The Centers for Medicare & Medicaid Services (CMS) recently released Transmittal R51SOMA, which provides a thorough explanation of the skilled nursing facility (SNF) infection control requirements and components of an effective infection control and prevention program. The transmittal relocated Federal Tags (F-tags) 442, 443, 444, and 445 to F441 and revised the guidance included in F441. F-tags provide investigative protocols and clarification of CMS regulations for long-term care surveyors.
The revisions, which take effect September 30, do not include any CMS regulatory changes. However, the level of detail included in the guidance is substantial.
The transmittal, which issues policies in regards to infection control programs, preventing the spread of infection, and the handling, storing, processing, and transporting of linens, also provides CDC definitions, investigative protocol for surveyors, and compliance criteria, as well as a brief overview of the role infections play in nursing facilities. The latter cites infections as the reason for almost half of all resident hospital transfers, resulting in "an estimated cost of $673 million to $2 billion annually."
SNFs will have to look at their infection control and prevention programs and determine what needs to be changed to comply with the revised guidance. "Since there is always the potential for harm with failed infection control and prevention practices, the lower deficiencies (A-C) do not apply to this F-tag. Facilities will receive higher deficiencies (D-L) for noncompliance," says Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, a clinical services consultant at LTC Systems, a long-term care clinical consultant firm in Bella Vista, AR, and an HCPro Boot Camp instructor.
Most facilities will have to develop a more thorough infection control program, educate staff across all departments, and constantly monitor infection control and prevention efforts.
"The nursing home environment is very fast-paced and it is not uncommon for nurses and nursing assistants to forget to change gloves or clean equipment in between residents," Rubertino says. "Even though the guidance does not take effect until the end of September, facilities should start preparing now because the practices and procedures have to become habits for all staff members."
The new guidance comes at a time when providers are preparing for a potentially virulent flu season. In addition to a rise in cases of the traditional flu, this flu season may facilitate the spread of the H1N1 virus (also known as the swine flu), which the World Health Organization declared a global pandemic on June 11.
The Joint Commission has again received deeming authority from the Department of Health and Human Services' Centers for Medicare & Medicaid Services for the accreditation of critical access hospitals, according to an official announcement by The Joint Commission.
CMS determined that critical access hospital standards established by the Joint Commission met or exceeded standards established by the Medicare and Medicaid programs. With this approval, any critical access hospital the Joint Commission has accredited may choose to be "deemed" as meeting Medicare and Medicaid certification requirements.
Critical access hospitals have no more than 25 acute care beds and the average length of stay lasts no more than 96 hours. Normally, these hospitals receive cost-based reimbursement from Medicare, and are usually not more than 35 miles from another critical access hospital. While accreditation is completely voluntary, seeking deemed status through accreditation is an option.
"Critical access hospitals are an important safety net," said Mark Felletier, RN, MS, executive director, Accreditation and Certification Services, The Joint Commission, in an official statement. "The Joint Commission is pleased to collaborate with CMS to provide quality oversight for these important providers of rural health care."
The CMS notice of approval will be effective through November 21, 2011.
The Joint Commission also has deeming authority for ambulatory surgery centers, durable medical equipment suppliers, home health, hospice, hospitals and laboratories.
In this blog post, pathologist Seymour Handler, MD, says cost inflation is "the most important problem facing healthcare in the United States." He outlines a few key factors in our healthcare system that contribute to this challenge, including public perception of what medical care can offer and entrepreneurial zeal.
During these tough economic times, many competent hardworking people have been laid off. It's likely you know some at your company or organization who have gotten the ax simply by being in the wrong place at a time of severe budget constraints.
But what I'm writing about today often happens regardless of the economic climate. As a member of the senior leadership team, what happens to you if your CEO gets canned?
Don't tell me you haven't thought about it. If you haven't, you should. The new leader is going to want to make some very substantive changes right away. Will getting rid of you be one of them, or will you be on the new team?
The thought came to me as we've been observing a change in leadership locally at Vanderbilt University Medical Center. Though VUMC's vice chancellor for health affairs (equivalent to hospital CEO in most instances) didn't get canned at all (he retired), his replacement, Jeff Balser, who's a smart and talented man that has his own ideas on how to run the system, has wasted no time in elevating some people in the organization to the top echelon. Meanwhile, some have "announced" they will be leaving.
How do you make sure that in a similar case, you're not the one making that "announcement?" In short, you can't. There are no easy answers here.
