CMS released a new FAQ on the Recovery Audit Contractor (RAC) program April 29 with important news that may have previously flown under the radar of many healthcare providers. Medical record requests necessary for complex reviews by RACs are based on 2008 calendar year claim volume—not 2007 numbers.
The new FAQ reads as follows: Q: I heard that Recovery Audit Contractor (RAC) medical record request limits will be based on my 2007 claims volume, then I heard on 2008. Which is it?
A: We apologize for the confusion. Limits in the remainder of the fiscal year ending September 30, 2009, are based on claim volume in the 2008 calendar year. This differs from our original announcement that limits in the current year would be based on 2007 claim volumes.
Our original plan was to use the previous calendar year's volume to calculate the following fiscal year's limits. In other words, we envisioned using claims paid from January 2007 through December 2007 to develop limits for October 2008 through September 2009. Claims paid in calendar 2008 would then drive limits in fiscal 2009, calendar 2009 would drive fiscal 2010, and so on.
Unfortunately, the RAC program was subject to a several-month delay while various contract issues were being resolved. By the time we were ready to resume work in February 2009, claim data for all of 2008 was available. Recognizing that many providers have grown or contracted due to changes in the economic environment, we decided to use the most current figures available to us instead.
CMS closes the FAQ by indicating this is admittedly confusing and that it will explore alternatives for the future. (CMS also welcomes your suggestions at rac@cms.hhs.gov.)
This point was not mentioned during the RAC Open Door Forum calls in April. Nor was it included in the outreach sessions CMS and the RACs held throughout April for the provider community, says Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc.
Beckley says she isn't certain if CMS' clarification via an FAQ update is adequate at this stage in the RAC rollout process. "This type of change is more suitable for a special announcement on the top of the CMS RAC Web page—as well as via other outreach methodologies that can be used to quickly reach the vast majority of the provider community," she says.
The task of persuading physicians to set up a practice is a daunting one for rural areas across the country.
And the vast acres of California's Central Valley, where town signs boast claims such as "The World's Fruit Basket" and "The Raisin Capital of the World," are no exception.
"Physicians don't want to come to Kaweah in large part because of the payer mix," says Steve Jacobs, physician recruiter for the Kaweah Delta Health Care District. Centered in the city of Visalia, Kaweah Delta serves a population spanning three geographically large agrarian counties.
Here, the population receiving Medicaid (Medi-Cal) is more than one in three. But of dozens of primary care physicians in the region, only 10 are willing to accept it, Jacobs says.
"Reedley, (pop. 22,000) has a beautiful new community clinic, but can't get a physician to come to a rural town. The town of Porterville (population 39,000) has been looking for an orthopedic surgeon for at least two years," he says. "The area surrounding us is very rural, and there's not a lot of infrastructure."
Jacobs said the district finally found a gastroenterologist after a five year search, "but he's 58, and in a few more years he'll retire and we'll have to start looking again. We tend to find physicians who are later on in their career. But the job of looking for any specialist for the area can take up to three years."
Kaweah Delta's challenge was clearly documented this week by a federal report entitled "Hard times in the Heartland," which noted that while urban areas across the country have, on average, 72 physicians per 100,000 population, rural areas have 55 and small rural areas have only 36.
"Rural areas continue to suffer from a lack of diverse providers for their communities' healthcare needs," the report said. There are half as many specialists in rural areas compared with urban ones, and a third as many psychiatrists. The situation is only going to get worse, because rural areas have a higher percentage than urban areas of physicians nearing retirement. "Recruitment and retention continue to be a challenge."
According to a multitude of studies, the lack of rural physicians translates into a lack of healthcare, and that means more disease and premature death in rural areas compared with urban parts of the nation.
The shortage of physicians is largely blamed on the fact that one in five of the nation's uninsured, or 8.5 million people, live in rural areas, which have a larger number of residents classified as unemployed and poor than urban areas. Those who lack health insurance or have large deductibles are more likely to avoid or defer care, as the report, issued by the U.S. Department of Health and Human Services, noted.
And if the number of patients willing to seek care isn't enough, the doctors just can't afford to come.
For these residents, many of whom have worked their entire lives in small businesses or for themselves, their only guarantee of healthcare comes only after they turn 65.
At the fourth in a series of stakeholder discussions in Washington after the report's release, ranchers, farmers, and fishermen from the nation's heartland gathered with Nancy-Ann DeParle, President Obama's new director of the White House Office for Health Reform, to discuss the root of the physician shortages in their communities.
