and reduce the number of subsequent hospital appeals to the Provider Reimbursement Review Board (PRRB).

The final rule also provides hospitals that receive a new CMS Certification Number (CCN) more time - 180 calendar days from the date identified as the ‘‘open date’’ on CMS’s Online System Certification and Reporting (OSCAR) system - to submit a RHQDAPU participation form. This change will make it possible for CMS to verify accurately whether these hospitals intend to participate in the RHQDAPU program, while ensuring that they have a sufficient amount of time to implement the operational requirements. Hospitals will still be required to report data starting with the calendar quarter following the date that they submit their RHQDAPU participation form.

Finally, CMS has modified the validation requirement starting with FY 2012 to improve the reliability and quality of the process. CMS will randomly select 800 hospitals on an annual basis, and will validate 12 medical records on a quarterly basis throughout the year from each selected hospital. CMS will increase the quarterly sample size from the current 5 records to 12 records to achieve a more reliable validation estimate of the RHQDAPU data reported by the hospital. CMS will also develop targeting criteria to supplement the random sample beginning in FY 2011 to make sure that hospitals do not receive quality payments that have failed validation in the past or have not been included in the sample several years in a row.

HOSPITAL-ACQUIRED CONDITIONS UPDATE: The final rule does not change the list of hospital-acquired conditions (HACs) in FY 2010. During the coming fiscal year, CMS is planning to conduct a joint evaluation of the program’s impact, working with sister agencies within the Department of Health and Human Services - the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), and the Office of Public Health and Science (OPHS). The evaluation will provide valuable information about the program’s impact with regard to preventing HACs.

Under the HAC payment provision, Medicare has selected ten categories of conditions that are reasonably preventable through adherence to evidence-based guidelines, and that, when present as a secondary diagnosis at discharge, result in the case being assigned to a higher paying MS-DRG. Beginning for discharges on or after October 1, 2008, CMS no longer pays at the higher MS-DRG if the only secondary diagnoses on a claim are on the HAC list and were not reported as present at admission.

The HAC payment provision was mandated by the Deficit Reduction Act of 2005 to provide hospitals a payment incentive to encourage the prevention of these conditions. CMS designated eight categories of conditions as HACs during the IPPS rulemaking for FY 2008 and expanded the list of HACs in FY 2009. Although CMS has not yet evaluated the impact of this policy, CMS has received anecdotal reports that hospitals across the country are increasing their efforts to prevent HACs from occurring.

The final rule was placed on display at the Federal Register today, and can be found under Special Filings at: www.archives.gov/federal-register/public-inspection/index.html.
It will appear in the August 27, 2009, Federal Register.
For more information, please see: www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp.

Hospital Aquired Conditions Section @ National Guideline Clearinghouse

Most of us are probably aware of www.guidelines.gov as being a searchable clearinghouse of evidence-based clinical practice guidelines.

Did you know that there is a section specifically about preventing the hospital acquired conditions that CMS says they will no longer pay for?

http://www.guideline.gov/resources/hac.aspx


It appears that they (National Guidelines Clearinghouse (NGC), an initiative of the Agency for Healthcare Research and Quality (AHRQ)) intends to keep this page current. The most recent update was July 27th.

AHRQ says Health Care Quality in Indiana is "Weak".

After compiling over 100 measures for all states, Indiana falls between weak and average on the National Health Care Quality Report (NHRQ) - a report funded by the Agency for Health Care Research and Quality (AHRQ).

You can view the dashboard and the elements that contribute to Indiana's overall score here.

Indiana Heart Failure Readmission Rates

CMS has made available the heart failure readmission rates for all hospitals in the country on its http://www.hospitalcompare.hhs.gov website.

The database behind the website is also available from CMS.

In the State of Indiana:

• 12 hospitals were better than the national average.
• 103 hospitals were no different than the national average.
• 2 hospitals were worse than the national average.

Who were these top performing hospitals?

• BALL MEMORIAL HOSPITAL INC
• COLUMBUS REGIONAL HOSPITAL
• KOSCIUSKO COMMUNITY HOSPITAL
• LAPORTE HOSPITAL AND HEALTH SERVICES
• MEMORIAL HOSPITAL AND HEALTH CARE CENTER
• MEMORIAL HOSPITAL OF SOUTH BEND
• PARKVIEW HOSPITAL
• PORTER, VALPARAISO HOSPITAL
• SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND
• SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH
• ST FRANCIS HOSPITAL AND HEALTH CENTERS
• ST VINCENT HEART CENTER OF INDIANA LLC

Additional Notes:

• Readmission rates for the Indiana better than national average hospitals ranged from 19.3% to 21.5%.
• Readmission rates for the two Indiana worse than national average hospitals were 27.7% (pt. n=690) and 28.7% (pt. n=606).

