Patient volumes at the nation's acute care hospitals fell slightly in April, and are expected to be weak into the second quarter of 2010, according to the Deutsche Bank Hospital Volume Tracker.

Deutsche Bank's survey of more than 375 acute care hospitals found inpatient volumes down 2.2% and outpatient volumes down 1.1% for April. Inpatient surgeries were up 3%, outpatient surgeries were up 3.5%, and births were up 1.1%. ER visits fell 1.8%

"Uninsured mix looks fairly stable on a sequential basis, thus alleviating concerns about short-term bad debt volatility, although we are going to have to keep a close eye on MCO mix given steeper inpatient declines in recent months," the report stated.

Deutsche Bank said inpatient MCO volume declines are down about 5% on a rolling three-month basis. "This trend could be an indication that COBRA is beginning to roll-off, although we emphasize that we are not seeing corresponding growth in the uninsured volume," the report said.

Deutsche Bank anticipated Q2 volume growth of between 1% and 2%. "We believe our models have cushion in them with respect to conservative bad debt assumptions. We'll reassess volume, pricing and bad debt assumptions once we've gained a fuller picture on Q2 trends in the coming weeks," the report said.

Despite the soft volumes, Deutsche Bank said it will continue its Buy ratings on the major investor-owned hospitals, including Community Health Systems, Health Management Associates, Inc., LifePoint Hospitals, Inc., Tenet Healthcare Corp., and Universal Health Services, Inc., "based on reasonable valuations, upside risks associated with healthcare reform, accretive acquisitions, the potential for better volume and mix with an economic recovery, and continued execution with expense management over the short-run."

Hospitals and critical access hospitals (CAH) will soon be able to use credentialing and privileging information about telemedicine providers from the remote location, according to proposed Centers for Medicare & Medicaid Services (CMS) changes to the Conditions of Participations (CoP). The proposed rule will be published in the Federal Register for public comment on May 26.

Previously, CMS allowed hospitals and CAH to accept credentialing information about telemedicine providers from the distant site, but not privileging information.

"CMS has become increasingly aware, through outreach efforts and communication with various stakeholders in the telemedicine community . . . of the urgent need to revise the CoPs in this area so that access to these vital services may continue in a manner that is both safe and beneficial for patients and is free of unnecessary and duplicative regulatory impediments," the agency stated in its proposed rule.

Additionally, CMS cited smaller hospitals' lack of clinical expertise to adequately evaluate a variety of privileges as one of the reasons why a change was needed.

CMS will post the proposed rule on the Federal Register for a 60-day comment period, and the public can submit comments to www.regulations.gov. The revised language is contained in two sections of the CoPs: §482.12, "Governing body," and §482.22, "Medical staff."

"Upon reflection," CMS noted, "we came to the conclusion that our present requirement is a duplicative and burdensome process for physicians, practitioners, and the hospitals involved in this process, particularly small hospitals, which often lack adequate resources to fully carry out the traditional credentialing and privileging process for all of the physicians and practitioners that may be available to provide telemedicine services."

Under current CMS regulations, hospitals receiving telemedicine services from a distant site must privilege each physician or practitioner providing services to their patients as if the practitioners were onsite. While those hospitals could use third-party credentialing and verification organizations to make the process easier, the hospital's governing body remains responsible for all privileging decisions.

This process had been simplified: Hospitals that were accredited by The Joint Commission were deemed to also have met their Medicare condition of participation—including credentialing and privileging requirements—under the Commission's statutory deeming authority.

But with the passage of the Medicare Improvements for Patients and Providers Act of 2008, the statutory recognition of The Joint Commission's hospital accreditation program was ending—effective in several weeks on July 15. The law now would require The Joint Commission to secure CMS approval of its standards to confer Medicare deemed status on hospitals.

With this change, small and critical-access hospital medical staffs using telemedicine services could face "the burden of privileging hundreds of specialty physicians and practitioners" that large academic medical centers make available to them, CMS noted in the Register proposal.

Clostridium difficile, a germ that causes deadly intestinal infections in hospital patients, has long been thought to be spread only by contact with contaminated surfaces. But a new study finds that it can also travel through the air. British researchers emphasized that there is no evidence that C. difficile can be contracted by inhaling the germs. Rather, they float on the air, landing in places where more people can touch them, the New York Times reports.

