CMS Tries to Encourage Accountable Care Organizations in Rural Communities

The Patient Protection and Affordable Care Act (PPACA) intends to implement a system to monitor the quality and efficiency of health care providers. Last March, the Centers for Medicare & Medicaid Services (CMS) released proposed regulations to guide doctors, hospitals, and other health care providers as they attempt to form accountable care organizations (ACOs) under health care reform. These rules included certain provisions designed to encourage rural participation, and CMS recently provided clarification for these rural providers.

Under the general regulations, for ACOs to receive shared savings, they are required to meet a minimum savings rate (MSR). The MSR is the required percentage that ACO expenditures fall below certain standards. In the one-sided model, the MSR ranges from 2.0 percent to 3.9 percent, with variations due to the number of beneficiaries the ACO has assigned. Once the ACO meets the MSR threshold, it is eligible to share in the savings above the MSR amount. Therefore, the ACO is not eligible for “first dollar”savings. Under the one-sided model, ACOs can receive no more than 52.5 percent of their savings (50% for quality performance and up to 2.5% for including a federally qualified health center (FQHC) or rural health clinic (RHC) as a participant in the ACO).

Recognizing the need to encourage the formation of smaller ACOs in underserved rural populations, the Medicare Shared Savings Program proposed an exemption  under the one-sided model from the two percent (2%) savings threshold for ACOs with less than 10,000 beneficiaries. These ACOs would be eligible to share in the first dollar savings provided they comport with the performance standards, generate savings, and meet one of the following criteria:

  • Be comprised of ACO professionals in group practice arrangements or networks of individual practices;
  • 75% or more of the ACO’s beneficiaries reside in counties outside a Metropolitan Statistical Area (a geographical region with a relatively high population density at its core and close economic ties throughout the area) for the most recent year for which data is available;
  • 50% or more of the ACO’s beneficiaries were assigned to the ACO because a critical access hospital (CAH) provided primary care services while billing under the optional method (Method II); or
  • 50% or more of the ACO’s beneficiaries had at least one encounter with an ACO participant FQHC and/or RHC in the most recent year for which data is available.

All ACOs in the two-sided model that satisfy the requisite performance standards and generate savings in excess of the minimum threshold would also be eligible to share in savings on a first dollar basis.

The new regulations would also provide for an incentive to smaller ACOs by using a lower confidence interval. ACOs with at least 5,000 beneficiaries would have a minimum savings rate based on a 90% confidence interval.  ACOs with 50,000 beneficiaries would have a minimum savings rate based on a 99% confidence interval.

FQHCs and RHCs may not form their own ACOs under current regulations. These entities may join an ACO as an ACO participant, however, along with other organizations. Therefore, these proposed rules offer incentives to ACOs that choose to include FQHCs and RHCs in their mix.

Additional information about the Shared Savings Program can be found HERE.

 

 


 

Health Care Is Up in Arms About Firearms

Physicians around the nation are up in arms about some proposed legislation that may limit their communications with patients. One such measure is from Florida, where the State Legislature recently passed the “Don’t Ask” bill. It waits for the likely signature of Governor Rick Scott. Florida House Bill 155 will prohibit in part a physician or other health care professionals from asking patients or members of their families whether they own a firearm or have one in their home.

Supporters of the bill, including the National Rifle Association, contend the legislation is important to stop doctors from invading their privacy, especially when they are concerned the information may be used against them by insurance companies. According to Marion Hammer, executive director of United Sportsmen of Florida: “Simply, it’s none of their business.”

Representatives from the American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA) all agree on the importance of the physician-patient relationship, and the importance of maintaining these open channels with strict confidentiality exists at its very core.

Together, these three groups oppose any legislation — including laws relating to the possession of firearms and an office visit discussion about guns in the home –  that places limitations on the free exchange of information within the patient-physician relationship. Any restriction, according to the groups, may cause harm to the patient’s and family’s health.

The 300,000 plus physicians within these organizations firmly believe that they must have open and honest communication with patients about all aspects of health and safety. One critical aspect of this process is safety and injury prevention. By providing meaningful patient education, physicians can help improve patient well being.  The AAFP, ACP and AOA have long standing policies in support of this notion.

