St. Louis-area emergency rooms already burdened by an increase in uninsured patients are now facing a recession-spurred boom in business. For many local hospitals still grappling with capacity concerns, a crush of new patients who cannot pay for care could further strain an ailing safety net.
An anonymous Dallas donor has given $1.8 million to Parkland Health & Hospital System's Community Oriented Primary Care program. "The goal of Community Oriented Primary Care is to treat medical conditions before they become more severe or require a hospital visit, and this gift is a much-appreciated aid in achieving that goal," said Sharon Phillips, senior vice president of Community Medicine at Parkland. The donor sought to help people who've been laid low by the economic downturn.
Suburban Philadelphia healthcare provider Crozer-Keystone Health System is eliminating 400 jobs. The system has experienced a decline in admissions, a drop in outpatient volume, an increase in bad debt, and reductions in reimbursement from the state, according to a spokeswoman.
Ambulatory Services of America said that it has formed its seventh joint venture that offers cancer treatment services. ROSA of South Alabama LLC will own and operate four cancer centers in Gulf Shores, Brewton, Foley and Monroeville, AL. It is a joint venture among Ambulatory Services' subsidiary Radiation Oncology Services of America Inc. and Gulf Coast Cancer Center.
Iowa is facing a shortfall in the next budget year that some think will top $600 million, and in response Gov. Chet Culver has ordered immediate spending cuts and called for reductions. However, neither Culver nor Democratic lawmakers who run the Legislature have done anything to tamp down ambitious and costly goals for healthcare in Iowa. At the top of the list was an effort to ensure healthcare to nearly all Iowa children by 2010.
The Massachusetts Attorney General's office has announced Boston Medical Center has agreed to pay $600,000 to settle allegations it overcharged the state for emergency services provided to low-income patients. The hospital and its East Boston Neighborhood Health Center will also begin talks with the state about improving emergency services. Attorney General Martha Coakley's suit alleged Boston Medical overcharged the Massachusetts Uncompensated Care Pool for services provided at the health center from 2003 to 2006.
In this opinion piece for the Wall Street Journal, former senior official at the Centers for Medicare and Medicaid Services Scott Gottlieb says accumulating medical data shows that Medicaid recipients' poor health outcomes aren't just a function of their underlying medical problems, but a more direct consequence of the program's shortcomings. Gottlieb questions why Barack Obama now wants to build on this system despite its shortcomings.
The Joint Commission has announced that, as part of its application to the Centers for Medicare & Medicaid Services, a number of changes will be made to the accreditation process.
Many of the changes have resulted in added specificity to existing standards, though others have required the creation of entirely new standards. The new standards were released January 5, 2009, but went into effect January 1, 2009. These requirements will not be scored, however, until July 2009. The Joint Commission has a policy that it will, when possible, give its accredited organizations six months notice for new requirements.
Among the chapters hardest hit by these changes are the Leadership (LD) and Provision of Care, Treatment, and Services (PC) chapters. Record of Care, Treatment, and Services (RC) and Rights and Responsibilities of the Individual (RI) were also extensively reworked.
Industry experts have noted that many of the changes are requirements hospitals already meet due to existing state or other regulatory requirements. According to The Joint Commission's announcement, many of the requirements are already being met by accredited facilities.
"A lot of these [requirements] are current law or regulation," says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor.
Di Giacomo-Geffers suggests facilities compile a list of the changes to see which changes the hospital already complies with--a checklist of yes, no, or not applicable.
"If the answer is no, you're not complying with the requirement, then ask, what do we need to make this happen?" she says.
“Fortunately, at least on the Environment of Care side of things, the overarching take is that this is all stuff that is already (or should already be) in place by any organization that can be surveyed directly under the Conditions of Participation,” says Steve MacArthur, a consultant with The Greeley Company, a division of HCPro, Inc., Marblehead, MA.
For instance, MacArthur notes, the expansion of consideration of radiation as a hazardous material under EC.02.02.01 is a direct reflection of section 482.53(c) under the Physical Environment section of the COPs; likewise the change in language relating to equipment management and the qualifications of staff in the inspection, testing, etc. of nuclear medicine equipment.
