Monday, November 30, 2015
By: Kelli Robinson, Kelli is a member of the Health Care Law Consulting Group at Sirote & Permutt, P.C. She also serves as a hearing officer for the Board of Dental Examiners of Alabama.
Most healthcare practitioners have heard of the National Practitioner Data Bank (NPDB), but many are unfamiliar with exactly what it is, how it operates, and what implications it might have on a healthcare practitioner’s career. The NPDB acts as a national clearinghouse for information relating to the professional competence of healthcare practitioners, and it is administered by the Health Resources and Services Administration (HRSA), a division of the United States Department of Health and Human Services (HHS).
The information reported to the NPDB is intended to be used in combination with information from other sources in making determinations on employment, affiliation, clinical privileges, certification, licensure, or other decisions. Hence, if the name of a physician or dentist, or other healthcare practitioner, is found in the NPDB, it could affect the ability of that healthcare practitioner to obtain privileges with a hospital or a state license.
On April 6, 2015, the HRSA released a revised NPDB Guidebook - the first update in more than ten years. An electronic copy of the 2015 NPDB Guidebook can be found on the NPDB web site (www.npdb.hrsa.gov).
The 2015 NPDB Guidebook contains detailed information about what entities and individuals must or may query the NPDB, including information about the type of information available to the specific entities or individuals and how the specific entities and individuals are permitted to use the information they obtain from the NPDB.
Following are two examples of federally-mandated queries of the NPDB:
• Hospitals are required to query the NPDB when a physician, dentist, or other healthcare practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital, including temporary privileges.
• Every two years, hospitals are required to query the NPDB on all physicians, dentists, and other healthcare practitioners who are on its medical staff (courtesy or otherwise) or who hold clinical privileges at the hospital.
Other healthcare entities may query the NPDB when they have or may be entering into employment or affiliation relationships with healthcare practitioners; when healthcare practitioners apply for clinical privileges or medical staff appointments; and/or when they are engaging in professional review activity.
Entities like health plans and state licensing and certification agencies also may query the NPDB when they are determining the fitness of individuals to provide healthcare services; when they are protecting the health and safety of individuals receiving healthcare through programs they administer; and/or when they are protecting the fiscal integrity of programs they administer.
Practice Pointer: A healthcare practitioner may self-query the NPDB at any time by submitting a request through the NPDB web site (www.npdb.hrsa.gov) and paying a small fee (currently $5.00). Healthcare practitioners should regularly request a NPDB self-query to ensure all information in the data bank is correct. If any inaccurate information is discovered, promptly follow the steps below to correct or dispute the NPDB report.
NPDB reporting requirements by entity are set forth in detail in the 2015 NPDB Guidebook. Below is a summary of the information required to be reported to the NPDB:
• Medical malpractice payments resulting from a written claim or judgment;
• Certain adverse licensure actions related to professional competence or conduct;
• Certain adverse clinical privileges actions related to professional competence or conduct;
• Certain adverse professional society membership actions related to professional competence or conduct;
• DEA controlled substances registration actions;
• Exclusions from participation in Medicare, Medicaid, and other Federal health care programs;
• Negative actions or findings by peer review organizations;
• Negative actions or findings by private accreditation organizations;
• Exclusions from participation in State health care programs;
• Health care-related civil judgments in Federal or State court;
• Health care-related Federal or State criminal convictions;
• Federal licensure and certification actions; and
• Other adjudicated actions or decisions.
Information reported to the NPDB is maintained permanently unless it is corrected or voided from the system.
Practice Pointer: Healthcare practitioners at risk of being reported to the NPDB should immediately consult with experienced legal counsel to assess whether there are opportunities to avoid a report to the NPDB. Even when a NPDB report must be made by a reporting entity, legal counsel can help mitigate the adverse consequences of a report by negotiating the wording of the report, as well as classification codes and basis of action codes.
Subject Statements and the Dispute Process
When the NPDB processes a report, the NPDB notifies the subject of the report. The notification provides instructions for obtaining an official copy of the report from the NPDB web site.
The subject of a report submitted to the NPDB should review the report for accuracy, including the description of the reported event. If any information in the report is inaccurate, the subject of a report can request that the reporting entity file a correction. The NPDB is prohibited by law from modifying any submitted information, even if the healthcare practitioner who is the subject of the information can prove its inaccuracy.
