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Ditto here GruntDoc†

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iCryptex

via Rob Hyndman from Darren Barefoot:

Also catch The Norman Rockwell Code.

Specialty Hospitals, Costs Mounting

Although the post is for the topic “specialty hospitals,” the press release touches upon numerous important topics:

Physician-Owned Specialty Hospitals, Mark B. McClellan, MD, PhD, Administrator, CMS Senate Finance Committee | Press Release | 5.18.06

{annotations and hilites added}

…

At CMS our chief concerns are the quality of care for people with Medicare and Medicaid and the efficiency of Medicare and Medicaid spending. We make no differentiation in the application of our quality standards whether a facility is rural or urban, or for-profit or not-for-profit. Through Medicare’s conditions of participation requirements and the survey and certification process, CMS monitors and enforces quality requirements for all hospitals. If necessary, CMS has the authority to terminate a hospital’s participation in the Medicare program; and, CMS recently used this authority to put a facility in Oregon on track for such action. {not to mention Tenet}

CMS also is actively working to ensure payments for services promote quality and accurately reflect the cost of providing care. As you know, how Medicare pays for medical services can significantly impact quality and medical costs for our beneficiaries and our overall health care system. With a reimbursement system based on admissions and procedures and not outcomes or efficiency, the current system may pay for services that are ineffective, inefficient and out-of-date, instead of recognizing and encouraging quality care that prevents complications and errors. Moving toward a performance-based payment system could potentially enhance fair competition across health care settings. By leveling the financial playing field for all hospitals, Medicare payments to hospitals will more accurately reflect actual resource needs. This can be achieved, in part, for example, by reconfiguring payments to better recognize severity of illness. CMS also is considering ways to improve patient safety and the Medicare payment system by addressing “never events,” which are serious, preventable medical errors.

Public disclosure of hospital pricing and quality data also has the potential to spur quality improvements at all hospitals. Quality and cost information is increasingly available and being used by patients to create a health care system that is more transparent. We hope that this will eventually provide every patient with an opportunity to get a clear idea of the quality of providers and the price of treatment options available to them and will help them to make an informed choice about their own health care. And people may find more opportunities to save when they use such information effectively.

…

Hospitals have two options when it comes to the survey. They can seek accreditation from an approved body such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or they may apply directly to CMS for a review. Reviews for CMS are carried out by individual State Survey Agencies, under contract with CMS.

…

CMS Proposes to Level the Financial Playing Field for All Hospitals

In addition to the above mentioned long-range plans and goals for improving the quality of care provided at all hospitals, CMS also has taken more immediate steps designed to improve quality and tailor its payment systems to more accurately reflect the cost of care. CMS has undertaken a number of activities to improve the quality and efficiency of care delivered to Medicare beneficiaries, but also recognizes the ability of Medicare payment systems to promote quality and more accurately reflect the costs of providing services to our beneficiaries. Currently, there are several different fee-for-service payment systems under Medicare that are used to pay health professionals and other providers based on the number and complexity of services provided to patients. In general, all providers to which a specific Medicare payment system applies receive the same amount for a service, regardless of its quality or efficiency. As a result, Medicare may often pay more to hospitals that deliver care that is not of the highest quality or include unnecessary services.

CMS Developing Revisions to Ambulatory Surgical Center Payment System

In its 2005 Report to Congress, CMS found that many orthopedic and surgical specialty hospitals were more similar to ambulatory surgical centers (ASCs) than to acute care hospitals. Despite the similarity in the care provided, difference in payments for the same services encourages providers to enroll what are essentially ASCs as specialty hospitals. {D’oh!}

To address this problem, CMS is developing revisions to the list of procedures eligible for payment in ASCs to include most surgical procedures performed in hospital outpatient departments. The basic structure of the payment rates for ASCs has not been updated since 1990 and CMS is considering revising the payment methodology in ASCs to align more closely with the payment rates in other payment systems for the same procedures, which would remove much of the incentive for physicians and other investors to form orthopedic and surgical specialty hospitals in order to take advantage of the typically higher payments under the inpatient and outpatient hospital prospective payment systems.