Other experts see this as a black mark on The Joint Commission from the perspective of accredited hospitals.
"This type of action is what is going to be the catalyst in getting hospitals to go with another accrediting body," says, Dean Samet, CHSP, director of regulator compliance services at Smith Seckman Reid, Inc., based in Nashville.
Like the smothering Vandal horde that plagued Europe nearly two millennia past, recovery audit contractors will soon swoop down on your hospital, thumb through your records, slosh coffee rings on the paperwork, and pore through every Medicare bill you've filed in the past few years, hoping to earn a commission of between 12 cents and 15 cents for every dollar they find that you've allegedly overcharged the feds.
OK. I hyperbolize. Not all RACs drink coffee.
The fact remains, RACs are coming—if not this year, then next year as the pilot program expands beyond the test states of New York, Florida, and California. And they will be authorized to look through your Medicare filings with a start date of Oct. 1, 2007.
Are you ready?
John Dugan, a consultant for the Health Industries Sector at PriceWaterhouseCoopers, has worked with hospitals involved in the RAC pilot program, and he recommends having a strong multidisciplinary team in place to deal with records requests and challenges.
"We believe there should be an organized RAC committee in each hospital with one individual on point for the organization," Dugan says. That team typically includes representatives from finance, compliance legal, case management, health information management, and a physician liaison. It might be a little tougher for smaller hospitals to assemble such a team or add new staff, Dugan concedes, which may mean an increased workload for existing management.
RACs are permitted to select up to 200 records every 45 days for an inpatient hospital. "You have a tremendous amount of volume coming through and data-gathering that needs to be produced to make sure you are filing on a timely basis," Dugan says. And with a strong multidisciplinary team in place "you've got the perfect protocol to handle appeals successfully," he says.
Many challenges to Medicare billing fall in the gray areas of medical necessity and medical judgment, and Dugan says that's why it's imperative to have a physician on your team who understands the particular medical issue under scrutiny, a case management officer who understands your hospital's quality policies, and a finance officer who understands the reimbursement impact associated with an adjustment. "When we say 'multidisciplinary,' we mean don't make the mistake of putting in one person's hands what a team should be doing so you are getting the best outcomes," says Dugan, who also recommends building a control mechanism to deal with RAC records requests.
Hospitals should also understand their potential reserve requirements and establish a fund for Medicare overpayments. This is tricky, both in terms of finding money for a reserve fund and determining the appropriate amount. If a hospital proactively attempts to understand its potential liability through a self-audit, for example, that hospital then becomes liable — under the False Claims Act —for overpayments it finds. That also opens the door for a deeper RAC audit.
"It's a tough balance from running a limited sample to understand processes, to doing something significant and having a high enough error rate that you've got bigger obligations that are beyond those claims you just looked at," Dugan says. "Hospitals need to think through their objectives for managing risk. You don't want to examine the records, have your findings, and then say 'Oh, what did we do!'"
Rather than delving too deeply into the past, which can't be corrected and which the RACs will probably find anyway, Dugan recommends focusing on the present and reviewing internal controls that are now in place around risk areas. "If I'm a CFO, I want to mitigate my risk, but I don't necessarily want to turn over money to the government that I wasn't necessarily obligated to do previously," he says. "If I'm focusing on short-stay admission, maybe I don't want to look at medical records. What I may want to do is look at my current processes and internal controls and strengthen them going forward."
If you don't have the time, data, or resources to estimate the value of your reserve fund, Dugan suggests an amount representing 2% of Medicare revenues, which he concedes is still a lot of money, especially in these tough economic times.
As arduous as the RAC process may be for larger facilities, Dugan says it could be even tougher for community and rural hospitals, both in terms of resources constraints and financial pressures. Small hospitals may not have the extra bodies needed to throw at a RAC review, and they definitely don't have the operating margins. In addition, Medicare usually makes up a larger percentage of the patient load in smaller and rural hospitals, where fewer treatment options could also raise red flags about medical necessity. "If you've got a patient who shows up at the ED on Friday night without a primary-care physician and no processes in place or other alternatives, that patient will likely be admitted," Dugan says. "It will be interesting to see if the RAC treats this group of hospitals any differently."
