CMS recently released new guidance for nursing home surveyors regarding 11 F-tags, many of which focus on the quality of life provided to nursing home residents. The guidance, which can be found in Appendix PP, Guidance for Surveyors, of the State Operations Manual, went into effect June 12.
The quality of life F-tags were originally adopted in 1991. "However, some of the regulatory language of these F-tags was very general, leaving providers and surveyors on their own to determine what the regulations actually meant," says Karen C. Schoeneman, MPA, deputy director of CMS' division of nursing homes. "The new guidance will make sure everyone is on the same page."
The new guidance provides further clarification and revises the interpretive guidelines for the following F-tags:
F172 Access and Visitation Rights
F175 Married Couples
F241 Dignity
F242 Self-Determination and Participation
F246 Accommodation of Needs
F247 Notice Before Room or Roommate Change
F252 Safe, Clean, Comfortable and Homelike Environment
F256 Adequate and Comfortable Lighting
F371 Sanitary Conditions
F461 Resident Rooms
F463 Resident Call System
"If your facility does not comply with these F-tags, you can expect to receive deficiencies during your next survey," Schoeneman says.
Implementing all the practices outlined in the new guidance may seem like a daunting task but, fortunately, there are some simple things nursing facilities can do to work toward compliance. For example, facilities can ensure adequate lighting, F256, by using daylight as much as possible and adding table or floor lamps where light is insufficient. Facilities can address the revised guidance for F246, Accommodation of Needs, by individualizing residents' physical environments. For example, staff members can adjust door handles, mirrors, closet rods, and other items in the resident's room and bathroom to better suit the resident's needs.
Although there are simple solutions to help facilities comply with some of the new guidance, complying with other components will not be as easy. The revised guidance for F242, Self-Determination and Participation, clarifies that residents have the right to make choices about things that are important to him or her, such as method of bathing and schedules. In the majority of nursing homes, residents follow the schedule of the facility, not their own. Changing this will be a challenge.
The new guidance for F252, Environment, says that all facilities should work to decrease the institutional character of the environment and can do so by eliminating certain features, such as nursing stations, medication carts, and audible chair and bed alarms. However, unlike other components of the new guidance, a facility will not be considered non-compliant if they still have some of the institutional features.
"The guidelines for F252 include a caveat, or softening sentence, saying that many facilities may not be able to immediately address all of the issues, but they should work toward the changes," Schoeneman says. "Decreasing the institutional character of nursing homes is our vision for the future and, by including this language into the new guidance, we are hoping to point providers in the right direction."
Democrats are working to create healthcare reform legislation that could be approved quickly within several weeks in the House and the Senate before the summer recess. However, on the way, the committees have been sidetracked by forks in the road, which have slowed them down as they discuss and evaluate how—and who—should pay for the reform legislation.
In the House, the tri-committee reform bill that was expected on Friday could be introduced as early as today, with amendments added later. The delay came when the self-described group of fiscally conservative Democrats, nicknamed the "Blue Dogs," pushed for changes in the draft bill late Thursday. Among their requests were:
Deficit neutrality, or finding savings within the current delivery system and "maximizing the value of our healthcare dollar before we ask the public to pay more."
Delivery system reform, or encouraging ways to promote innovative delivery system reforms, such as value based purchasing and the value index to realign incentives to promote high quality, efficient care.
Small business protections, or support efforts to address the challenges faced by small businesses.
Rural health equity, or addressing underlying problems and inequities that plague rural providers. A strong rural package is critical to the Blue Dogs' support, they said.
Tax on benefits
One of the House tri-committees—the House Ways and Means Committee, which is chaired by Rep. Charles Rangel (D-NY)—proposed a tax on those earning more than $350,000 per year. This would raise $540 billion over 10 years. The tax, as proposed, would begin in 2011.
Whether that is something the president would agree to remains to be seen. Appearing on CNN on Sunday, Health and Human Service Secretary Kathleen Sebelius said the president indicated that he wanted to pay for the healthcare reform through targeting healthcare savings in the system and capping itemized tax deductions in the higher income brackets.
"I think the bottom line is, it's got to be paid for," Sebelius said. "We all need to play a role."
On the Senate Finance Committee side, efforts were still continuing to find ways to pay for healthcare reform. While it seemed to be a popular idea before the July 4 break, the committee may be backing away from taxing employee health-related benefits, specifically for those in the upper tax brackets.
Also, the idea to raise taxes on sodas and sugary drinks appears to have lost momentum as well.
Lawmakers say President Obama's overhaul of the nation's healthcare system is unlikely to be completed by the White House's August deadline. Democrats and Republicans said the administration's healthcare reform proposals are moving forward on Capitol Hill, but they cautioned against rushing into a spending plan that could cost trillions of dollars over the next decade. Health and Human Services Secretary Kathleen Sebelius, however, said she remains optimistic about Congress sending the legislation to the White House before the year ends.
A deal announced last week between the White House and three hospital groups to reduce payments to hospitals by $155 billion over the next 10 years had groups representing safety net hospitals and health systems asking: What could happen if "disproportionate share hospital" (DSH) payments were reduced by $50 billion over the next 10 years?