The AAFP is one of the largest national medical organizations, representing more than 100,300 family physicians, family medicine residents and medical students nationwide. Founded in 1947, the group’s mission is to preserve and promote the science and art of Family Medicine, and at the same time advance high-quality, cost-effective health care for everyone.

The ACP is a national organization of internists who specialize in the prevention, detection and treatment of illnesses in adults. The largest medical-specialty organization and second-largest physician group in the United States, the group’s 130,000 members include internists, internal medicine subspecialists, as well as medical students, residents, and fellows.

The AOA serves as the professional family for all osteopathic physicians (DOs) and osteopathic medical students. In addition to being the primary certifying body for DOs, the AOA is also the accrediting agency for all osteopathic medical schools, and it has federal authority to accredit hospitals through its Healthcare Facilities Accreditation Program.

AAFP President Roland Goertz, MD, MBA, explained: “The AAFP believes that patient confidentiality must be protected. Any proposal that seeks to intrude on these rights and place restrictions on what can be discussed jeopardizes a patient’s health and represents unwise governmental intrusion.”

Only in an environment of confidence and trust can a patient freely share the necessary information for a physician to understand, diagnose, and treat patients properly.  ”The American Osteopathic Association opposes any and all efforts to censor communication that occurs between patients and their physicians,” said AOA President Karen J. Nichols, DO. “Any legislation that impedes on this relationship jeopardizes the health and safety not only of our patients, but also their families.”

Representatives from the physician groups content that the proposed legislation in Florida and other states attempts to preclude physicians from asking patients about firearm ownership, thereby preventing any discussion about safe storage and handling. Historically such education has been shown to decrease the likelihood of unintentional injury or death.

“On this particular issue, ACP’s policy encourages physicians to inform patients about the dangers of keeping firearms, particularly handguns, in the home and to advise them on ways to reduce the risk of injury,’” said ACP President Virginia L. Hood, MBBS, MPH, FACP. “However, this issue is much bigger than guns, it is about whether the government or any other body should be allowed to tell physicians what they can and can’t discuss with their patients.”

MedPAC: Keeping an Eye on the Medicare Program

Established by the Balanced Budget Act of 1997 (P.L. 105-33), the Medicare Payment Advisory Commission (MedPAC) advises the U.S. Congress on all matters of Medicare. This independent agency enjoys an expansive mandate — from advising Congress on payments to private health plans participating in the Medicare program to the assessment of access to, and quality of, Medicare treatment.

MedPAC’s 17 members are appointed to three-year terms by the Comptroller General. The commission meets publicly to discuss policy issues and prepare recommendations to Congress. MedPAC may consider information contained within staff research, presentations by policy experts, and comments from interested parties.

MedPAC issues two reports each year (March and June). The March 2011 report contains 13 chapters, including one chapter that provides context for documenting the rise in Medicare and total health care spending nationwide, another setting forth the Commission’s framework for assessing the integrity of Medicare’s payment process, nine chapters relating to Medicare payments and program integrity concerns, one chapter discussing the Medicare Advantage plans, and a final chapter on Medicare prescription drug coverage.

The entire report, consisting of more than 350 pages, can be found HERE.

The Commission’s schedule of public meetins can be found HERE.

In a recent press release announcing the newest members to the commission, Gene L. Dodaro, Acting Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO) stated: “Policymakers continue to rely on MedPAC’s expert advice, and with the passage of health care reform, MedPAC’s role will continue to be particularly important. I am pleased to report that, once again, we had many qualified applicants for MedPAC. The four new individuals selected will bring impressive credentials and valuable experience and insights to the commission.”

 

 

HHS Issues Final Rules To Review Insurance Premium Increases

The Department of Health and Human Services (HHS) issued a final regulation to review large health insurance premium increases while at the same time providing consumers with clear access to this information.

HHS hopes that this transparency will help lower insurance costs, especially when in September 2011 state or federal agencies must review rate increases of 10-percent or more.

“Effective rate review works – it does so by protecting consumers from unreasonable rate increases and bringing needed transparency to the marketplace,” said HHS Secretary Kathleen Sebelius. “During the past year we have worked closely with states to strengthen their ability to review, revise or reject unreasonable rate hikes. This final rule helps build on that partnership to protect consumers.”