$10 Million for your idea?

Do you have an idea for changing healthcare in the US that will improve the health value of a 10,000 person community by more than 50% in 3yrs? The X PRIZE Foundation is creating a competition where the team to achieve this first will be awarded $10 Million.

Note: This is the same X-Prize foundation that awarded $10M to the first team to build a privately funded spaceship to deliver a 3 person crew to space x2 within 2wks. http://space.xprize.org/ansari-x-prize

From the Website:
The Grand Challenge for the Healthcare X PRIZE is to create an optimal health paradigm that empowers and engages individuals and communities in a way that dramatically improves health value. The proposed prize is designed to improve health value by more than 50 percent in a 10,000 person community during a three year trial. In order to effectively compete for this prize, teams will need to fundamentally change health financing, care delivery, and create new incentives that will result in achieving the required improvements in health value for both individuals and communities.

http://www.xprize.org/future-x-prizes/healthcare-x-prize

CMS updates RAC Schedule

CMS released an updated schedule of RAC roll out. The updated schedule can be found here: http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf

Note that Indiana is considered a yellow/green state.

Medicare Fraud Strike Force Hits Detroit

HHS issued a press release on 6/24/09 detailing the arrests of 53 physicians and healthcare executives. You can find the complete release at: http://www.hhs.gov/news/press/2009pres/06/20090624a.html

Excerpts:

Today, federal agents from the FBI and the HHS Office of Inspector General
(HHS-OIG) began executing arrest warrants in Detroit, Miami and Denver as part
of a concentrated effort to address fraud in the metro-Detroit area. Charges
were unsealed today against 53 individuals who are accused of various Medicare
fraud offenses, including conspiracy to defraud the Medicare program, criminal
false claims and violations of the anti-kickback statutes. The Strike Force
operations in Detroit have identified two primary areas – infusion therapy and
physical/occupational therapy providers – in which schemes were allegedly
orchestrated to defraud the Medicare program.

According to the indictments, the defendants charged today participated in
schemes to submit claims to Medicare for treatments that were in fact medically
unnecessary and oftentimes, never provided. In many cases, indictments
allege that beneficiaries accepted cash kickbacks in return for allowing
providers to submit forms saying they had received the unnecessary and not
provided treatments. Collectively, the physicians, medical assistants,
patients, company owners and executives charged in the indictments are accused
of conspiring to submit more than $50 million in false claims to the Medicare
program.

Side-by-Side Healthcare Reform Proposal Comparisons

http://www.kff.org/healthreform/sidebyside.cfm

The Kaiser Family Foundation has created a website that will allow you to compare all the current healthcare reform proposals. It is at the link above. The website says that the information was last updated 6-16-09. Very interesting site.

APIC Study Finds Hospitals Are Cutting Back on Infection Prevention???

The Association for Professionals in Infection Control and Epidemiology issued a press release on June 9th reporting its findings that hospitals are cutting back on the infection control/prevention function across the country.

You can download the press release here.

Excerpts:

The “2009 APIC Economic Survey” found that of nearly 2,000 infection preventionists who responded, 41 percent reported reductions in budgets for infection prevention in the last 18 months due primarily to the economic downturn.

According to the survey, three-quarters of those whose budgets were cut experienced decreases for the necessary education that trains healthcare personnel in preventing the transmission of healthcare-associated infections (HAIs) such as MRSA and C. difficile. Half saw reductions in overall budgets for infection prevention, including money for technology, staff, education, products, equipment and updated resources. Nearly 40 percent had layoffs or reduced hours, and a third experienced hiring freezes.

“Infection prevention departments at our nation’s healthcare facilities are severely understaffed and under-resourced,” said APIC CEO Kathy L. Warye. “Without enough trained professionals, funding and high-tech solutions that speed access to infection-related data, we are not going to continue to make progress in eliminating preventable infections. While cuts in staff, training and technology may ease budgets in the shortterm, the effect of increased infections will erode the bottom line over time, not to mention cause needless pain, suffering and death.”

First RAC, now HEAT????

The new HHS Secretary issued a press release on May 20th announcing a new interagency Healthcare Fraud Prevention and Enforcement Action Team (HEAT).