Objectively, you may have done the best work anyone's ever done in your position, but often politics are involved. Maybe the new CEO has worked on the same team as you, and you don't get along. Maybe she has someone in mind that she's worked with before who is able to hit the ground running. She doesn't have to develop a working relationship with that person. Maybe he's one of those "change is good" people who just want a clean slate in your area of expertise. Those scenarios you can't do anything about.
If having twins has taught me nothing else, it's allowed me to focus on things over which I have some control. But even if your CEO seems secure and is pleased with your work, you should prepare for the fact that he will be leaving sometime. It may be 10 years from now. He might get hit by a bus tomorrow. You should be ready for the "hit by a bus" scenario.
Before the new CEO makes any final decisions, he will want to meet with you. Make no mistake, this is a job interview. So follow the Boy Scout Motto: Be Prepared.
Here's what you should be able to do shortly after the new CEO takes over:
You can defend the work you're doing, whether it be weathering a financial downturn, reorganizing processes to make them more efficient, or building a sense of teamwork in your department. Document those successes.
You can think about what you would ask about if you were in the CEO's shoes, trying to determine whether to keep you on the team after the transition. Anticipate those questions, and have answers ready.
You can justify the money you're spending on certain initiatives
You can develop a culture of teamwork within your department and in conjunction with other departments.
You can build collaborative relationships with your fellow department heads. It's rare that new bosses sack everyone in the previous leadership team. Those who will remain are your allies in helping the CEO make the decision whether to keep you or not.
Just don't get too comfortable. Remember, there's always someone who thinks they can do their job better than you. Your job is to let the new CEO know that no one can.
If you don't, whether they can do your job better or not, they may get that opportunity.
Editor's Note: You can read about HealthLeaders Media's take on the annual American Hospital Association's Leadership Summit. I attended the event, along with my colleague Jim Molpus, and we have been blogging live from San Francisco.
Note: You can sign up to receiveHealthLeaders Media Corner Office, a free weekly e-newsletter that reports on key management trends and strategies that affect healthcare CEOs and senior leaders.
Senate Democrats announced Thursday that they will not meet their self-imposed August 7 deadline to vote on a marked-up healthcare reform package on the Senate floor. No announcement has been made yet on whether the House will vote by July 31—its selected deadline.
However, the lack of hearings since Monday by the House Energy and Commerce Committee on the Tri-Committee's reform bill (H.R. 3200) may imply that momentum has slowed down on the House side as well to get a bill voted on by Congress' summer recess.
President Obama, hosting a town hall meeting outside of Cleveland on Thursday, said of the delay: "That's OK, I just want people to keep on working." However, Obama emphasized that he wants the legislation to be "done by the fall."
So what has slowed down the process? Here are five reasons:
1. These bills are immense. One thing that can't be disputed by either Democrats or Republicans is that all reform legislation introduced has been lengthy and detailed. The initial House bill, issued July 14, for instance, is more than 1,000 pages long—or one ream of paper printed on both sides.
In between meetings on Wednesday with the Senate Finance Committee—which has yet to introduce its legislation—Sen. Kent Conrad (D-ND) seemed nonplussed that the committee has not produced a bill yet. He talked about the immensity of the reform legislation and the "levels of complexity" that are "just beyond typical legislation."
2. "Blue Dogs" make themselves known. Currently, there are 52 self-proclaimed fiscally conservative Democrats in the House that call themselves "Blue Dogs." In a House controlled 256 178 by Democrats, the Blue Dogs—if they stick together—could be a formidable voting block for (or against) the legislation. They have become more vocal in asking House leadership and the President to listen to their ideas about ways to hold down health costs and finding innovative ways to deliver healthcare.
3. Debate about public insurance plan. From the beginning, this has been a hot button item. The option is included in the House and Senate Health, Education, Labor and Pensions Committee bills. While some senators have said they would not vote for a bill without the option, a number of "centrist" Democratic lawmakers have voiced their reservations about the idea, including Sen. Ben Nelson D-NE), Sen. Mark Pryor (D-AR), Sen. Blanche Lincoln (D-AR), and Sen. Mary Landrieu (D-LA) Louisiana, as well as former Democratic Sen. Joseph Lieberman (I-CT).
4. Questions about how exactly should pay. A surtax on millionaire families is one of the ideas being considered in the House. Legislation passed by House Ways and Means last week called for a surtax on families earning $350,000-plus, but House leaders have said that could be rolled back.
The Senate Finance side reportedly has been cool about any type of surtax. The committee had been looking at limiting tax exclusion on higher income individuals but has moved away from that idea.