Starting September 1, 2011, the rule requires independent experts to review any proposed increase of 10-percent for most individual and small group health insurance plans. States will have the primary responsibility for oversight, and HHS will serve in a backup role if certain states are unable or unwilling to comply. Starting September 2012, the 10-percent threshold will be replaced by state-specific thresholds that reflect the insurance and health care cost trends in each state.

“Strong and transparent rate review processes are necessary to help bring down costs for consumers,” said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight. “Rate review will ensure that increases are based on reasonable estimates and real-time data on medical cost trends and health care utilization.”

For more information about recent trends in health insurance rates and the final rule, visit HERE.

 

Zombie Apocalypse Preparedness 101

The Centers for Disease Control and Prevention has posted information on how to prepare in the event of a zombie invasion. Assistant Surgeon General Ali Khan provides valuable information from stocking up on food to first aid supplies to “where you would go and who you would call if zombies started appearing outside your door step.”

The CDC blog also explains:  “If zombies did start roaming the streets, CDC would conduct an investigation much like any other disease outbreak, CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation. This assistance might include consultation, lab testing and analysis, patient management and care, tracking of contacts, and infection control (including isolation and quarantine).”

Among other things, the CDC also recommends advance planning of the appropriate escape route:  ”Plan your evacuation route. When zombies are hungry they won’t stop until they get food (i.e., brains), which means you need to get out of town fast! Plan where you would go and multiple routes you would take ahead of time so that the flesh eaters don’t have a chance! This is also helpful when natural disasters strike and you have to take shelter fast.”

For more information about what to do when the zombies arrive, or information about disaster preparedness in general, visit the CDC’s Website HERE.

 

A Final Newsletter0

Hello Everyone:

In many respects, today is like any other for Coast Plaza Hospital. Just as we have since opening our doors more than 50 years ago, we stand proud and ready to address any emergency our community might face, welcoming one and all in times of need. And yet, though unbeknownst to our many neighbors, patients and friends who have come to look upon the hospital as a constant, fixed entity toward which to turn in the midst of chaos, behind the scenes a torch will shortly be passed from one hospital owner to another.

Under the past twenty-one years of present ownership I have shared the title of Chief Executive Officer with only one other. In this, my final report to the Coast Plaza Hospital community, I would like to honor the individual who held my title for the 12 years before me, my father, Gerald J. Garner, since in my opinion it is his legacy that has made our hospital a name our community has come to trust.

Born December 17, 1936, my father was raised in New York and did not move his family to California until he was 40. It was to be another decade before he assumed the position of Coast Plaza’s CEO, a role he accepted with pride. His sudden death on April 28, 2002 came as a great surprise to both his immediate family and the employees at Coast Plaza, many of whom knew him from the beginning of his tenure.

Today, my father is survived by my mother Joan, my sister Robyn and her husband Keith, my brother Scott and his wife Karen, me and my wife Natalya, and six grandchildren. While he adored Robyn and Keith’s children Tyler and Evan, sadly Gerald never had the chance to meet Scott and Karen’s three children, Espen, Annika, and Helena, or our newborn son Rodion. I like to think he would be proud of the new elements within his family.

Gerald taught many people many things in life, but it was perhaps his passing that taught our hospital family its most important lesson: We achieve greatness together, and only together. I have heard it said that the whole is by nature greater than the sum of its parts, and when it comes to health care in the modern age that is certainly true, be it the correlation between community and hospital, employees and hospital, or even investors and hospital. As different as each of these entities may seem from the others, all three survive only by existing together. Just as the loss of my father affected my immediate family greatly, the transition from old guard to new will have its moments of uncertainty for the Coast Plaza family. Even so, though these past few weeks have given me the opportunity to witness first hand the ways in which change can make for a stressful environment, I have also been pleased to regard the strength and dedication shown by our members in their effort to maintain the superlative standard of health care that our community has come to expect, regardless of any temporary internal fluctuations. Nine years of consistency will undoubtedly lead to a certain amount of confusion for a time, no matter who is waiting in the “on-deck circle.”