If a reporting entity refuses to change the report it submitted to the NPDB, the affected healthcare practitioner may initiate a dispute to the NPDB and/or add a statement to the NPDB report, which any subsequent requestor would receive. The dispute process allows a healthcare practitioner to protest the factual accuracy of the report or whether the report was submitted in compliance with the NPDB reporting requirements. A healthcare practitioner, however, is prohibited from disputing the underlying reasons for the reports, such as the merits of a medical malpractice claim or the appropriateness of, or basis of, other types of reports.
Practice Pointer: A healthcare practitioner should seek the assistance of experienced legal counsel before determining the best way to respond to an inaccurate NPDB report, including contacting the reporting entity directly, drafting a subject statement for inclusion with the NPDB report, and/or navigating the NPDB dispute resolution process.
Reports to the National Practitioner Data Bank can have a significant impact on a healthcare practitioner’s future. Therefore, it is important for healthcare practitioners to understand how the National Practitioner Data Bank operates, as well as the healthcare practitioner’s rights with respect to the information reported, how information is reported, who is allowed access, and what can be done to ensure the accuracy of the information in the National Practitioner Data Bank. Finally, healthcare practitioners must be aware of which types of adverse actions will be reported to the National Practitioner Data Bank and should take care to mitigate any potential future impact.
Wednesday, November 25, 2015
By: Matthew Stoll, M.D., Ph.D., MSCS, treats pediatric rheumatology patients at Children’s of Alabama. Dr. Stoll is also an associate professor in the University of Alabama at Birmingham Department of Pediatrics, Division of Pediatric Rheumatology.
The Pediatric Spondyloarthritis Clinic at Children’s of Alabama is devoted to the clinical care and research of children diagnosed with juvenile spondyloarthritis. The clinic was established in March 2014. Today, more than 150 children are being treated for spondyloarthritis at Children’s.
According the Arthritis Foundation, nearly 300,000 children — from infants to teenagers — in the United States have some form of arthritis. Juvenile idiopathic arthritis (JIA) is the most common type of arthritis in children, in which the immune system mistakenly attacks the body’s tissues, causing inflammation in joints and potentially other areas of the body.
Spondyloarthritis is one of six types of JIA. It involves inflammation and tenderness in areas where the ligaments and tendons attach to the bones, accompanied by pain and swelling in the joints. In some cases, spondyloarthritis primarily affects the spine. Some forms can affect the peripheral joints, primarily — but not exclusively — those in the legs. Typical symptoms are low back pain and stiffness, joint swelling and pain in areas such as the Achilles tendon.
In addition, some patients with spondlyoarthritis may experience inflammation in parts of the body other than the joints. My research has focused specifically on the links between inflammation in the gut and in the joints of children and adults with spondlyoarthritis.
Children who are referred to the weekly Pediatric Spondyloarthritis Clinic benefit from the continuity of care from a team of doctors with targeted clinical expertise in this area. While there are few effective therapeutic options in the management of spondlyoarthritis, current treatment regimens include conventional therapeutic drugs, as well as newer biologic therapies.
While the exact cause of juvenile idiopathic arthritis, including spondlyoarthritis, remains unknown, clinic patients can participate in our ongoing research that will help advance understanding of pediatric spondyloarthritis.
The Pediatric Spondyloarthritis Clinic also provides screening and treatment specifically for temporomandibular joint arthritis (TMJ), a joint frequently ignored in children with JIA as a whole.
To refer a patient, please contact the Pediatric Rheumatology Clinic at 205-638-9438.
The Division of Pediatric Rheumatology at the University of Alabama at Birmingham (UAB) and Children's of Alabama was created in 2007 in response to a great need for pediatric rheumatic care in the state of Alabama, the largest state population without a pediatric rheumatologist at the time. A partnership between UAB, Children’s, the local chapter of the Arthritis Foundation and the greater Birmingham community helped to establish new clinic space, the creation of an endowed chair in Pediatric Rheumatology and ongoing support for the growth of the division.
Tuesday, November 24, 2015
By: Nathan Ross, MD, OB/GYN at Brookwood Medical Center
This month Brookwood Medical Center was excited and honored to be the first hospital in Alabama and the sixth hospital nationwide to receive the Joint Commission Perinatal Certification. As Alabama’s first women’s hospital, Brookwood has continued to push the envelope in providing high quality medical care to both mothers and their newborn infants.
The Joint Commission has recently initiated a program that recognizes hospitals that are committed to achieving integrated, coordinated and patient-centered care for mothers and their newborns. Brookwood saw this as an opportunity to demonstrate the quality work that has been ongoing for years. Members from multiple departments including obstetrics, neonatology, pediatrics, anesthesiology, and our nursing staff worked together to prepare for the onsite review which occurred in October.