You can find the press release here: HEAT

The following are some excerpts from the press release:

• Holder (Attny General) and Sebelius (HHS Secretary) also announced the expansion of Strike Force team operations to Detroit and Houston. Medicare Fraud Strike Forces, currently in operation in South Florida and Los Angeles, fight Medicare fraud on a targeted local level.
• “Today, we are turning up the heat on perpetrators who steal from the taxpayers and threaten the future of Medicare and Medicaid,” said Secretary Sebelius. “Most providers are doing the right thing and providing care with integrity. But we cannot and will not allow billions of dollars to be stolen from Medicare and Medicaid through fraud, waste and serious abuse of the system.
• The HEAT team will include senior officials from DOJ and HHS who will build upon and strengthen existing programs to combat fraud while also investing new resources and technology to prevent fraud, waste and abuse before it happens.
• Efforts will include the expansion of joint DOJ-HHS Medicare Fraud Strike Force teams that have been successfully fighting fraud in South Florida and Los Angeles. Established in 2007, these teams have a proven record of success using a “data-driven” approach to identify unexplainable billing patterns and investigating these providers for possible fraudulent activity.
• Prevention is critical to reforming the system and the HEAT team will also focus critical resources on preventing fraud from occurring in the first place. The team will build on demonstration projects by the HHS Inspector General and the Centers for Medicare & Medicaid Services (CMS) that focus on suppliers of durable medical equipment (DME).
• The Attorney General and the HHS Secretary also called on the American people to visit a new Web site www.hhs.gov/stopmedicarefraud or call 1-800-HHS-TIPS (1-800-447-8477) to report suspected Medicare fraud.
  

IHI Global Trigger Tools (Second Edition)

The IHI recently released a document describing the concept of Global Trigger Tools to identify adverse events that are unreported through the usual voluntary event reporting systems.

The description of the document is here.

...or you can go directly to the document here. You may need to log in to the IHI website to download the document.

In my previous hospital, I was able create a monitoring system that would scan the EMR from the previous day to look for these events. If a person with limited SQL programming skills can do this (via an ODBC connection to the back-end tables of the EMR), you can be sure that EMR vendors in the future will be offering such a module (at a high cost no doubt!).

Having such a global trigger function in your organization via EMR is a great way to add a little more objectivity in what was a voluntary, subjective, and political function in the past.

The "Diff" in C. Difficile

Infectious Disease News published a story in March about a presentation by Dr. Dale Gerding at the Annual Meeting of the Society for Healthcare Epidemiology of America.

You can view the story here.

Essentially, it was reported that hand washing is not as effective as we want it to be for removing the C. Difficile spores. No usable product was found to be able to remove more than 90% of the spores. This reinforces the importance of wearing gloves.

What Does it Cost a Physician to Deal with Health Insurance?

This Commonwealth Fund sponsored research was recently published in Health Affairs. You can download a document of the highlights here.

Summary:

• Study of 900 physician and medical groups
• Average of 142hrs per physician annually is spend on interacting with health plans
• Average cost to the practice is $68,274 per physician.
• Primary care physicians spend significantly more time than specialists interacting with health plans.
• "Nearly three-quarters of respondents said their cost of interacting with health plans have increased over the past two years."

Apologies....

My apologies for not keeping this blog updated despite all the happenings in healthcare reform over the past few weeks. We had a planned "unannounced" visit by the Joint Commission last week that I had to prepare for (Disease Specific Care Certification).

I will scan through the 300 unread items in my RSS feed and post any relevant happenings to keep you updated.

Ed.

Proposed future changes in RHQDAPU

As mentioned earlier, CMS posted its annual Proposed Rules in the Federal Register today. You can access the entire 1,228 page document here.

Although the entire document may be of interest to the healthcare quality professional, of particular interest would be the section describing new quality measures linked to payment - especially ones that will require additional chart abstracting.

• The RHQDAPU section starts on page 323 with a history of the program.
• Proposed FY2010 measures are listed on page 329.
• Proposed FY2011 measures are listed on page 345.
• Two of the FY2011 proposed measures will require chart abstraction: 1) SCIP-Inf 9 - Postoperative Urinary Catheter Removal on PostOp Day 1 or 2; 2) SCIP-Inf 10 - Postoperative Temperature Management.
• Page 347 starts a list of possible additional measures for consideration for FY2012.

If you don't like what you see, you can send comments to CMS until June 30, 2009.