National Nurses United at its founding convention last December vowed to create a unified agenda and push for staffing ratios at every local affiliate. They're making good on that pledge in Minnesota, and they are showing themselves to be formidable. Pay attention to this fight, because it may soon come to a hospital near you.

Last week, 12,000 members of the NNU-affiliated Minnesota Nurses Association at 14 Minneapolis-area hospitals overwhelmingly voted to authorize a one-day walkout on June 1 unless their contract demands are met. Linda Hamilton, president of the MNA, says the fight is about patient safety, not money.

"What are we fighting for? The simple answer is this: We're fighting for you. We're fighting for any patient who ever walks through the doors of one of our hospitals," Hamilton wrote in a May 15 editorial in the Pioneer Press.

"The math doesn't lie: The thinner nurses are spread in hospitals, the greater number of patients who die… Despite what the Twin Cities hospital systems want readers to believe, this contract fight is not about economics. For nurses, this is much more personal than a paycheck or a pension benefit. This is about our patients," Hamilton wrote. "Everybody knows a nurse, and everybody knows nurses are not greedy."

Hamilton may be sincere. Or, you can argue that staffing ratios are just a clever way for nurses' unions to protect jobs and increase membership under the guise of "patient safety." Whether or not a specific level of nurse staffing has any affect on patient safety or quality of care is one of the most hotly contested issues in healthcare.

There is also the blatant contradiction of a walkout in the name of patient safety. How can the MNA say that staffing ratios are critical to patient safety, and then threaten to abandon the patients they claim to be "fighting for?" Who bears the responsibility if a patient is harmed by this walkout? Is this about patient safety, or isn't it?

Still, Hamilton's argument is compelling for the general public because the union has made its grievance a fight for the little guy. The cause of patient safety is something that resonates with everyone. Who hasn't been either a patient or visited a loved one in a hospital, in pain, at their most vulnerable? This chord strikes deep.

The local news videos of rank-and-file MNA nurses marching in front of their hospitals, wearing their uniforms, waving picket signs, and demanding patient safety gets prime air time. Nice visuals! Very powerful!

Hamilton skillfully works the corporate greed angle when she complains that the six "nonprofit" (quotations hers) health systems made a combined $700 million in profits during recession-wracked 2009, and spent money on huge executive pay hikes and frivolous projects that add nothing to patient care.

The 14 Twin Cities hospitals have mounted their own media counteroffensive, and they've done an admirable job. They make themselves available to the media. They've set up a website and posted the union's contract demands with each health system, and each health system's counter-offer. They've banded together to get their message out, using amiable spokeswoman Maureen Schriner to quickly address media queries. (Their first spokeswoman was fired earlier this month after local news reported that she had pleaded guilty in 2006 to the misappropriation of about $15,000 at a South Dakota hospital. D'oh!)

Schriner's arguments are also compelling, but they're harder to fashion into an easily digestible sound bite. She says full-time nurses average about $79,000 a year plus benefits at the 14 hospitals, which is hardly chump change. She notes that Minnesota hasn't needed strict staffing ratios to score among the best states in the nation when it comes to patient safety, quality outcomes, and efficiencies. "Minnesota is a national leader. We have a reputation for quality patient care and innovative initiatives on patient safety," Schriner says. "For us to go to a national standard, why would we want to do that? We are above the national standards in so many areas already. We want to look to the future."

Technology is another issue.

"The union is asking for the contract to say you cannot introduce any new technology if it is going to reduce staff," Schriner says. "Of course we want to introduce new technology if it's going to benefit patients. Is the deciding factor of whether or not we use technology based on how it affects (full-time employees)?"

Despite their efforts, Twin Cities Hospitals' fight for public opinion will be an uphill slog. The hospitals' message is about economics. The nurses' message is also about economics, but they're calling it patient safety—easily identifiable, succinctly encapsulated, with an immediate emotional connection with the public. Plus, they control all the compelling video.

A hospital executive in a business suit explaining proposed pension reductions as a percentage of overall payroll expenses, or a website detailing contract specifics on "mandatory low need days," "unit closures," and "flex time summer deferral bonuses" cannot compete for the public's heart with video of a uniformed nurse holding a picket sign looking earnestly into a camera and saying she is fighting for you.

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