The nation's largest nurses' union and professional organization reached tentative agreement on a new contract with one of the biggest hospital systems in the country. The deal includes a collaborative effort to contain the spread of pandemics such as H1N1. The California Nurses Association/National Nurses Organizing Committee and Catholic Healthcare West agreed to establish a systemwide emergency task force of nurses and hospital representatives to monitor preparedness and set uniform standards that meet federal, state, and local government guidelines.
Attorney General Wayne Stenehjem says North Dakota law limited his review of a merger of two large healthcare companies. Stenehjem says he may ask the Legislature to expand his authority. Stenehjem hired the Brady Martz accounting firm to review the proposed merger of Sanford Health of Sioux Falls, SD, and MeritCare Health System of Fargo, ND. It said MeritCare's books showed "significant operating losses" in its last two budget years.
Tens of thousands of California healthcare workers are scrambling to get vaccinated for the H1N1 flu. Federal officials, who list healthcare workers among those at greatest risk for H1N1 flu, had promised California 6.2 million doses by now. But the state has received just 2.7 million doses due to manufacturing shortages, said Mike Sicilia, a spokesman for the California Department of Public Health. Nationwide, only about 27 million of an expected 40 million doses are available. With so few doses in hand, doctors and nurses say they have been forced to wait in line or volunteer at public clinics to get vaccinated, the Los Angeles Times reports.
Backed by some of the most powerful members of the Senate, a little-noticed provision in the healthcare overhaul bill would require insurers to consider covering Christian Science prayer treatments as medical expenses. The measure would put Christian Science prayer treatments on the same footing as clinical medicine. While not mentioning the church by name, it would prohibit discrimination against "religious and spiritual healthcare."
Medical device companies like Medtronic have been under fire lately for their deals with doctors who can influence purchases of medical products, and a Boston doctor says he was fired when he complained about these types of relationships. A lawsuit filed in state court in Massachusetts by David Gossman, an interventional cardiologist formerly on staff at the Lahey Clinic hospitals in the Boston area, who says he complained about Medtronic's offering the hospital a new experimental heart-valve device "predicated on the purchase and increased utilization of other products made by Medtronic." Gossman says he was fired after he complained about the Lahey-Medtronic link in a conversation this summer with Thomas Piemonte, the director of cardiac catheterization at Lahey.
The 2010 OPPS final rule released on Friday contains few surprises, but does finalize two changes that received considerable attention when CMS proposed them.
"The information CMS has finalized for physician supervision and drug reimbursement are two key areas for hospital review, though for slightly different reasons," says Jugna Shah, MPH, president of Nimett Consulting in Washington, DC.
First, CMS adopted a new standard for supervision in the hospital and for on-campus outpatient departments. The physician must be present on the same campus and "immediately available," rather than in the department. CMS defines "in the hospital" in the new regulations and discusses "immediately available" extensively.
"APC coordinators, your revenue cycle team, and compliance officers need to carefully review this and other discussion items from the final rule," says Shah.
CMS made some important distinctions in the preamble that people will need to pay attention to, says Kimberly Anderwood Hoy, Esq., CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA. CMS specifies that the person must be "immediately available" to step in and take over the procedure. CMS also specified that the person must be close enough to be able to step in, not simply anywhere on the campus.
"They have to be immediately able to drop what they are doing and step and take over the procedure if necessary," Hoy says. "And they have to be close enough that they would be immediately available. They can't be two blocks away."
For example, if the physician is in the hospital cafeteria, he or she would be considered "immediately available," but if the physician is in the middle of providing a procedure to a patient, he or she is unable to stop to provide direct supervision to another patient—so is not immediately available, explains Shah.
CMS also clarified that the person providing supervision would have to be able to perform the procedure under his or her license and within the scope of his or her privileges at the hospital.
CMS made clear through a regulatory change that the direct supervision requirement for off-campus provider-based departments did not change, and still requires the practitioner to be present in the off-campus department, as discussed in the 2009 final rule.
CMS finalized its proposal to permit physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and clinical psychologists to provide direct supervision for hospital outpatient therapeutic services when their license allows them to do so. One change from the proposed rule is the addition of licensed clinical social workers. CMS agreed with commenters that licensed clinical social workers should also be included in the list of non-physician practitioners allowed to provide direct supervision.
These changes come, in part, as a response to commenters, including the American Hospital Association, who complained to CMS that the rules were confusing and unclear. In the 2009 proposed rule, CMS discussed physician supervision requirements and finalized some changes for 2009, but still received considerable comments to their proposed changes in 2010.
The fact that CMS has finally conceded that it can see how there was confusion on physician supervision requirements prior to 2009 should come as a huge relief to hospitals who have been concerned that audits may occur going back many years that could result in financial take-backs, says Shah. Hospital administrators have been worried that the OIG, recovery audit contractors, Medicare administrative contractors, and other auditors would use the fact that hospitals have raised questions on this topic as a reason to begin investigations and potentially take back large amounts of money.
Because CMS agrees that, perhaps, things were confusing in the past, it stated it will not sanction audits or reviews of the supervision requirements for 2000-2008, but also stated enforcement action would be appropriate for 2009. "I think that makes an even stronger case for concern about enforcement in 2009 and providers should take a close look at their risk for that year in light of the clarifications published in the 2009 rule," says Hoy.
The final rule does make clear that non-physician practitioners will not be able to supervise cardiac, intensive cardiac, and pulmonary rehabilitation services. A physician must still be present to provide supervision.
"I think that is something people are going to have to pay close attention to as they implement new policies allowing non-physician practitioner supervision because we have always lumped those services together with all of the other outpatient services," says Hoy.
Reimbursement for separately payable drugs
CMS finalized its new payment calculation method for the hospital pharmacy overhead costs of separately payable drugs and biologicals. In the final rule, CMS discusses payment calculations at length, yet ends up with the same reimbursement for 2010 as hospitals have today for separately payable drugs—average sales price (APS) plus 4%.
"This is deeply frustrating because the industry has worked diligently to help Medicare to understand that that ASP plus 4% is simply insufficient to cover drug acquisition costs and pharmacy handling," Shah says.
Hospital administrators generally believe they are underpaid for drugs, but CMS seems unwilling to change its position, Hoy says.
"I think it's interesting that the two sides are so far apart on such a vital reimbursement issue," Hoy says.
In addition to CMS' discussion of separately payable drug reimbursement, hospitals should be aware that CMS has changed the packaging threshold from $60 to $65 and will no longer provide separate reimbursement for 5-HT3 antiemectics. Also, current cost-based reimbursement for therapeutic radiopharmaceuticals and brachytherapy sources will migrate over to regular APC payment rates.
"Taken in sum total, these drug reimbursement changes are likely to have an impact on a hospital's bottom line," says Shah.