The H1N1 flu is expected to hit hard this fall. Healthcare professionals, for obvious reasons, are particularly susceptible to falling ill at a time when hospitals are having a hard enough time finding adequate staff. With this in mind, it's time for states or the federal government to mandate vaccinations for healthcare employees with direct contact with patients.

Consider the case of Seattle-based MultiCare Health System. The four-hospital system recently ordered its healthcare professionals with direct patient contact to either get an H1N1 vaccination, use a flu mist, or wear a protective face mask.

MultiCare says the policy was implemented in the best interests of patient safety, and is based on the recommendation of a team of physicians, nurses, and infection control experts. "As always, our first priority is patient safety. We developed our flu policy to protect our patients, visitors, and staff during this heightened flu season," MultiCare says in a media statement.

This all seems reasonable enough.

Not so, says the Washington State Nurses Association. The 16,000-member union has filed a federal lawsuit against MultiCare, claiming that the health system was "unilaterally implementing a mandatory vaccination policy," threatening to fire employees who don't comply, and thus violating the bargaining agreement with the union. Barbara Frye, RN, WSNA's assistant executive director of labor relations, says the union was trying to negotiate a vaccination policy with the health system when it took the action on its own.

"MultiCare's unilateral implementation of this policy blatantly ignores their legal obligation to bargain with the union," Frye says. "Their refusal to bargain and to cease and desist forced us to take this extraordinary measure to seek relief from federal court."

WSNA says it fully supports a voluntary vaccination program and is urging its members to get vaccinations. The union is not opposed to mandatory vaccinations if they are uniformly applied. "We believe that any mandatory vaccination policy should be implemented on a federal or state level, not through a patchwork of hospital-by-hospital policies," says Judy Huntington, RN, executive director of WSNA.

WSNA is also questioning MultiCare's insistence on the use of masks for nurses who refuse to be vaccinated, even though the union says there is no evidence that the masks prevent influenza transmission.

"In fact, masks can give a false sense of security for nurses, patients, and their families. Unfortunately, MultiCare's focus on masks is not based on evidence or research," Frye says.

This too seems not unreasonable.

In fact, it's hard to find fault with either side in this issue. There are no black hats here.

Here's my take: First, let's acknowledge that MultiCare and WSNA believe they are acting in the best interests of patients and healthcare professionals.

Small picture: MultiCare is correct. It acted because of the seriousness of H1N1 and because there was no controlling authority above it to mandate vaccinations.

Other small picture: WSNA is correct. The union sued because a unilateral mandate on vaccinations violates the bargaining rights of employees and could set a mandate for future unilateral actions.

Large picture: A government mandate on vaccinations for healthcare workers is needed. Hospitals should not respond to H1N1 in a patchwork fashion. Not only is it confusing, it's ineffective.

This is an issue that won't pass when H1N1 runs its course. This year it's H1N1. Next year, who knows? Avian flu? Contagious disease experts have been saying for years that it's not a question of "if" but "when" the nation confronts a major influenza pandemic or epidemic. Healthcare workers will be on the front lines when that happens. They need to be protected, both for their own sake, and for the sake of patients. Let's take the patchwork out of this.

The Centers for Medicare and Medicaid Services (CMS) needs to do a better job "of providing guidance and regulatory enforcement" for detecting the abuse of controlled substances by Medicaid beneficiaries, said Sen. Thomas Carper (D-DE), chairman of the Homeland Security and Governmental Affairs subcommittee on federal financial management, at a hearing last week.

In a report to the committee, the General Accountability Office (GAO) found in an analysis of Medicaid claims from five states—California, Illinois, New York, North Carolina, and Texas—that thousands of Medicaid beneficiaries and providers were involved in purchasing controlled substances fraudulently through the Medicaid program, Carper said.

In one instance, GAO found 65 medical providers and pharmacies in the states previously had been barred or excluded from federal healthcare programs, including Medicaid, when they wrote or filled Medicaid prescriptions for controlled substances—which act as painkillers, sedatives, and stimulants—during fiscal 2006 and 2007. However, Medicaid approved the claims at a cost of approximately $2.3 million.

On the other side, GAO found that approximately 65,000 Medicaid beneficiaries in the five states investigated had visited six or more physicians to acquire prescriptions for the same type of controlled substances in the selected states during fiscal years 2006 and 2007. These individuals—many of whom may have been involved in "doctor shopping"—incurred approximately $63 million in Medicaid costs for the drugs.

Some beneficiaries may have justifiable reasons for getting prescriptions from multiple medical practitioners—such as visiting specialists or several doctors in the same medical group. However, analysis of Medicaid claims found at least 400 of them visited 21 to 112 medical practitioners and up to 46 different pharmacies for the same controlled substance, Gregory Kutz, managing director of GAO's Forensic Audits and Special Investigations unit, told the panel.