5. Disallowed savings stall process. In June, the Congressional Budget Office said that only a "subset" of the initiatives proposed by major healthcare groups including the American Medical Association, the American Hospital Association, and America's Health Insurance Plans could result in meaningful savings to be incorporated into CBO health reform cost estimates.
Most of the proposals were for steps that did not require the federal government involvement or "are not specified at a level of detail that would enable the CBO to estimate budgetary saving," CBO Director Doug Elmendorf wrote. This meant, especially for the Senate Finance Committee, going back to the drawing board to find ways to meet the 10-year, $1 trillion-plus price tag of healthcare reform.
Robert Reich may be short in stature, but he's not above poking fun at himself, or the healthcare industry.
"The economy wore me down," said the diminutive former Clinton administration labor secretary, who now is professor of public policy at the University of California, Berkeley. "Eighteen months ago I was six-foot-two."
In one of the two keynote speeches at the American Hospital Association's annual Leadership Summit in San Francisco, Reich told the crowd of about 1,000 senior healthcare leaders that the economy's recovery will come soon, but it'll be shallow, and he's not ruling out a further dip later on, simply because the American consumer is tapped out.
"I wish I could be more positive," he said. "The banking crisis is not over. Rallies peter out because they're not based on fundamentals." He said the dominant view that the economy is recovering leaves out the fact that 70% of the economy is the consumer, and consumer spending isn't coming back anytime soon.
So regardless of whether a healthcare reform bill gets done this year or not, healthcare's in for a long period of likely declining reimbursements, so Reich told leaders to prepare to seek cost reduction through a program of cost reduction.
As healthcare spending by individuals goes up, consumers are burdened to a greater extent, he said. Healthcare eats into the pocketbooks to a greater extent than ever before. Now it's 16% of the GDP; 20 years ago it was 8%.
He predicts further stimulus will be needed, going so far as to predict that in 2010, as midterm elections approach, legislators fearful of losing will push through a tax holiday on the first $15,000 of personal income, giving a short-term boost to the economy. But don't expect that to help healthcare much.
Pressures to restrain healthcare costs and to improve quality are only going to increase, regardless of the way healthcare reform is enacted, he said.
"Families just won't be able to afford it." Capitation, even if it's called something else, is likely.
"Here's a piece of good news to leave you with," he said, concluding the speech. "You are all in a position of leadership in your industry. The easiest time to make fundamental reform is when times are bad and pressures are building," he said. "Past success is an enemy of change, and these tough times fortify you as a change agent. You are now authorized."
Notes:
Three hospitals were honored for leadership and innovation in quality, safety and commitment to patient care. The AHA-McKesson Quest for Quality Prize was awarded to Bronson Methodist Hospital in Kalamazoo, MI; Beth Israel Deaconess Medical Center in Boston was honored as a finalist. Duke University Health System in Durham, NC, received the Citation of Merit.
Jeffrey Selberg, President and CEO of Exempla Healthcare in Denver, moderated a panel of representatives of the winning hospitals and health systems. All three systems have made huge strides in quality in the past few years. One of the most interesting questions in the session came from Selberg, when he asked the three representatives if they'd ever had a moment when they wondered if the quality drive was "worth it."
Frank Sardone, president and CEO of Bronson Methodist: "We made the difficult decision to try to move the medical staff from being a political entity to being solely focused on patient care." There were times when that was a difficult journey, he said.
Kenneth Sands, MD, Senior Vice President, Department of Healthcare Quality, Beth Israel Medical Center, Boston: "We had a wrong-site surgery a couple of years ago. It was a big learning lesson. The rest of the organization needed to hear about it. We communicated it broadly throughout the organization. The decision to do so took about five minutes. Five years ago, the decision also would have taken five minutes, but the decision would have been a completely different.
Kevin Sowers, interim CEO and COO of Duke University Hospital: "We had a transplant mistake. We were challenged as leaders to find different safety issues we weren't aware of. We decided to share the mistake with front-line staff. Legal and risk management didn't want to, for good reasons. That was when I wondered if it was worth it. That difficulty is all worth it now, but it was a challenge at the beginning."
Management guru-visionary-grump Tom Peters told the assembled leaders of the American Hospital Association's annual Leadership Forum Thursday that they have no more excuses for poor performance. He had personal evidence. He spent 5.5 hours recently waiting in an emergency room while his wife suffered from a broken ankle.