But that is what makes a hospital such a special place to work. As chaos tries to rule the day, something happens, and a wake up call of sorts is given, reminding us all of the reason we have come together in this building on any given day. Our daily dose of reality connects us with the real issues at hand, as we remember that our community truly values the support we provide in times of need, just as we do the same for one another. After all, that is what relationships are all about.

Throughout this period of transition, Coast Plaza Hospital did exactly as it should, relying on a network of relationships already in place and building on the new to continue its focus on providing care to the community. In hindsight, the past nine years under my tenure were in many ways defined by these relationships, and our focus was strong. As a result, the community received exactly what it had come to expect and deserve — a first-rate hospital.

Seven months ago I met the individuals who will write the next chapter for Coast Plaza Hospital. They are a competent, generous, able group, to be sure. But though they may steer the course, they will not write this story alone. If there is one fact which Gerald and I knew to be true while tending our posts, it is that the strength of this particular hospital comes not from its leadership, but from the dedication of its nearly 400 stellar employees. Working together for the common good, you are indeed greater than the sum of your parts, and I do not expect that to change.

Regardless of what the future holds for Coast Plaza, there is one thing of which I am sure: The extended family that has for nine years made it an honor and a privilege for me to lead this hospital will continue to provide excellence in care for the people in and around Norwalk. Indeed, that is what health care at Coast Plaza Hospital is all about.

Thank you all.

Bringing the Relationship Back Home0

This article first appeared on the PBS affiliated Website This Emotional Life.

“As you get older, it is harder to have heroes, but it is sort of necessary.” — Ernest Hemingway

It starts with lavender.  Then I notice the tiny, neatly folded outfit set aside by the changing table. A dragon in the corner smiles at me, performing ironic double-duty as humidifier and protector, providing respiratory ease rather than spewing the requisite fire so common to his kind.

Through the dim lighting I spot a small bottle waiting to provide the next meal when necessary, along with an array of accoutrements placed strategically throughout the room in anticipation of what the night may bring. And, of course, I hear the alternating tonic and dominant harmony in D flat.  This is my house, and yet I cannot help but ask myself where this room has come from.  It seems to have magically appeared overnight, while I was at the office crunching numbers and doing my best to contain health care-related chaos.

As I have mentioned in earlier articles, the last few months have been interesting for me, for a variety of reasons. Thus far, 2011 has seen fit to grant me a beautiful baby boy as I relinquished ownership of a family hospital handed down to me by my father.  Never before have I seen the Wheel of Life turn so up close and personal than in the last few months, and the combined experience has forced me to take account of the daily minutiae.  Simply put, things are changing, and fast.  The past seems suddenly far behind while the future stretches out before me, full of exciting new events that remind me just how far out of my league I am.  And through it all, the scent of lavender lingers as a reminder of my transition.

With the livelihood of over 400 employees – who I consider extended family members – at stake during the ongoing sale process of a local hospital on which the very community has come to depend for more than 50 years, I am the first to admit that the last two months have not afforded me as much time to spend with my newborn as I would have liked.  Late night phone conferences and early morning briefings have left little time for more than the occasional bottle-feeding or diaper change. That’s what comes to mind as I make my way across this odd little room in the heart of my house and realize just how much work my wife has put into creating a warm, safe haven in which to raise our son.  My lack of familiarity with many of the products on the nightstand only serves to reinforce how much she has learned recently, and put into practice on her own.

While I have been managing to survive my recent professional upheaval with the support of a hospital family nine years in the making, two strong-willed brothers, a handful of professional advisors with over 75 collective years of experience, and plenty of luck, that dragon’s smile stands as a reminder that she alone has borne the brunt of maneuvering through the uncharted waters of first time parenthood.  Any initial feelings of personal guilt as a result of my situation are quickly succeeded by the pride I feel on her behalf as it dawns on me that the foundation she has so gracefully provided exists not just for my son in his first months, but for me as well as I close out an important and emotional chapter in the history of my family tree.