A key point was the need for health reform to create insurance programs–perhaps cooperative group health plans–that can provide health coverage for adults before they are eligible for Medicare.
"There needs to be more choices in the insurance market for affordable health coverage," she said. "The call was very clear; we need more choices for affordable options."
Many panelists told of their personal experiences in trying to access affordable healthcare even after they got sick.
"My father is recovering from colon cancer surgery, but he put off getting his port removed until he turned 65," said a man from Holton, Kansas. He hopes the reform package includes incentives for rural areas to find innovative ways to help people get affordable coverage.
One Nebraska resident told DeParle that he pays $1,000 a month for a health plan with a $10,000 annual deductible. "My mother, who just turned 90, never had health insurance until she became eligible for Medicare."
One of the panel members was Congressman Mike Ross, D-AR, who was born in Texarkana. He said that in his home town, "we used to have a hospital, but now we don't. We had six doctors, now only two. We had two dentists, and now one, and the number of pharmacists is down as well," he said. "We need country doctors," especially pediatricians. "That keeps everyone from having to take the whole day off."
Rhonda Perry, a livestock and grain farmer who directs the Missouri Rural Crisis Center Program, noted that farmers spend 15% of their income on catastrophic health policy premiums.
Ambulatory care centers may be part of the solution. A multitude of research papers issued recently point to how such care settings can, with relatively minimal expense, thwart the need for more acute and expensive hospitalizations months or years down the road.
According to a White Paper released last fall by the American College of Physicians, a group representing the nation's internists, rural areas that have more primary care physicians have lower rates of all-cause mortality, and specifically deaths from cancer and heart disease.
"Nonurban counties with a greater number of primary care physicians had 2% lower all-cause mortality, 4% lower heart disease mortality, and 3% lower cancer mortality than nonurban counties with a smaller number of primary care physicians."
The American College of Physicians advocates a number of measures to continue to attract foreign medical school graduates to practice in the U.S., a source of physicians it called extremely important for rural and underserved areas.
If all international medical graduates in primary care practice were removed, one out of every five non-metropolitan areas in the U.S. that now have an adequate supply of physicians would be reclassified as having a physician shortage, the ACP paper said.
Perhaps through a combination of more incentives for physicians and more financial support for hospitals, some of the severe gaps in healthcare to the heartland may be filled. There is potential for better use of providers other than physicians, such nursing or other types of health professionals to fill the needs in these areas. And there's a potential to build and support new models of clinics or urgent care centers that don't necessarily have to be staffed at all times by doctors.
The Agency for Healthcare Research and Quality released two reports today that shows that most patients are not getting recommended medical treatments and quality of care for non-whites and poor people is not improving.
A little more than half of patients get medical treatments that are recommended.
Only 40% of patients with diabetes received the three exams they're supposed to have each year.
One in seven Medicare patients experience an adverse event in a healthcare setting.
Compliance with hospital patient safety measures have worsened by nearly 1 % in each of the last six years.
A second report issued by the agency, the National Healthcare Disparities Report, found that quality of care is not improving for non-whites and poor people in at least 60% of quality measures, which include timeliness of care, communication with providers, and prenatal care.
"Today's reports show why we can't wait to enact comprehensive health reform," said Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services. "Patients expect to get better in healthcare facility, not worse," she said.
Sebelius also promised $50 million in American Recovery Act funds for states to help fight health setting-acquired infections. Of that, $40 million would be awarded through competitive grants to eligible states to expand prevention and surveillance efforts and strengthen the public health workforce. Another $10 million would go to states to improve inspections for ambulatory surgical centers.
And while stimulus package money will help providers improve safety, Sebelius said, "We need hospitals to do more. Today I'm challenging hospitals to take basic steps to fight infections that are weakening our healthcare system and threatening patient safety."
One reason for the poor quality improvement is the struggle to reduce blood stream infections from central lines in intensive care units. She challenged hospitals to reduce the number of infections by 75% over the next three years and issued a 20-step checklist to prevent mistakes and infections.
Overall, healthcare-associated infections acquired in a nursing home or hospital are "among the top 10 leading causes of death in the U.S. and drive up the cost of healthcare by up to $20 billion per year," the agency said in a statement.
It's always nice to come home from a conference with a few ideas that you can implement quickly and inexpensively, especially in this economy. I was at the 2009 PRC client education conference in New Orleans this week where I collected a bunch of them for you. And some of them aren't just inexpensive—they're free.