Both the expansion to the list of procedures eligible for payment in ASCs and the payment revisions are expected to be in effect by January 1, 2008. When implemented, Medicare payments to ASCs are expected to better reflect the resources required to perform specific surgical procedures and to be similar to payments under other payment systems.

CMS Clarifies EMTALA Responsibilities in Proposed Rule

Many specialty hospitals, especially orthopedic and surgical hospitals, do not have emergency departments. As a result, there has been some confusion regarding whether these facilities are required under the Emergency Medical Treatment and Labor Act (EMTALA) to accept an appropriate transfer of an individual from a requesting hospital. The FY 2007 IPPS proposed rule clarifies that all hospitals (including specialty hospitals) with specialized capabilities must accept, within the capacity of the hospital, appropriate transfers of unstable individuals covered by EMTALA, without regard to whether the hospital has an emergency department. This clarification of current policy may result in an increase in the number of specialty hospitals accepting transfers of individuals with emergency conditions on nights and weekends. This clarification was recommended by the Secretary’s EMTALA Technical Advisory Group. The community hospital associations have supported this position. Public comments on the proposed rule are due by June 12, 2006.

Hmmmmmmmmmmmm, looks like the reasons to have a specialty hospital are dwindling…incentivized behavior trumped by governmental imperatives…a big big big “go figure.”

See also:

1. Cover the Uninsured Week
2. delicious :: 3.7.06
3. Pincher Maneuver
4. Helen Wilson
5. Cream Skimming, Souring
6. delicious :: 11.13.05
7. Specialty Hospitals 1.3
8. Specialty Hospitals 1.2
9. Specialty Hospitals 1.1
10. Specialty Hospitals 1.0
11. Shifting Burden
12. Cream Skimming

Did You, Do You, Can You

Oh so common in the ED…

Questions:

• Did you bring your medicines?
• Do you know the names of your medicines?
• Can you have someone bring them in?

Answers:

• The white one.
• The little one.
• The blood pressure one.
• Same as the last time, when you wrote them down.
• Call my doctor’s office (regardless of the fact it is 3 AM)
• Call the Walgren’s on 16th.
• I don’t know, they were stolen.
• Mine? Or the ones my sister gives me?

What Drugs Do You Take? | Hospitals Seek to Collect | Better Data and Prevent Errors | WSJ | 5.23.06

In the movie, “Something’s Gotta Give,” Jack Nicholson plays an aging Lothario, rushed to the emergency room after a heart attack, who won’t admit to taking Viagra in front of his young girlfriend. But then he yanks his IV tube out in a panic when the doctor warns of a potentially dangerous interaction between the erectile dysfunction drug and the nitroglycerin drip he just started.

The scene gets big laughs, but there’s nothing funny about the danger when hospitals have inaccurate or incomplete information about a patient’s medications. With drug errors responsible for killing more than 7,000 hospitalized patients a year, new national patient-safety standards, which went into effect in January, require hospitals to have formal processes known as “medication reconciliation.” This means hospitals must have a set routine for collecting complete drug and allergy histories and comparing them with new medications that doctors order. The aim is to avoid problems both while patients are in the hospital and when they are discharged with new drug regimens.

Joint Commission Issues Alert to Improve Medication Safety | JCAHO | 1.25.06

The Joint Commission on Accreditation of Healthcare Organizations today issued a new Sentinel Event Alert that urges intensified attention to the accuracy of medications given to patients as they transition from one care setting to another, or one practitioner to another. The failure to reconcile medications during these transitions can cause serious patient injuries and even death.