While I was focusing my energies on external responsibilities, it was my wife who kept the home front intact. We never did plan any such allocation of duties, nor could we have anticipated this perfect storm of sorts when her pregnancy was first announced.  Yet somehow during the process, perhaps when I wasn’t even paying attention, Natalya became both anchor and life preserver, in many ways taking care of me in much the same way as she did our son.  In this forum I have had ample opportunity to discuss the many relationships that have formed my understanding of health care and its continued survival throughout innumerable pressures. But I may have been remiss by not making it unmistakably clear that the relationships that form behind the scenes within the family nest are often what make it possible for health care workers to give their best in emergency situations day in and day out. Personally speaking, my support group is an army of one. On behalf of my son, my hospital family, and myself, I am forever grateful to my wife and my hero, Natalya.

As an aside, my mother-in-law recently arrived from Belgium to lend a hand and offer advice.  Her arrival underscores what I am sure the dragon must also be thinking as he watches what transpires in that little room: “A mother’s work is never done.”

The Relationships Behind the Healing0

This article first appeared on the PBS affiliated Website This Emotional Life.

In an 1889 essay, The Decay of Lying, Oscar Wilde argued that life often imitates art because “the self-conscious aim of life is to find expression,” and art provides an appropriate release. In many ways the same could be said of the current relationship between those who provide health care to the community and those who draft legislation governing such care. As the debate around health care reform enters its second year, perhaps it is time to stop and consider the full impact of the bill, not just on the health care system as a concept, but on the fate of the local hospital as a living, breathing entity.

The obvious uncertainties brought to life by today’s health care climate have over time become an unfortunate source of anxiety affecting nearly every patient-doctor relationship, as well as giving pause to the hundreds of thousands of health care workers industry-wide. For those on either side of the equation, the future of these relationships is now at a crossroads, in large part because neither professionals nor patients know what may be waiting around the next corner. Sadly, this all too often adds undue pressure to the already difficult task of care for the sick in the event of an emergency.

Next month will mark my nine-year anniversary as CEO of a hospital in Los Angeles County, California, in a role I had honestly never expected. I remember walking into that job on my first day, to face a group of intelligent, dedicated hospital managers who were devastated by the loss of their former leader.  As I addressed this room full of people – some of whom were in tears, some of whom remained stoic, all of whom were scared of what the future might hold – I wondered how I could ever comfort them for the loss they had just endured and assuage their fears of what was to come. The Hospital’s former CEO had died the day before from injuries sustained in a car accident, and it was my job to regain control of the facility and keep things functioning while learning the ropes as I went. There was no question I had some rather large shoes to fill, and but for the fact that the prior CEO had also been my father, I imagine I never would have accepted the challenge.

On the day of that first meeting with my new staff, we did not focus on our need to provide health care to the surrounding community.  Instead, we addressed the obvious issues of how best to continue forward as a team. Even so, no one working that day forgot the primary goal of any hospital, regardless of the surrounding chaos. Notwithstanding, for the next 3,300 consecutive days – almost 80,000 uninterrupted hours – the hospital did exactly as it should, using the network of relationships already in place and building on the new to continue its focus on providing care to the community.  In hindsight, the past nine years under my tenure were in many ways defined by these relationships, and our focus was strong.  As a result, the community received exactly what it had come to expect and deserve — a hospital.

Five months ago I began what would become a new chapter in this story, although initially I had no reason to anticipate the scope of its impact. It had become increasingly clear that the time had come to enter into discussions to sell the hospital to a larger health care group with the resources necessary to continue providing the area with top quality care. Throughout the process, which was long, arduous, and quite emotional for me, our focus was always to ensure that the community received what it deserved — that same hospital it had come to rely on for over fifty years.  Yet even in those moments when my focus waned, I knew I could depend on an extended family nearly 400 strong who made sure that we were well-positioned to deliver medical care to those who needed us. In the end, that’s what health care is all about.

Just the other day I entered that same room, filled with many of the same people from nine years ago.  While there were plenty of new faces as well, most of them had long ago become a part of our family. I explained that I had been preparing for this day for nearly nine years, although what was originally a day to which I had looked forward with anticipation was now one I truly dreaded. This time, I was to deliver a different message – that I would soon be stepping down as their leader. Looking out at the crowd as I gave news, every face reminded me of a lesson taught or learned, a favor asked or granted, or an experience shared.