Opening keynote speaker, author Barbara Glanz, told the audience that many managers think that employees' primary motivator is money and job security—two things many employers have little control over today. But when you ask employees, their top motivators are interesting work and appreciation.
How you treat your employees has a direct impact on how they treat patients. And how your organization treats patients has a direct impact on the bottom line.
Here are a few of her low- or no-cost tips on employee engagement and satisfaction.
Make employees happy: Start every meeting with three minutes of good news
Show respect for your employees as human beings with a life outside of work: Find out what each of your employees is passionate about.
Say good morning to your employees: Glanz cited a survey of 1,200 people in which 7% said they quit their jobs because their boss didn't pay them this simple courtesy.
Lighten up: No, work isn't all fun and games, but it doesn't have to be no fun and games at all.
Show appreciation for sacrifices: Thank employees' families when they've been working longer-than-usual hours.
Check your attitude: Are you "contagiously enthusiastic" about the important work you and your team is doing?
Give out lollypops to people who seem to be having a tough day: "You cannot crab with a lollypop hanging out of your mouth," Glanz says.
Bucyrus (OH) Community Hospital's HealthLink community outreach program manager Tammi Wolfe and Nate Roshon, PR and marketing coordinator at BCH, spoke at a session on community outreach, which helped change the perception of their hospital from a "Band-Aid factory" to the healthcare provider of choice in their market. BHC has enjoyed great success with its health events, which are eagerly anticipated and very well-attended in the community. Although the events themselves aren't free, they did offer some low- and no-cost ways to promote the events:
Listen up: Get to know and keep in touch with your community and what residents want.
Be creative: The hospital used prison inmates to help them paint wooden snowmen that decorate the hospital during the holidays. The materials cost $45.
Don't rely solely on traditional advertising: BCH found that ads in newspapers didn't attract nearly as many attendees as flyers in physicians' offices.
Keep those sponsors happy: Don't forget to invite VIPs from sponsoring companies and other stakeholders, such as board members, to events.
Talk up events all year round: Start promoting next year's event at this year's event to create buzz and generate word of mouth.
Note: You can sign up to receive HealthLeaders Media Marketing, a free weekly e-newsletter that will guide you through the complex and constantly-changing field of healthcare marketing.
Due to a $6 million deficit under the state's recently-enacted budget, the university will phase out its nursing program by May 2011—when all currently enrolled students complete their course of studies. SUNY New Paltz announced it will also eliminate 70 jobs and delay admission for other education courses at the university.
According to an article in the university's student newspaper, The New Paltz Oracle, President Steven Poskanzer stated the program which is offered only to licensed RNs or transfer students eligible for RN licensure was "expensive" and had low enrollment. Poskanzer also wrote in a campus e-mail that SUNY New Paltz had "difficulty recruiting, retaining, and awarding tenure to fully credentialed nursing faculty."
Still nursing faculty and students are upset with the university's decision to cut the program that has been in place for 30 years—a decision that may limit nurses' opportunities to expand their knowledge in the profession and further complicate the nursing shortage.
"All faculty and students are disappointed and shocked. There is no justification for this," says Eleanor Richards, PhD, RN, associate professor and chair of SUNY New Paltz's nursing department. "Many of the graduates of the master's program are recruited upon graduation to teach at area community colleges and students enroll in our RN to BSN program from seven community colleges in the Hudson Valley."
Richards refers to the nursing students as a nontraditional adult learner population who maintain full- and part-time positions in healthcare organizations and know they need to continuously improve their practice and ultimately patient outcomes.
"Data reported by the Healthcare Association of New York State show that 40% of RNs in the region hold the BSN," Richards says, adding that SUNY New Paltz is a major force to this percentage. "I have no doubt that the rank will drop dramatically and the quality of patient care will significantly decline."
And while Poskanzer stated the nursing program had low enrollment, Richards, who has been employed at SUNY New Paltz for 12 years, highlights its considerable growth. Enrollments for the university's BSN program, for example, almost quadrupled between 2003 and 2008. Other institutional data illustrates 432 BSN enrollments for the spring 2009 semester.
Richards says data comparing nursing to other departments at SUNY New Paltz of similar faculty size, enrollments, and generated revenue has not been transparent, but it would seem that nursing is likely to be no more costly.
"It is reasonable to believe that there are more expensive laboratories within the college. Three out of five faculty are on lecturer/instructor lines and carry an academic year credit load of 24 credits," Richards says. "Lower salary and increased workload would account for lower department expense."