John Commins is the human resources and community and rural hospitals editor withHealthLeaders Media. He can be reached atjcommins@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media Community and Rural Hospital Weekly, a free weekly e-newsletter that provides news and information tailored to the specific needs of community hospitals.
The hospital industry is in the middle of a storm—a "quest for quality" storm. As government and other industry groups continue to make changes and issue mandates aimed at improving care practices and quality in America, hospitals need to closely look at report cards as a tool to document their course through the storm, toward improvement and best possible care.
Today, hospitals mostly leverage report card services conducted by organizations such as Hospital Compare, Consumer Checkbook, and Health Grades Inc. Still other organizations develop their own report cards based on data assembled by outside organizations such as those mentioned above plus the National Voluntary Hospital Reporting Initiative, Select Quality Care, the Leapfrog Group and the Health Care Acquisition Performance System (HCAPS). Whatever route your organization uses to collect and display its quality improvement information is fine, but is your organization smartly reporting the data?
While the report card concept can be painful and the process to develop one can be even more agonizing, they are a great opportunity for telling and documenting your hospital's quest for quality and, eventually, your hospital's arrival.
Report cards should tell a story
Consumers—past patients, future patients, family members, friends—physicians and others eagerly look through report cards to see how a particular hospital is performing in a certain category or measure and to see what they are doing to improve. Report cards should not just list numbers/data such as average wait time in the emergency room and number and type of hospital-acquired infections in a certain period. Rather report cards should tell a story – a story about what your hospital is doing to achieve quality.
Report cards should contain detailed information and explanations about various clinical performance initiatives that are underway throughout the organization. For example, talk about national or regional programs your hospital is participating in to improve performance in a certain clinical condition, such as VHA Inc.'s (the national health care alliance) New England region Rapid Adoption Network for pressure ulcers, the Institute for Healthcare Improvement's 100 Lives from Harm Campaign or the Centers for Medicare and Medicaid Services (CMS)/Premier healthcare alliance Hospital Quality Incentive Demonstration. Your patients or potential patients already are reading about these programs in the media; why not tell them about how your hospital is participating in these programs?
Don't limit your quality story to what you're doing with organized groups, but also include what your hospital is doing on its own. What kinds of systems, protocols and procedures has your facility implemented to ensure service excellence? What is your hospital doing to improve wait times? Tell us. If your surgical teams take 10 minutes before making an incision to review out loud what area of the body is being operated, whether antibiotics have been administered one hour prior to incision, and whether the area has been decontaminated, then say so in your report card. Anything that your facility is doing or any program your facility is participating in or developing to improve the quality of care for its patients has a place in your hospital's report card.
Review community newsletters, your local newspaper and blogs to see what is being said about your hospital. Address these issues in your report card to support or correct any erroneous information that might be circulating in your market.
Don't limit your quality story
Finally, don't limit your quality story to report or score cards. Leverage your hospital's newsletter, community education programs and materials, and physician and service line communications as vehicles to tell your story. Make your report card visually stimulating. Use imagery and photography to help convey your story and passion for delivering quality care. Include photos of actual hospital staff so that consumers can identify these persons as they walk through your facility. It will help to build a personal connection and brand loyalty.
Unfortunately, stories about hospital and medical errors, poor conditions and/or treatment etc. appear daily. Hospital quality is a serious issue to consumers and a scary topic to consider as a patient or friend of a patient-to-be. Hospitals need to communicate about their quality efforts and achievements.
Used correctly, hospital report cards prove and demonstrate that your hospital is set on a course towards clinical quality improvement. Whether your hospital uses an outside source or chooses to develop its own report card, make sure the information contained is simple, not complicated to interpret, and clearly tells your hospital's quality story—what's been done, what's underway, what's next. Don't miss the opportunity to use your hospital's report card smartly and use it to demonstrate your organization's quality improvement journey.
Veronica Hunt is account supervisor at the public relations firm CRT/tanaka, headquartered in Richmond, VA. You may contact her at VHunt@CRT-tanaka.com.
For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