I’ve heard it said that the whole is greater than the sum of its parts. When it comes to health care in the modern age that is certainly true, be it the correlation between community and hospital, employees and hospital, or even investors and hospital. As different as each of these bonds is from the other, all three survive only by existing together. These past few days I have witnessed first hand the ways in which change can make for a stressful environment.  The staff is nervous, the patients may be confused, and emotions run high. Nine years of consistency will undoubtedly lead to fear and uncertainty for a time, no matter who is waiting in the “on-deck circle”.

But that is what makes a hospital such a special place to work.  As chaos tries to rule the day, something happens, and a wake up call of sorts is given, reminding us all of the reason we have come together in this building on this day. Our dose of reality connects us with the real issue at hand. We remember that our community truly values the support we give in times of need, just as we do the same for one another.  After all, that is what relationships are all about.

If life could really imitate art, or at least the spirit of the law, it would make health care reform a much easier pill to swallow. To succeed in this endeavor, our primary goal should be to remember not just why we are here, but what the underlying purpose of health care in America is really all about.  For me, it has always meant faithfully serving the people who depend on us.  Though we may all sometimes forget why we do what we do, the relationships around us that maintain the hospital infrastructure so that it can operate all day, every day, are too important to ever be taken for granted.  Hopefully those who oversee the nationwide debate will one day come to accept this fact.

The Future of Medicare Reimbursement Is Here

The Centers for Medicare and Medicaid Services (CMS) will start paying hospitals bonuses based upon performance, an adherence to quality measures, and on patient satisfaction.  These final Medicare rules were published last week. This Hospital Value-Based Purchasing Program is another step toward shifting the reimbursement infrastructure from the cost of services during a hospital stay to improvements in patient health and performance during a hospital stay.

Proponents of this idea — which was part of the Patient Protection and Affordable Care Act — contend it could help save money in the Medicare system as it improves patient care nationwide. “For the first time, hospitals are going to be paid for inpatient hospital quality, not just the quantity of the care they provide,” CMS administrator Donald Berwick, MD, told reporters on Friday morning.

The rule goes into effect in October 2012. In the program’s first year, hospitals will be entitled to share bonus money from an $850 million fund based upon their performance. For a complete list of the quality measures, visit here.  CMS will also evaluate patient satisfaction during hospital stays. Quality measures will weigh at 70% and patient satisfaction results at 30%.

In fiscal year 2013 (starting October 2012), hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS) as these funds will be used to pay for the performance bonuses. By 2015, hospitals who continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement.

When asked if the rule would be unfair to hospitals with less money who might have greater challenges adhering to the quality measures and focusing on patient scores, Berwick stated: “We need all boats to rise on the rising tide of quality.”

 

A Possible Reprieve for Hospital Retrofitting Requirements

In February, Hospital Stay posted an overview on California’s seismic safety requirements for hospitals.  That article can be found HERE.  Recently Governor Brown signed SB 90 and AB 113, which in part provide hospitals with a possible seven year extension to comply with the State’s seismic safety requirements.

To qualify, there are some legislative events which must occur first on both a state and federal level. If and when that occurs the seismic extensions set forth in SB 90 last up to seven years, but no later than 2020.  For a hospital to obtain this optional extension, OSHPD must consider public safety when determining whether to grant an extension or length of an extension on a case-by-case basis using the following criteria:

  • Structural integrity of the building based on its HAZUS score. HAZUS is a nationally applicable standardized methodology that contains models for estimating potential losses from earthquakes, as well as other natural disasters.
  • Community access to health care if the hospital building is closed.
  • Financial capacity of hospitals to complete the construction project.

No later than March 31, 2012, hospitals that wish to apply for the extension must:

  • Submit a letter requesting an extension.
  • Specify what the project will be (rebuild, retrofit, other).
  • Specify the time necessary for the project.
  • Submit a schedule detailing the extension work.
  • Specify how the project will stay on track as proposed.

No later than September 30, 2012, a hospital must submit its HAZUS application No later than January 1, 2015, a hospital shall:

  • Submit plans and a schedule for the project identified.
  • Submit a financial report describing the ability to complete the project.

No later than July 1, 2018, a hospital must obtain a building permit for its project, thereby ensuring sufficient time to meet the statutory deadline.