According to the Alert., medication reconciliation should occur whenever a patient moves from one location to another location in a health care facility (for example, from a critical care unit to a general medical unit); or from one health care facility to another or to home; and/or when there is a change in the caregivers responsible for the patient. When effective medication reconciliation does not occur, patients may receive duplicative medications, incompatible drugs, wrong dosages, or wrong dosage forms among the array of potential errors. The medication reconciliation process also provides an important opportunity to assure that the patient is receiving all medications necessary to his or her care and to eliminate any medications that are no longer needed by the patient

Using medication reconciliation to prevent errors | JCAHO | 1.25.06

Transitions in care include changes in setting, service, practitioner or level of care. This process comprises five steps:

1. develop a list of current medications;
2. develop a list of medications to be prescribed;
3. compare the medications on the two lists;
4. make clinical decisions based on the comparison; and
5. communicate the new list to appropriate caregivers and to the patient.

[T]he Joint Commission recommends that health care organizations consider:

1. Placing the medication list in a highly visible location in the patient’s chart and including dosage, drug schedules, immunizations, and allergies or drug intolerances on the list.
2. Creating a process for reconciling medications at all interfaces of care (admission, transfer, discharge) and determining reasonable time frames for reconciling medications. Patients, and responsible physicians, nurses and pharmacists should be involved in the medication reconciliation process.
3. On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications* that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with him or her and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists and other caregivers.
4. When the patient is unable to actively or fully participate in the medication reconciliation process and has requested assistance from another person(s) (e.g., family member, significant other, surrogate decision maker), involve the authorized person(s) in the medication reconciliation process. This involvement should occur at all interfaces of care, and on admission to and discharge from the facility.

The Medication Reconciliation Process ( PDF) | JCAHO | 5.21.06

See PDF

This is a very important aspect of care, but fraught with so many obstacles and assumptions. If you can convince some family member or friend to go to the home and bring in the “BOM” (better yet, if EMS would only remember too; I can’t tell you how many times I hear “the captain got the meds”—poor cap’ always getting the blame… ) you will be shocked as to how many different medicines “the white one” really is. Not to mention polypharmacy is almost always accompanied by “polypractitioner” (too many chefs and too many kitchens). One patient I had seen once was reported by the California CURES program as seeing over 50 practitioners within 4 months. Of course this was for certain controlled substances and represents one extreme; but I have no doubt that we would find similar stats with antibiotics and many of the other common classes of drugs.

The typical MRF I see in the ED is:

• completely blank;
• says “see medication list”;
• lists “the white one” and “the blood pressure one”;
• the patient’s best guess at name;
• the patient’s best attempt at spelling;
• the nurse’s best guess at name;
• the nurse’s best attempt at spelling (of course this applies to the physician—that’s why we scrawl);
• name without dose;
• name without interval;
• etc.

And then, have you reviewed the medication list and acknowledge any changes… Right, review and acknowledge a two page list of over twenty medications all for a 10 minute visit for the treatment of an ingrown nail. The real-world need for the MRF does not jive with the realities of the ED and what the public commonly perceives to be emergencies. Where is this going—it has to go to a true universal EHR—anything short of this and we will be forever mired in documenting what a horrible health system we have. Lofty and needed goals, but the devil is in the execution. The ship will never be held fast as long as the predicate is BYOM and mandatory self-stringing of the weakest links—GIGO.

See here.

Robbing Peter to Pay Paul

U.S. Plan to Lure Nurses May Hurt Poor Nations | NYT | 5.24.06

As the United States runs short of nurses, senators are looking abroad. A little-noticed provision in their immigration bill would throw open the gate to nurses and, some fear, drain them from the world’s developing countries.

The legislation is expected to pass this week, and the Senate provision, which removes the limit on the number of nurses who can immigrate, has been largely overlooked in the emotional debate over illegal immigration.

…

Based on surveys, Dr. Galvez Tan estimates that 80 percent of the country’s government doctors have become nurses or are enrolled in nursing programs, hoping for an American green card. “I plead for justice,” he said in a telephone interview. “There has to be give and take, not just take, take, take by the United States.”

Doctor to nurse, all for a green card—what about nurses from Canada and South Africa? I’ve known many, and all are excellent.