CMS Proposes Policy and Payment Rate Changes for Inpatient Stays in Acute Care and Long-Term Care Hospitals in FY 2010

This annual announcement was posted in the Federal Register today. The public comment period ends June 30. The press release associated with this is copied in its entirety below. Items of interest to healthcare quality professionals are colored red.

.......

FOR IMMEDIATE RELEASE

May 1, 2009

Contact: CMS Office of Media Affairs
(202) 690-6145

CMS PROPOSES POLICY AND PAYMENT RATE CHANGES
FOR INPATIENT STAYS IN ACUTE CARE AND
LONG-TERM CARE HOSPITALS IN FY 2010

The Centers for Medicare & Medicaid Services (CMS) today proposed the fiscal year (FY) 2010 policies and payment rates for inpatient services furnished to people with Medicare by both acute care hospitals and long-term care hospitals.

In the announcement issued today, CMS is proposing to update acute care hospital rates by 2.1 percent for inflation less an adjustment of 1.9 percentage points to remove the effect of increases in aggregate payments due to changes in hospital coding practices that do not reflect increases in patient’s severity of illness. CMS is similarly proposing to update long-term care hospital rates by 2.4 percent for inflation less an adjustment of 1.8 percentage points to account for changes in documentation and coding practices that do not reflect increases in patient’s severity of illness. Beginning October 1, 2008, Medicare adopted a new classification system for general acute and long term care hospitals to better recognize severity of illness and the cost of treating Medicare patients.

However, hospitals changed their documentation and coding of patient diagnoses under the new system in a manner that leads to an increase in aggregate payments without corresponding growth in actual patient severity. The proposed documentation and coding adjustments help ensure that estimated aggregate payments to these hospitals under the new classification systems would not increase solely as a result of the changes to the classification system and hospital coding practices. Although CMS has the authority to make a much greater downward adjustment to payment rates to address these changes in hospital coding practices, CMS believes it would be prudent to phase-in the adjustment carefully over time.

The proposed rule would apply to approximately 3,500 acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), and 400 long-term care hospitals paid under the Long-Term Care Hospital Prospective Payment System (LTCH PPS), beginning with discharges occurring on or after October 1, 2009. The proposed payment rates are based on the most recently available data and are subject to revision in the final rule to reflect more current data.

The projected 2.1 percent update for inflation for inpatient acute care payment rates is lower than the updates applied in recent years and reflects the slowing rate of inflation in the economy. The inflation updates are specifically designed to measure the inflation in the costs of resources (the market basket) used by hospitals in delivering care to inpatients. Because long-term care hospitals generally use a different mix of resources than acute care hospitals, their inflation update of 2.4 percent is determined using a different market basket than the market basket used for acute care hospitals.

In FY 2008, CMS adopted a new, more accurate classification system for inpatient stays. The Medicare Severity Diagnosis-Related Groups (MS-DRGs) are designed to better take into account the severity of the patient’s illness by providing higher payments for treating sicker patients – treatments that are more costly – and lower payments for other, less severe conditions.

“We understand hospitals will be concerned about lower than historical update amounts” said Charlene Frizzera, CMS Acting Administrator. “However, we are proposing an adjustment that minimizes the effects on FY 2010 payments while still meeting the requirements of the law, which may mean larger reductions in the next two years. We are asking for comments from the public to help us ensure that these proposals are the best ways to meet the requirements of the law.”

As required by the TMA [Transitional Medical Assistance], Abstinence Education and QI Programs Extension Act of 2007 (TMA), CMS has already applied adjustments of -0.6 percent in FY 2008, and -0.9 percent in FY 2009 to the acute care hospital rates. However, if CMS’s review of claims data shows that the adjustments set by the TMA were too low to maintain budget neutrality under the new classification system, the TMA requires CMS to adjust payment rates to account for that difference in subsequent years. This means that CMS must adjust payment rates between FYs 2010 and 2012 as necessary to recapture any excess payments made to hospitals in FYs 2008 and 2009 that resulted from changes in hospitals’ coding practices.

The Medicare Actuary found based on analysis of 2008 data that additional coding that did not reflect actual changes in the severity of patients’ illnesses increased total payments under IPPS by 2.5 percent in FY 2008 and will further increase total payments in FY 2009. Based on current estimates, the Medicare Actuary estimates that total adjustments of approximately 8.5 percent would have to be made to the acute care hospital rates to address changes in hospitals’ coding practices, including the increase in FY 2008 payments and the estimated increase in FY 2009 payments. CMS is proposing a prospective adjustment of 1.9 percentage points for FY 2010, which means additional adjustments of approximately 6.6 percentage points, will be needed in FY 2011 and FY 2012. CMS is requesting public comment on whether to apply a different documentation and coding adjustment than the one being proposed for FY 2010.