While referring to the facility only as "a top hospital you will just have to figure out on your own," he recalled the four-minute interactions with a variety of physicians, and the terse, unsympathetic "no" he got when he asked if his wife could have some water. Peters said he understood that emergency rooms had to prioritize based on the acuity of patients brought in, but that alone could not justify why the visit was so poor.
"It was not a great experience. It was an awful experience," Peters said.
Peters—who describes himself alternately as a German engineer and a statistician hobbyist—said that the nationwide variations in hospital performance were not justified based on circumstances, singling our performance leaders such as Geisinger and Griffin Health as examples of health systems that have excelled in service and outcomes despite having the same constraints facing most of the nation's hospitals. "You just can't explain it away," he said.
So Peters offered his own list of "Principal Management and Leadership (as opposed to policy) Issues":
Should we be doing what we are doing? Will it work? How do we know?
Are we doing what we decided to do safely?
Do we do too much—are we in the overuse category as determined by agreed-upon standards measures?
Are we doing what we are engaged in doing effectively by local standards, by global standards (as determined by best practices, best hard evidence and minimal internal variation) in terms of quality, safety, and cost?
Is the situation systematically organized to very consistently deliver the goods in more or less optimal fashion (low variation)?
Do all the bits talk to-engage-consult obsessively with the other bits? Is the delivery turnkey?
Are the patient and the patient's family at the epicenter of the universe?
Is the institution acknowledged as a best place to work?
Do we acknowledge that the people issues-capabilities involving the entire staff affect the outcomes far more than capital-technology issues?
Is sustained follow-up at least as important as the event itself? "Do you want your tombstone to read 'He could have saved lives but instead wanted to get reimbursed.'"
Are we successful in terms of outcomes-quality of life-patient satisfaction with the overall experience?
Are all connected via an effective electronic network that extends the EMR to social networking?
Do we acknowledge that most of the choices involved in executing No. 1 through No. 12 are mostly within our discretion regardless of the nature of Obamacare?
Do we acknowledge that throughout the system there is today enormous variation in outcomes concerning every one of the above issues that can mostly be explained in terms of institutional leadership effectiveness?
Other kernels flowing from Peters:
"The CEO is not supposed to be the top strategist. The CEO is supposed to hire the top strategist."
"Leaders do people. It's the only damn thing they do."
"Excel at sucking down." (Covet relationships with people who do hard, often unrecognized jobs)
"Be astonishingly careful of who the hell you promote."
"Everyone has bad days. When 18 out of 22 days are crappy, there is a message."
Senate Majority Leader Harry M. Reid has acknowledged that his chamber is unable to pass healthcare reform before its August recess, a move that highlighted internal Democratic divisions on the legislation and is likely to result in significant changes to the shape of the final bill. The Aug. 7 deadline that President Obama set for House and Senate leaders to move their versions of reform served as a tool for congressional leaders in minimizing dissent as the $1 trillion package moved through five committees.
More evidence that doctors in certain geographic areas order a lot more unnecessary tests comes from a new federal report suggesting questionable ultrasound scans for Medicare patients in 20 counties where they are performed more often per beneficiary.
The recent U.S. Office of Inspector General report, which looked at 2007 numbers, could mean another specialty field may be targeted for more scrutiny and spending cuts in an effort to rout out inefficient health spending and waste.
Going forward, the report recommends that CMS "should examine claims for characteristics" consistent with unnecessary overuse and make sure they are legitimate prior to payment.
If they are not, "it should take steps to revoke (providers') Medicare billing numbers. Toward that end, we will provide CMS with information on the providers that we identified as having submitted high numbers of questionable ultrasound claims." One problem highlighted is that in many potentially fraudulent cases, the doctor never billed Medicare for examining the patient before the ultrasound was given.
The big-spending counties include Miami-Dade, Palm Beach, Charlotte, St. Lucie, Broward, De Soto, Marion, Indian River, and Sarasota in Florida; Kings, Nassau, Suffolk, Queens, and Richmond in New York; Willacy in Texas; Union, Middlesex ,and Ocean in New Jersey; Macomb in Michigan; and Walker in Alabama.
For example, in the top-spending county, Kings, NY, 35% of Medicare beneficiaries received ultrasound tests in 2007 at an average charge per beneficiary of $235. Kings was followed by Miami-Dade, FL, with $232, Nassau, NY, $202, Willacy, TX, $195 and Suffolk, NY, $181. In the rest of the counties in the U.S., ultrasound spending was $55 per beneficiary.