How to install Linux for the total n00b

How to install Linux for the total n00b | NCAAbbs.com | 5.21.06

via digg

I have walked people through installing Linux soooooo many times, I have decided to write a definitive guide. This is that guide.

Lexicon: Leet, n00b

See translators: 1337, Google, Jay’s

Voice Encryption May Draw US Scrutiny

Voice Encryption May Draw U.S. Scrutiny | NYT | 5.21.06

del.icio.us tags: Technology VoIP Cryptography

On Sunday, he released a free windows software program, Zfone, that encrypts a computer-to-computer voice conversation so both parties can be confident that no one is listening in. It became available earlier this year to Macintosh and Linux users of the…

Lexicon: Cryptography, Telephony, VoIP

21M and Folding Tents

Tenet Settles San Diego Hospital Suit | WSJ | 5.17.06

Tenet Healthcare Corp. agreed to pay $21 million as part of a civil settlement reached with the U.S. Attorney in San Diego to resolve a criminal case after two separate federal juries were unable to reach a verdict on charges first brought by a grand jury in mid-2003.

…

The lawsuit concerned physician-relocation agreements at Alvarado Hospital, a 311-bed Tenet hospital. In order to conclude the settlement, Tenet acceded to a demand that it sell or close Alvarado Hospital or have the hospital face exclusion from federal health-care programs.

Tenet plans to classify Alvarado Hospital as discontinued operations starting in the second quarter, and said it may incur impairment and restructuring charges for the sale or closure of the hospital.

…

The OIG alleged that from 1992 to 2003 Alvarado entered into physician relocation agreements through which Alvarado funneled money to existing physician practices in the San Diego area in exchange for patient referrals. The agreements mainly benefited the established physician practices where the new doctors were placed, the agency said.

Alvarado Hospital to be closed or sold in lawsuit settlement | SDUT | 5.17.06

…

As part of its settlement with the U.S. Attorney’s office, Tenet Healthcare Corporation of Dallas also agreed to pay $21 million, according to a statement from Tenet released Wednesday morning.

The settlement averts a third criminal trial over an alleged kickback scheme between 1992 and 2002 to pay doctors for referring patients to Alvarado. Two previous trials, in 2004 and 2005, ended in deadlocked juries.

…

Dr. Ted Mazer, an Alvarado physician and president of the San Diego County Medical Society, said closing Alvarado “would be devastating to the East County.

…

Tenet Agrees to Divest Alvarado Hospital (PDF) | OIG | 5.17.06

Inspector General Daniel R. Levinson announced today that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) and Tenet Healthcare Corporation reached an agreement concerning Tenet’s divestiture of Alvarado Hospital Medical Center (Alvarado). This agreement resolves OIG’s possible exclusion of Alvarado from participation in Medicare and all other Federal health care programs.

On May 8, 2006, OIG notified Tenet that OIG intended to propose to exclude Alvarado based on Alvarado’s alleged payment of kickbacks to physicians. Alvarado had 30 days from that prior notice to submit to OIG documentary evidence and written argument concerning the proposed exclusion. The OIG would have considered any materials submitted by Tenet when determining whether to propose an exclusion. If OIG had proposed an exclusion, Tenet would have had the right to an administrative appeal prior to the exclusion going into effect. The agreement reached today allows Tenet to sell Alvarado prior to OIG initiating an exclusion of the hospital.

Today’s agreement allows for the orderly transfer of the hospital to a new operator in a manner that would not affect access to hospital services in the community. If Tenet chooses to close Alvarado, OIG will work closely with the Centers for Medicare and Medicaid Services and state and local authorities to ensure community access to emergency and other hospital services.

Tenet Announces Civil Settlement in San Diego Hospital Case | Press Release | 5.17.06

…

In order to conclude the settlement, Tenet acceded to the demand of the Office of Inspector General in the U.S. Department of Health and Human Services that the company sell or close the hospital within a specified period of time or have the hospital face exclusion from federal health care programs such as Medicare. The OIG had announced the potential exclusion of the hospital on May 8. Tenet will classify the operating results of Alvarado in discontinued operations beginning in the second quarter of 2006. Tenet said it may incur impairment and restructuring charges as a result of the sale or closure of the hospital.