Under current Medicare law, hospitals that successfully report the 2010 quality measures included in the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program will get the full update. Hospitals that do not participate in the quality reporting program will get the update less two percentage points. Ninety-seven percent of participating hospitals received the full update last year. The proposed rule adds four new measures for which hospitals must submit data under the RHQDAPU program to receive the full market basket update. Two of these measures are additions to the existing Surgical Care Improvement Project (SCIP) measure set, and CMS believes that the other two measures will promote hospital participation in nursing-sensitive care and stroke care registries.

CMS is also proposing changes to regulations affecting payment adjustments to teaching hospitals (hospitals that offer graduate medical education programs), and disproportionate share hospitals (hospitals that provide care to a disproportionate share of low income patients), and to clarify the regulations implementing the Emergency Medical Treatment and Labor Act (EMTALA). In addition, the proposed rule describes five applications for new technology add-on payments and CMS’ preliminary findings about those technologies.

The proposed rule was placed on display at the Federal Register today, and can be found under Special Filings at:

www.archives.gov/federal-register/public-inspection/index.html.

CMS will accept comments on the proposed rule until June 30, and will respond to comments in a final rule to be made publicly available no later August 1, 2009.

For more information, please see:

www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp.

IHA Update

The following is the most recent legislative update from the IHA. Items that may be of interest to healthcare quality professionals are in red.

General Assembly Faces April 29 Deadline
With the final day for action in the General Assembly less than one week away, conference committees are busy working out compromises between House and Senate versions of legislation. There are plenty of meetings today and rumors that more will be scheduled for Saturday and even possibly Sunday. Needless to say, many members of the General Assembly will not be headed home for the weekend.

Many significant bills failed to clear both chambers, but legislation that previously passed either the House or Senate is usually eligible to be placed into another “live” bill. Check the latest Bill Track to see which bills are headed to conference committee, which ones could be brought back, and which ones likely remain off the table in 2009.

In addition to monitoring the final days of the legislative session, IHA will also participate in the American Hospital Association’s annual meeting in Washington, D.C. and engaging with members of Congress. Key topics that will be addressed are the needs of hospitals in the current economic and financial crisis, concerns over the Employee Free Choice Act, possible reductions in Medicare reimbursement, and national health reform.

HIP Changes in Limbo (SB 472)
IHA has closely followed SB 472, authored by Sen. Pat Miller (R-Indianapolis), even after the hospital assessment and the “HIP 2” proposal was removed earlier this session. As it passed the Senate, this legislation would have allowed certain Hoosiers to buy into the HIP program without state support by paying the full premium as well as making any POWER account contributions. It also would have specified that the minimum POWER account contribution required for HIP enrollees would be $60 (FSSA believes that this minimum payment is critical to maintaining the element of personal responsibility within the HIP program).

In addition to the eligibility changes, SB 472 would have also permitted non-for-profit foundations to contribute to a participant’s required POWER account payments. As passed in the Senate, the amount a not-for-profit could contribute would be 50 percent. Later amendment in the House increased the share to 75 percent.

Other amendments added in the House would have broadened HIP eligibility by reducing the time for which an individual must be without health insurance from six to three months. Another change would increase the share that participating employers can pay for employees’ POWER account payments from 50 percent to 75 percent.

The bill was withdrawn before a third reading vote in the House, and it did not pass before the deadline on April 16. Some raised concerns that certain elements of SB 472 could lead to Hoosiers dropping their private insurance to join HIP. It is important to note that while the cap of 34,000 has been reached for non-parental adults, sufficient funding remains available to enroll thousands more eligible parents or “caretaker adults” in HIP.

The language allowing foundations to contribute to POWER accounts was of particular interest to many hospitals, and it could be revived in a different bill before session’s end. Such language, however, has not yet been inserted into any other conference committee reports.

Indiana Innovation Alliance May Be Funded
There has been only one public conference committee meeting to date on HB 1001, but the prospects for Indiana Innovation Alliance funding improved when it was included in the Senate-passed budget. This proposal is a joint request by Indiana and Purdue Universities, and hospitals may be particularly interested in the component of the program to expand medical education to include two- to four-year programs in Bloomington, Evansville, Fort Wayne, Gary, Indianapolis, Muncie, New Albany, South Bend, Terre Haute, and West Lafayette.