In a joint statement, presidents of the National Association of Children's Hospitals (NACH) and the National Association of Public Hospitals and Health Systems (NAPH)—who were not at the White House meeting—said they could "support most of the provisions" in the agreement to finance healthcare reform. However, reductions related to DSH "could severely damage safety net providers if not carefully crafted."
Under the agreement signed by representatives of the American Hospital Association, the Catholic Health Association of the United States, and the Federation of American Hospitals, DSH programs that help pay for care for uninsured and the underinsured would not be reduced until 2015. Then, "roughly 60% of the existing DSH payments would be preserved" to assist the nation's safety net organizations.
"It's an implementation issue that's of concern," said Jim Kaufman, NACH's vice president of public policy. Most children's hospitals generally don't have a large number of uninsured patients because of Medicaid and state children's health insurance program provisions. Roughly, half of inpatient days for children in their facilities are paid by Medicaid.
However, Medicaid is an "abysmal payer" at the state level: On average, without DSH payments, Medicaid covers about 70% of the hospital's cost; with DSH, that rate climbs to 77%, Kaufman said. And while the House and Senate are looking at provisions to address Medicaid underpayment under healthcare reform, some unexpected shortfalls could occur.
For instance, under the tri-committee draft healthcare reform bill in the House, higher Medicaid reimbursement rates for primary care physicians are being proposed: The new federal minimum standard, as outlined in the draft, would be 80% of the Medicare rate in 2010, 90% of the rate in 2011, and 100% in 2012.
However, the House draft does not address additional reimbursements for specialty physician care. "If you take the DSH cuts away, you won't have adequate payments on Medicaid [patients] for hospitals: It's a huge problem for children's hospitals," Kaufman said. "And that's why we're really concerned about taking the DSH cut."
"We understand the goal: It makes perfect sense if kids are insured. That's great. But, however, the Medicaid piece has to be adequately reimbursing all its providers—not just primary care docs but everybody," Kaufman said.
Both NACH and NAPH said they support the DSH approach taken in the House tri committee draft bill that does not mandate specific DSH cuts to pay for healthcare reform. This provision suggests a study by the secretary of Health and Human Services to evaluate ongoing need for DSH payments after reform has been implemented.
NAPH's membership includes 107 large urban public teaching hospitals—about 2% of hospitals in the country—which provide 20% of the uncompensated care, said Larry Gage, NAPH's president. Add NAPH's member hospitals to the children's hospitals "and we're probably accounting for 30% to 40% of the Medicaid DSH payments," he said.
Gage said policymakers should look into the difficulties that various safety net hospitals and health plans in Massachusetts recently encountered when the state began phasing out special subsidies for hospitals as more people got coverage, Gage said.
"We're going to continue working on [the health reform] issue. We do expect if and when health reform is enacted that this issue will be addressed with the kind of sensitivity we [think it needs]," Gage said.
There are 16 physicians are members of the House and Senate as lawmakers struggle to overhaul the nation's healthcare system. Of the doctors elected to Congress, 11 are Republicans and 5 are Democrats. Two serve in the Senate and 14 in the House, 7 of whom are on the three committees preparing a healthcare bill. But they have taken different lessons from their experiences in medicine, and they do not agree on what a bill should look like.
Boston Medical Center is bracing for dramatic financial losses, which some fear will force it to slash programs and jeopardize care for thousands of poverty-stricken families. The hospital projects that it will lose $175 million in the fiscal year starting Oct. 1, an 18% operating loss that is unusually large even in Massachusetts' up-and-down hospital industry. The hospital estimates that it will close this year $38 million in the red, its first loss in five years.
Senior House Democrats have settled on a proposal to cover a significant portion of the cost to overhaul the nation's healthcare system by raising income taxes on the wealthiest Americans. House Ways and Means Committee Chairman Charles B. Rangel (D-N.Y.) said that the plan could generate as much as $540 billion over 10 years. Married taxpayers earning more than $350,000 a year in adjusted gross income and single filers making more than $280,000 a year would pay a surtax of at least 1%.
The sputtering Michigan economy is dragging down the state's healthcare system, offering a preview of how a lingering recession could corrode U.S. hospitals, savings, and health. Years of auto-industry layoffs and benefit cuts to white-collar retirees have left hundreds of thousands of Michigan residents without employer-provided health coverage. To adapt, individuals are drawing down savings to fund their own insurance, going without treatments or tests, or leaning on the state.
At a time President Obama is pressing Congress to radically overhaul the nation's healthcare system with an eye to affordable insurance for everyone, a company called Doctors Express is trying to launch the nation's first urgent-care franchise. The company applies a model often associated with fast food and car repair to centers that would deliver affordable, non-emergency treatment to almost anyone who walks in.
A Doral, FL, company is suing the Turks and Caicos government, alleging the distressed British colony has not paid $16 million in South Florida medical bills for its citizens. The lawsuit was filed in Miami-Dade Circuit Court by Southern Health Network, which had a contract to arrange healthcare for seriously ill Turks and Caicos citizens who couldn't get proper treatment in the islands.