“It has always been our strong desire to keep this hospital and continue providing needed health care to the residents of East San Diego County, as we have at Alvarado for more than 30 years. Unfortunately, we were given no choice by the government except to sell or close the hospital if we wanted to settle this matter,” said Peter Urbanowicz, Tenet’s general counsel.

As part of the civil settlement, Alvarado and the Tenet subsidiary that owns the hospital denied the government’s allegations in the indictments. In both trials, they strongly maintained that physician relocation agreements are a common practice in the hospital industry as a means to bring needed health care resources to communities. However, Alvarado and the Tenet subsidiary agreed to include this explanatory statement as part of the settlement agreement:

• “The Alvarado case has been a sobering event for Tenet, and it has led to significant reforms and strengthening of compliance standards for physician relocation agreements at all Tenet hospitals, and at hospitals across the country.”
• “Between 1992 and 2002, the hospital and its former chief executive officer, Barry Weinbaum, recruited approximately 100 physicians to East San Diego County. The hospital’s relocation program provided money to these physicians to assist them in starting new practices in the area.”
• “Several of the relocated doctors joined `host practices’ of established physicians who were already affiliated with Alvarado and who referred patients to Alvarado. We were distressed to learn that certain host physicians had obtained excessive payments by representing that they needed money to make tenant improvements to accommodate new physicians when, in fact, they never made improvements. We regret that the hospital did not take adequate steps to assure that money provided to relocated doctors, including money earmarked for tenant improvements and office overhead was in fact used for those purposes and in all instances was justified. We were also distressed to learn as a result of the government’s investigation that Mina Nazaryan, a former Alvarado hospital employee, received payments from certain host doctors who received financial assistance from the hospital.”
• “We have always had a disagreement with the government over whether anyone at Alvarado knowingly set out to violate the law in connection with these physician recruitments, but we have never disputed that there are aspects of how the recruitment program operated that are troubling.”

…

What the jury could not provide…

See also:

• Unlucky in Court
• 52 Days for a Mistrial
• delicious :: 3.9.06
• delicious :: 3.7.06
• Tenet in the Dock
• Dismissive Fraud
• Relocation Plea Bargain
• Relocation Kickback
• Tenet Can’t Stay Off of Page A1

California Grade D

Nursing Shortage Report Card (Press Release PDF, Report PDF) | CINHC | 5.9.06

{modified}

CINHC is a 501(c)(3) nonprofit organization dedicated to collaboratively developing statewide solutions to a critical nursing shortage and related nursing issues that affect the health of all Californians.

In the first statewide study of its kind, an analysis of 24 California regions shows that the ratio of RN jobs (actual positions filled) per 100,000 population is lower in all but two regions than the U.S. average, according to the California Institute for Nursing and Health Care (CINHC). Half of the areas earned letter grades of D or F.

The 24 regions evaluated correspond to the U.S. Census Bureau’s “metropolitan statistical areas” or MSA’s (Counties within the MSAs can be found in the full report online at www.chcf.org). The highest mark was the Redding MSA with a B grade. There were no A’s. Other grades and study findings include:

• C: Sacramento; San Francisco; San Jose; Vallejo-Fairfield-Napa
• C-: Chico-Paradise; Fresno; Los Angeles-Long Beach; Modesto; Oakland; Santa Rosa
• D/D-: Orange County; Riverside- San Bernardino; Salinas; San Diego; San Luis Obispo-Atascadero-Paso Robles; Santa Barbara-Santa Mario-Lompoc; Santa Cruz-Watsonville; Stockton-Lodi
• F: Bakersfield; Merced; Ventura; Visalia-Tulare-Porterville; Yolo
• the range of RN jobs to population was from a low of 257 in Merced to a high of 1,079 in Redding
• only the Redding and San Francisco statistical areas exceeded the national average, with 1,079 and 864
  RNs jobs per 100,000 respectively. Redding’s grade reflects its role as the healthcare center for northern
  California
• Northern California areas fared slightly better than Southern California and the Central Valley
• compared to all other states, California received a D grade

According to the study, a “C” grade means the area has approximately the same ratio of RN jobs per 100,000 population as the U.S. average, which is 787. An A, B, or C+ means the region exceeds the national average. California averages just 622 RN jobs per 100,000 population, 20 percent lower than the U.S.