The Senate Republicans’ budget assumed the latest revenue forecast would reflect a shortfall of $1 billion, but by fully-utilizing the significant dollars allocated to Indiana through the stimulus legislation they were able to accommodate this program in their plan.

The Senate provided approximately $26 million for state fiscal years 2010 and 2011 as follows:

• $5 million/year: Medical Education Center Expansion (to increase the medical school class size by 30 percent statewide)
  
• $3.8 million/year: Technical Assistance and Advanced Manufacturing (to expand post-graduate pharmacy residency training for post-graduate biomedical engineering specialization and for the Healthcare TAP program at Purdue)
  
• $11.3 million/year: Core Research
  
• $5.6 million/year: Matching Grants for Federal Research Projects

IU and Purdue were seeking a total of $35 million per year, and the House budget funded the whole program at this level in its one-year budget bill earlier in the session. You can read more about the Alliance at http://www.indianainnovationalliance.org/.

Smokefree Air Legislation Revived
As indicated in the most recent IHA Bill Track, a good deal of legislation that was previously approved by only one chamber remains in play—very little is ever entirely dead during conference committees. HB 1213, the smoke-free air bill, passed the Indiana House by a vote of 70-26, but did not receive a hearing in the Senate Commerce and Public Policy & Interstate Cooperation Committee. However, the author of the original bill, Rep. Charlie Brown, has attempted to insert a revised proposal into HB 1208.

In a conference committee meeting this week, the contents of HB 1208 (establishing a mental health corrections quality advisory committee and a related multi-agency task force) were moved into another bill and replaced with a smoke-free air proposal. The conference committee has not yet acted on HB 1208, but Rep. Brown has asked other legislators to assess what level of support exists for his proposal. To move HB 1208 forward for a full vote in the House and Senate, all four conferees would have to sign off on the report. Rep. Eric Turner, Sen. Connie Lawson, and Sen. Vi Simpson are the other conferees along with Rep. Brown.

The bill as originally introduced contained a comprehensive smoking ban in public places, including bars, casinos, and all other enclosed areas of employment. The bill was lauded by IHA and the Indiana Campaign for Smokefree Air (of which IHA is a member) as a major step forward in protecting the health of Hoosier workers. The bill met a set-back when the House Public Policy Committee passed a heavily amended bill that exempted casinos and most bars.
Rep. Brown has proposed to exempt only casinos in HB 1208. However, since the chair of the Senate Commerce Committee did not hear the original bill, we do not expect that the conferee representing the Senate majority caucus (Sen. Lawson) would sign any conference committee report on this topic.

Admitting Privileges Receive Scrutiny
As it passed the Indiana Senate earlier this session, SB 89 would have required physicians performing abortions in Indiana to have “admitting privileges” at a hospital in that county or an adjacent county. When the bill came to the House Public Policy Committee, IHA was asked to testify on SB 89 solely to provide answers regarding the nature of admitting privileges.

SB 89 was later expanded greatly on the House floor on April 13 and passed the House on April 15. The changes to the bill include requiring any “health care provider licensed by the state” performing a “surgical procedure” to have admitting privileges at a hospital in that county or an adjacent county. “Surgical procedure” was not further defined, which meant that thousands of medical professionals could be impacted.

Although this problematic language passed, other proposals that would have mandated how hospitals award admitting privileges were defeated. It is likely that admitting privileges will continue to receive scrutiny from now until the end of the session on April 29. On Tuesday, the Indianapolis Star published an article on SB 89 and cited information provided by IHA. Read the article here: http://www.indystar.com/article/20090421/NEWS05/904210376.

Sen. Patricia Miller has dissented with the changes made by the House and the matter will likely be taken up by a conference committee. The Senate has appointed conferees and advisers but the House had not yet named its appointments as of April 23. IHA anticipates that the language broadening the requirement to all surgical procedures will be removed. IHA will continue to monitor the bill and defend against any possible attempts to dictate how hospitals grant admitting privileges.

State Revenue Forecast Mixed; Documents Online
The new state forecast projects that Indiana will take in slightly more tax revenue over the biennium than some had feared, but this optimism has been openly questioned by legislators. The budget writers will have about $830 million less than was estimated based on the December 2008 forecast, but some expected the shortfall to exceed $1 billion.

Following the presentation to the State Budget Committee, the forecast documents were posted to the Budget Agency’s website. The “Economic Outlook” document from Nigel Gault, chief U.S. economist for HIS Global Insight, is particularly interesting: http://www.in.gov/sba/2489.htm.