About 1,800 prescriptions were written for dead patients at a cost of more than $200,000 and another 1,200 prescriptions were "written" by deceased physicians in which Medicaid paid about $500,000 in Medicaid claims based on controlled substance. Kutz said GAO's analysis probably understates the instances and dollar amounts involved.

Kutz said the states need to continue efforts to monitor the execution of the prescription program—including matching Medicaid beneficiary files with third-party databases to determine eligibility and evaluate compliance.

While states are working to prevent Medicaid prescription abuse, a number of "significant issues" still need to be addressed," said Ann Kohler, director of the National Association of State Medicaid Directors. Many states are being hampered by tight state budgets that are slowing efforts to obtain technology-related improvements to detect fraud, she said.

Hospital readmissions, adverse events, and issues related to the American Recovery and Reinvestment Act of 2009 are some of the highlights of the 2010 OIG Work Plan.

"These are relatively new issues so this is pretty proactive on the OIG's part," says Steve Miller, JD, chief compliance and privacy officer at Capital Health in Trenton, NJ.

In previous years, many of the OIG's planned reviews were on topics that have been around for a while, such as bad debt, Medicare secondary payer, and wage indices.

"They're getting a jump on these newer issues right away," Miller says. This is a good move, he adds, because newer issues tend to present a higher opportunity for errors.

In the 2010 Work Plan, the OIG grouped ongoing and planned reviews into two major parts:

• CMS: Reviews related to Medicare, Medicaid, information systems controls, the Children's Health Insurance Program, and related investigation and legal counsel to OIG.
• Public Health and Human Services Programs and Department-wide Issues: Reviews related to agencies, such as the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, the Administration on Aging, and the Administration for Children and Families. This part also describes department-wide issues, such as financial accounting and information systems management.

Hospital readmissions
In 2004, CMS implemented an edit to reject subsequent claims for beneficiaries whom the hospital readmitted on the same day. According to the Medicare Claims Processing Manual, if a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay's medical condition, the hospital is entitled to only one DRG group payment and should combine the original and subsequent stays in a single claim. The OIG plans to test the effectiveness of this edit and determine the extent of oversight of readmission cases.

"It's interesting because this is an issue that is getting more attention from CMS this year," Miller says. In fact, in April, CMS announced a pilot program "Care Transitions" to focus on eliminating unnecessary hospital readmissions.

This is not only a quality of care concern, but also a hospital efficiency problem, says Marta G. Hernandez, BPS, HSA, CHC, RHIT, senior auditor in Miami.

"Most facilities that are efficient have been found to have a higher standard of patient care," she says. "This then results in better patient outcomes and less readmissions for the same conditions."

Adverse events
In the 2009 Work Plan, the OIG included a review of payments for and incidences of never events, focusing on CMS' administrative processes regarding detection of never events and payment. This year, it included five different reviews, using the term "adverse" events instead, to include hospital-acquired conditions (HAC). These reviews include:

• Hospitals: National incidence among Medicare beneficiaries—The OIG will employ a panel of physicians with expertise in patient safety to estimate the national incidence of adverse events, identify the type of event, and assess if the event was preventable.
• Hospitals: Methods to identify events—This review will examine methods of identifying adverse events, including:
  • Medical records reviews by both nurses and physicians
  • Administrative data analysis using the Agency for Healthcare Research and Quality's patient safety indicators and present on admission (POA) indicators
  • Hospital incident reports
  • Interviews with Medicare beneficiaries or their representatives
• Hospitals: Early implementation of Medicare's policy for HACs—The OIG will review CMS' administrative process, including how it identifies HACs and denies reimbursement for related care.
• Hospitals: Responses by Medicare oversight entities—In this review, the OIG will look at how state survey and certification agencies, state licensure boards, and Medicare accreditors responded to adverse events in hospitals.
• Public disclosure of adverse event information—This is another review of CMS policy and procedure, as well as selected patient safety organizations. The OIG will look at how these organizations handled the disclosure of information and patient privacy.

These detailed reviews show that the OIG is serious about analyzing how many adverse events are occurring across the nation and how all involved parties are handling the events from beginning to end, Miller says.

"They're really looking at that process from a lot of angles," Miller says.

Also, this is another quality of care issue, Hernandez says. The results of adverse events can be devastating for both the patient and the providers. Therefore, she says, the OIG must determine whether CMS is doing its job of enforcement so that facilities understand the repercussions of having an adverse event.

"If CMS pays for the [adverse event], there is no incentive for the facilities to improve," she says.