Nurse-patient ratio receives failing grades | Monterey County Herald | 5.10.06

Though the shortage may be bad now, Jones said, “we have an even worse shortage ahead of us. It’s really important that we work together before it gets any worse.”

Local officials say the county’s high housing costs exacerbate the challenge of hiring qualified nurses.

Natividad Medical Center may be the poster hospital for the state’s nursing woes. Unable to match the salaries of neighboring hospitals, traveling or temporary nurses have been an integral part of the hospital services. But that practice had further driven up costs, forcing the hospital further into the red.

Valley gets poor grade on nurse staffing levels | Fresno Bee | 5.10.06

Most regions in California lag behind the rest of the nation in the number of registered nurses, and the San Joaquin Valley fares worse than many parts of the state, according to a study released Tuesday by the California Institute for Nursing and Health Care.

The number of working registered nurses statewide was 622 per 100,000 people, below the national average of 787 per 100,000 people. The number earned the state an overall D grade in the report card, based on the deviation from the national standard.

See here, here, here, and here

Unlucky in Court

OIG Notifies Tenet of Potential Exclusion of Alvarado Hospital (PDF) | OIG | 5.8.06

Inspector General Daniel R. Levinson announced today that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has notified Alvarado Hospital Medical Center (Alvarado) and its parent company, Tenet HealthSystem Hospitals, Inc., of OIG’s intent to exclude Alvarado from participation in Medicare, Medicaid, and all other Federal health care programs. Today’s notice is based on OIG’s allegation that Alvarado knowingly and willfully paid kickbacks in order to induce referrals of patients to Alvarado for the furnishing of items and services payable by Federal health care programs.

OIG alleges that, from 1992 to 2003, Alvarado entered into physician relocation agreements through which Alvarado funneled money to existing physician practices in the San Diego area in exchange for patient referrals. Although the relocation agreements were purported to benefit the doctor who actually relocated to the San Diego area, in practice, the agreements primarily benefited the established physician practices where the new doctors were placed. OIG contends these often-excessive payments actually were used to buy referrals. The agreements typically provided the new physician a monthly salary and a monthly guarantee for overhead expenses. The new physician paid this money over, in large part, to the established practice. The agreements also provided the existing physician practices directly with money intended to make improvements to their offices and purchase equipment necessary to accommodate the new physician.

Alvarado was indicted on felony kickback charges in the Southern District of California for this conduct. The United States Attorney’s Office for the Southern District of California tried Alvarado for this conduct in two jury trials that both ended with hung juries.

Inspector General Daniel R. Levinson stated, “Today’s announcement should be a continuing reminder to health care providers that referrals of Federal health care program beneficiaries should be based on the quality of care that is to be provided to the beneficiary, and not as a result of a financial benefit to be realized by the source of the referral or the practitioner providing the services.”

Alvarado has 30 days to submit documentary and other evidence concerning the proposed exclusion and whether it is warranted. After reviewing the additional information Alvarado provides, OIG may propose to exclude Alvarado from participation in Federal health care programs. Alvarado would have the right to an administrative appeal of the proposed exclusion.

Unlucky in court leads to near-death by Medicare/Medicaid exclusion. Perhaps Tenet needs to distinguish between the bark and the bite of conviction of the institution v. death of the institution. This is really hardball now.

See also:

• 52 Days for a Mistrial
• delicious :: 3.9.06
• delicious :: 3.7.06
• Tenet in the Dock
• Dismissive Fraud
• Relocation Plea Bargain
• Relocation Kickback
• Tenet Can’t Stay Off of Page A1

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