The New Paltz Oracle reports Poskanzer said the college will honor all contracts with faculty and staff working in the nursing program. At the present, the nursing department has five full-time faculty members and one new faculty member will start working in the fall. Two adjuncts and one secretary are also employed. The college will transfer a secretary and one professor to another department of the college when the program wraps up.
The program will be funded by reserve money until it concludes.
"The administration has no plans to continue the nursing program and has not assumed a posture of listening to the 130 faculty and staff, students, alumni, healthcare consumers, and nursing organizations who disagree with the closure," says Richards, adding that SUNY New Paltz is the only campus in the state that plans to close their nursing program.
The normally bumpy road that is physician recruitment and retention can become pothole-riddled when the local economy turns sour. Now imagine your hospital is about 80 miles from Detroit. As the economy—and the auto industry—struggles, the healthcare environment is rapidly changing for Michigan hospitals, health systems, and physicians. However, Jackson's Allegiance Health has continued to employ successful physician recruitment, relations, and retention tactics even as the numbers of unemployed and, subsequently, the uninsured continue to climb.
"I've noticed the doctors are much more sensitive to their income," says Jerry Grannan, executive director of physician integration at Allegiance. "In our employed models, we try to emphasize the security aspects of it, like the automatic savings for retirement that we have. But we haven't seen big problems yet in docs reacting to the economy besides that."
But new recruits have different concerns than employed physicians. To counter primary care physicians' misperception that the growing number of uninsured means less business, Michael Houttekier, physician recruiter at Allegiance, stresses to potential primary care physician recruits that the area has an access-to-care problem and needs more doctors.
"Normally, when you present it like that to physicians, they see the longevity of themselves being a practitioner here, which ultimately overshadows the particular economic situation that we're currently in," Houttekier says.
Recruiting to retain
Allegiance's success boils down to a level-headed approach to recruitment and retention. Houttekier once hired a doctor from California who stayed only one year before returning home. He never made that mistake again. Now, he makes sure each recruit has a Michigan tie.
"You try to keep your strategies in line to recruit to retain, not recruit to just recruit," Houttekier says. "When you do that, you don't just get that warm body fill."
If new physicians have a preexisting Michigan connection, not only will they better integrate into the community, but they'll have a more accurate idea of what to expect.
"They come to the state knowing what they're getting into," Grannan says. "You can't come to Michigan and say, 'Oh my gosh, I didn't realize the economy was struggling.' They're coming for other reasons—proximity to family and all that. They know what they're getting into. And if they went into it strictly for economic reasons, they wouldn't come to the state, period."
Emphasizing new media
When filling a new position, Houttekier, who manages all physician advertising campaigns, doesn't believe in the blanket approach to marketing. He places ads in niche publications and Web sites, depending on the specialty he's hiring for, and has been dabbling in Facebook. He says any successful recruitment campaign must take advantage of new media, because younger and older doctors alike are computer savvy.
"Doing it electronically has spun off into Facebook. I think it will end up spinning off into MySpace to recruit physicians from there," Houttekier says. "I think it's the biggest media that we have at our fingertips, and it makes it relatively easy versus sending out a postcard to all the people." Houttekier uses postcards and other print materials (see the postcard featured at right and on p. 4) when appropriate, but tries to supplement them with online efforts. For example, an online streaming video of the health system's main facility is in the works.
"When we send out an e-mail blast or any type of literature in print, they can go on and log into the streaming video so they can actually see an advertising campaign for our facility," Houttekier says. "We have a brand-new heart center, a brand-new ED—things like that tend to increase someone's interest to say, 'Wow, this is a system on the move, and this is a place I'd really be interested to look at.' It kind of broadens your opportunities by doing something like that, plus it saves paper."
Keeping tabs on recruits
Once a new physician is hired, the responsibility moves from Houttekier to the physician liaison. Allegiance implemented an intensive follow-up process for new hires after some, such as the aforementioned California physician, left prematurely. A few years ago, the recruiter and liaison positions merged, but soon separated again once it proved to be too much work for one person.
"Our liaison goes out and keeps tabs on our new recruits for three years … to identify issues or concerns in real time—more than figuring out that there is a problem when they announce their resignation," Grannan says.
The liaison can take physician concerns directly to the CEO, if needed. Some of the most common issues are integration of physicians' spouses and children into the community and physicians' relationships with other doctors and staff members.