Hospital admissions with conditions coded as POA
According to the Work Plan, acute care hospitals are required to report on their Medicare claims which diagnoses were POA. The OIG plans to determine how many diagnoses were coded as POA and which diagnoses were coded most frequently as POA.

American Recovery and Reinvestment Act of 2009
This section of the Work Plan includes reviews of the many areas affected by this new act, passed by Congress on February 13, 2009. Top concerns include:

• Breach notification and medical identity theft in Medicare: This review will look at CMS' compliance with new breach notification requirements for personally identifiable information (PII). Section 13402 of the Recovery Act requires entities covered by HIPAA to notify individuals of PII breaches, which can lead to medical identity theft. The OIG also plans to examine CMS' internal procedures and processes related to the breach notification requirements.
• Medicare incentive payments for electronic health records (EHR): Sections 4101 and 4102 of the Recovery Act authorize incentive payments over a five-year period to physicians and hospitals that demonstrate meaningful use of certified EHR technology. The OIG will review Medicare incentive payment data from calendar year 2011 to identify erroneous payments. If the OIG identifies errors, it will assess CMS' actions to correct these mistakes.

With the federal government issuing great sums of money for EHR implementation, this project is open to scrutiny, Hernandez says.

This is also another example of how the OIG is being proactive with newer issues, scheduling the EHR incentive payments review ahead of time, Miller says.

Create your audit plan for 2010
As you're reading through the Work Plan, think about which reviews apply to your facility or practice. Include these reviews in your own audit plan to gauge your facility's compliance.

For example, "if you've had any adverse events involving a Medicare patient in the last year, you might expect the OIG requesting the record for that event," Miller says. In this example, review that case?determine how preventable the event was and how your staff members handled it. This will help you know what to expect and show government auditors that you and your staff members responded appropriately.

The Office of Inspector General (OIG) released its fiscal year (FY) 2010 Work Plan October 1, which listed the issues OIG plans to investigate in the coming fiscal year, including a variety of focus areas related specifically to nursing homes.

All nursing homes should be aware of the issues included in the Work Plan and ensure they are complying with the regulations. Otherwise, facilities run the risk of being audited by the OIG.

Some of the nursing home issues included in the FY 2010 Work Plan are:

Part B services: Mental health needs and psychotherapy. OIG plans to review Medicare Part B payments for psychotherapy services provided to nursing home residents during noncovered Medicare Part A skilled nursing facility (SNF) stays. A previous OIG review found that approximately 31% of outpatient claims for Part B mental health services allowed did not meet coverage guidelines, resulting in $185 million in inappropriate payments. OIG will determine the medical necessity of services, appropriateness of coding, and adequacy of nursing home documentation.

Medicare requirements for quality of care in SNFs. OIG will assess how SNFs have addressed certain federal requirements related to quality of care. Specifically, OIG will determine the extent to which SNFs:

• Developed plans of care based on assessments of residents
• Provided services to residents in accordance with these plans of care
• Planned for residents' discharges

OIG will also review SNFs' use of the Resident Assessment Instrument (RAI) to develop nursing home residents' plans of care.

Accuracy of SNF resource utilization groups (RUG) coding. OIG will review SNF claims for Medicare reimbursement to determine the accuracy of RUG coding. In 2006, OIG reported that 22% of claims had RUGs associated with higher payment rates than those generated in and supported by patients' medical records.

Nursing home emergency preparedness and evacuations during selected natural disasters. OIG will review nursing homes' emergency plans and emergency preparedness deficiencies cited by state surveyors to determine the sufficiency of the nursing homes' plans and implementation of the plans. In 2006, OIG reported that nursing homes in certain Gulf states had plans that lacked a number of provisions suggested by emergency preparedness experts and that staff did not always follow emergency plans.

Criminal background checks for nursing facility employees. OIG will determine the extent to which nursing facilities have employed individuals with criminal convictions.

Oversight of poorly performing nursing homes. OIG will review CMS' and states' use of enforcement measures to determine their impact on improving the quality of care beneficiaries received in poorly performing nursing homes and the performance of these nursing homes. OIG will examine enforcement measures and determine the extent to which CMS and states follow up to ensure that poorly performing nursing homes implement plans of correction.

Part B services in nursing homes. OIG will review the extent of Part B services provided to nursing home residents whose stays are not paid for under Medicare's Part A SNF benefit and assess patterns of billing among nursing homes and providers.

Nursing home residents aged 65 or older who received antipsychotic drugs. OIG will review the extent to which nursing home residents aged 65 or older received selected antipsychotic drugs in the absence of conditions approved by the Food and Drug Administration. OIG will also examine Medicare Part D and Part B program reimbursements for selected antipsychotic drugs received by elderly nursing home residents and the extent to which these drugs were prescribed and paid for in accordance with federal regulations.