Five characteristics of possible ultrasound claims fraud
In analyzing county-level claims files in the high use counties compared with other counties and in consultation with a fraud examiner, the IG "identified five characteristics that may indicate questionable ultrasound claims."
For example, in the higher-use counties, a prior service claim from the doctor who ordered the scan was more likely to be absent, which "raises questions as to whether the doctor who reportedly ordered the service ever saw the beneficiary." The ordering physician did not bill Medicare for treating the beneficiary, such as an office visit any time in 2006 or 2007 up until the day of the ultrasound.
Another clue was the finding of "suspect combinations of ultrasound services billed for the same beneficiary on the same day by the same provider, or specific procedures that are not effective in adults. An example would be duplicative services, such as billing for both a complete abdominal scan and a scan of an individual organ within the abdominal cavity.
"This raises concerns of unnecessary or inappropriate use of services."
A third area of potential overuse was seen in the fact that in some cases, more than five ultrasound services were provided to the same beneficiary on the same day by the same provider," raising "concerns of excessive utilization of services."
A fourth area highlighted beneficiaries who had ultrasound services billed by more than five providers in 2007, raising concerns of "misuse of beneficiaries' Medicare numbers."
The fifth clue was found in missing or invalid data in the claims' fields that identifies the physician who orders the service, raising "questions about whether the service was ordered by a physician treating the beneficiary."
Of the $2 billion paid out for more than 17 million ultrasound services in Medicare ambulatory settings in 2007, providers in just 20 counties received 16% of Medicare spending in this category, or $336 million, despite the fact that the counties have only 6% of the Medicare beneficiaries, Inspector General Daniel R. Levinson wrote.
His report said these 20 counties were in the top 1% of counties for both average allowed charges for ultrasound per Medicare beneficiary, and percentage of beneficiaries who received ultrasound services.
The report focused on billings for the technical component of conducting the ultrasound in ambulatory settings, covered under Part B, rather than the physician' fee for interpreting the image.
Other findings in the report:
Nearly one in five provider claims for payment nationally "had characteristics that raise concern about whether the claims were appropriate."
Average per-beneficiary spending on ultrasound in high-use counties was more than three times that for beneficiaries in the rest of the country. Part B spent an average of $171 on ultrasound tests for every beneficiary in the high-use counties compared to $55 in the rest of the country.
Twice as many beneficiaries received ultrasound services in high-use counties as in the rest of the country.
Beneficiaries in high-use counties who received ultrasound services received an average of 3.2 services compared to 2.5 services for beneficiaries in the rest of the U.S.
Certain providers appeared to file a greater number of questionable claims. For example, the report said, "a group of 672 providers each billed 500 or more claims with questionable characteristics. These providers collectively billed over half a million such claims representing over $81 million in Part B charges in 2007."
The report also noted that in high use counties, the ratio of ultrasound providers to beneficiaries was more than three times that for the rest of the country.
While the Inspector General's office did not conduct an investigation of the suspicious ultrasound claims, and said that the findings did not necessarily mean the claims were fraudulent, it nevertheless recommends more forceful efforts to verify that such tests were appropriate.
Shawn Farley, spokesman for the American College of Radiology, says that in addition to any financial incentives to perform these exams many physicians who perform inappropriate ultrasound exams may be simply practicing defensive medicine. Or the patient may be putting pressure on the doctor to perform an exam because he or she saw that a famous person received a certain imaging exam.
To be sure the exam is appropriate, the ACR offers all physicians access to the ACR Appropriateness Criteria, which ranks the most appropriate exams for more than 200 clinical indications, to use in determining which patients should have certain imaging tests, Farley says.
The Inspector General's report suggests that "compared to other types of diagnostic imaging machines, which can cost millions of dollars to acquire and install, ultrasound machines are relatively inexpensive. Providers can buy used machines for under $5,000 and roll them into examining rooms on carts."
Farley says the ACR encourages all providers to seek accreditation to make sure that equipment has been surveyed by a medical physicist to help ensure that the machine is functioning properly and is capturing the best images. ACR also encourages patients to seek out ACR-accredited facilities at which to receive imaging care.
House Speaker Nancy Pelosi said that she doesn't feel bound by the $235 billion in deals that the White House and the Senate Finance Committee cut with hospital and pharmaceutical companies to defray costs of a new healthcare plan, stating that she thinks the industries could do more. The nation's hospitals have agreed to forgo $155 billion in government healthcare reimbursements, and drug companies promised $80 billion, to help keep the cost of President Obama's healthcare reform plan under $1 trillion.