By recruiting using highly targeted ads, stressing the positives over the negatives, implementing selective hiring, and keeping track of new hires, the three-person Allegiance recruiting and retention team has created a system that remains strong even in today's uncertain economic environment. In the past four years, it has successfully recruited 54 physicians. Only six have left.
"The economy will end up turning around, so you have to look at the long-term in how you sell an opportunity," Houttekier says. "Try to focus on the future."
The Duluth (MN) Clinic Orthopedics department typically faces a lull from October to February. But instead of simply accepting that fact, the organization—which is part of the SMDC Health System in Duluth, MN—decided to do something about it. The team thought about patients who were putting off dealing with nagging bone and joint pain and asked itself: What is it going to take to get those people to call us?
The answer: Create an emotional connection with the target audience, and show they you understand their frustration, aggravation, and fear. In its submission essay, the SMDC marketing team wrote, "We wanted to raise awareness about the immediate access people in our region have to Duluth Clinic's … depth and breadth of orthopedic care, thereby gaining additional referrals."
The campaign, which won a gold award in the service line category at the 2008 HealthLeaders Media Marketing Awards, is also notable in that it had a relatively small budget. Using simple creative, including single-shot TV spots, the campaign came in under budget and still exceeded its goals.
The judges praised the campaign's emotional connection with the audience. "I really like this campaign," one judge said. "Its elements immediately caught my eye, and its theme will resonate with every aging adult who feels his or her bones aching. It's even better to learn that this was creative with such a small budget."
"Message, creativity, and objectives are all top notch," said another.
In the three months following the campaign, patient encounters in the department were up 14% when compared to the same period the previous year. The campaign surpassed its goal by 527 patients. The clinic saw 1,019 new patients and conducted 49 more surgeries.
This Campaign Spotlight was excerpted from Hospital Campaigns That Work, featuring the winners of the 2008 HealthLeaders Media Marketing Awards.
Lake Wales (FL) Medical Center patients are now more likely to be placed in a private room because of the hospital’s new wing with single occupancy rooms. The 32 rooms will be open to the public on Wednesday for an open house that also celebrates the hospital’s 80th anniversary.
Creating a strong brand message isn't enough in today's competitive market. Brands must be generous and provide an added value in the life of its audience, whether that value is related to entertainment, social, or beliefs. Consumers won't purchase a product merely because they recognize the label, they must have positive feelings associated with it.
Boston, the home of leading medical schools and hospitals, a high physician population, and universal healthcare coverage, also leads the nation's 15 largest cities with the longest waiting times to schedule a doctor's appointment, according to a new survey by physician recruiters Merritt Hawkins & Associates.
The survey of 1,162 medical offices also found that only 55% of physicians, on average, accept Medicaid patients because of the low reimbursements and filing hassles.
The survey tracks the average time needed to schedule a doctor appointment in five areas: cardiology, dermatology, obstetrics/gynecology, orthopedic surgery, and family practice.
In Boston, it takes 70 days to see an obstetrician/gynecologist, 63 days to see a family physician, 54 days to see a dermatologist, 40 days to see an orthopedic surgeon, and 21 days to see a cardiologist, according to the survey.
Philadelphia and Los Angeles are next on the list, with average doctor appointment wait times exceeding 45 days in some specialties, followed by Houston, Washington, DC, San Diego, Minneapolis, Dallas, Miami, New York, Denver, Portland, Seattle, Detroit, and Atlanta. Physician appointment wait times tracked in the survey varied from as little as one day to as long as one year.
"Finding an available physician can be challenging today, even in large urban areas where most doctors practice," says Mark Smith, president of Irving, TX-based MHA.
In 2006, Massachusetts implemented mandated health coverage for all residents, insuring hundreds of thousands of previously uninsured patients. Demand for doctors greatly increased, and even though Massachusetts has more physicians per population than any other state, patients are encountering more difficulty in scheduling physician appointments.
Smith says accessing physicians would be even more problematic for many patients nationwide if national universal health insurance is implemented.
Many physicians not accepting Medicaid
The survey also tracks which medical offices are accepting Medicaid. Minneapolis has the highest rate of Medicaid acceptance at 82%, Dallas the lowest at 39%. The overall Medicaid acceptance rate for all metro markets was 55%.
Many physicians are not accepting Medicaid because it often pays less than what it costs physicians to provide care.
"Merely having medical coverage does not always ensure access to a physician. Many doctors simply can no longer afford to see Medicaid patients," Smith says.