Some of the key requirements included:
• Integrated, coordinated patient-centered care that starts with prenatal and continues through postpartum care
• Early identification of high-risk pregnancies and births
• Management of mothers’ and newborns’ risks at a level corresponding to the program’s capabilities
• Available patient education and information about perinatal care services
As one of Alabama’s busiest maternity hospitals, Brookwood feels that this is yet another way to help demonstrate the commitment to quality maternal and neonatal medical care. The team approach that we were able to demonstrate to the Joint Commission was self-evident and the quality of the services and programs was able to shine as well. Our commitment to improve care in the areas of elective inductions, cesarean section rates, and breast feeding rates were at the forefront of the review process. Not to be lost in the maze of numbers and statistics, we were able to share personal stories of success and triumph as well.
Brookwood looks forward to sharing with other hospitals the ways in which we were able to excel and we look forward to providing quality maternal and neonatal care far into the future of an ever changing world of medicine.
Dr. Nathan Ross is a board-certified OB/GYN at Brookwood Medical Center. Learn more about Brookwood women’s services at iChooseB.com .
Thursday, November 19, 2015
By: Julian Carlo, MD, surgeon at The Brookwood Orthopedic Sports Medicine Institute
The thumb is an essential part of our anatomy and one of humans’ most important anatomic features. The thumb plays a vital role in most hand functions through a combination of flexibility and strength. The carpometacarpal (CMC) joint of the thumb is integral in providing the thumb the flexibility to position itself in space. The joint’s complex saddle-like morphology allows it to abduct, oppose, and rotate the thumb into numerous positions necessary for the hand to deftly interact with the world and its objects. The large thenar muscles can apply forces delicate enough for a precision pinch or strong enough for a power grip. Given its importance, it should be no surprise that without the thumb, the hand loses about 50% of its function.
Although the CMC joint seems elegantly designed, the freedom of mobility and tremendous demands placed on the thumb can predispose it to developing osteoarthritis. The biomechanical design of the thumb concentrates forces on the CMC joint by a factor of 12 times the original applied force. In addition, the laxity essential for allowing wide range of motion often translates into instability, which can increase joint contact forces and accelerate cartilage wear. As a result, the thumb CMC joint is one of the joints most susceptible to osteoarthritis. Up to one in four post-menopausal women may be affected.
Most patients present with complaints of activity-related pain, aching, or burning at the base of the thumb that results in functional disability. Activities that are particularly painful include a forceful pinch (such as when holding dishes, turning a key, or pulling up a pair of pants), the positioning of the joint at extremes of motion (such as reaching across to the small finger), and a forceful grip (such as opening a jar). On exam, reproduction of symptoms by palpation at the CMC joint or an axial “grind” test are suggestive of the diagnosis. Radiographs show findings typical of arthritis, including joint space narrowing, sclerosis, erosion, loose bodies, and osteophytes.
When I see patients with this condition, I feel it is important to lay out the goals of care: reduction of pain and improvement of function. Patients should embark on a trial of nonoperative treatment because many people can improve without surgery. Activity modification, use of assistive devices, and splinting the thumb CMC joint are a good place to start. Nonsteroidal anti-inflammatories or acetaminophen can also help improve symptoms. Injecting the CMC joint with corticosteroid or a hyaluronidase can also provide relief that may help delay or eliminate the need for surgical treatments.
When should a patient be referred to a hand surgeon? It is appropriate for primary care physicians or other healthcare providers to diagnose and initiate care for this common condition as described above. Patients can be referred if they are failing nonoperative management and surgery is anticipated. Referral can also be initiated at any time in treatment, if the diagnosis is uncertain, or if more specialized treatment such as a CMC joint injection is desired.
When nonoperative management has failed to adequately improve the overall condition, it is reasonable to consider surgery. Many patients are unaware that a surgery can help their condition. There are a number of outpatient surgical procedures that reliably improve pain and function. The most common surgeries include excision of the trapezium with or without a reconstruction of ligaments that stabilize the thumb. In young patients a fusion of the joint may be indicated. Other procedures that preserve the trapezium or replace the joint have been devised. The surgeon will decide which operation is best for a patient’s particular presentation. Postoperatively patients require a short period of immobilization and most benefit from hand therapy to regain motion and strength. Improvement in pain, strength, and function can reliably be achieved, and there is generally a high satisfaction rate after surgery.
Julian Carlo, MD is an orthopedic hand and upper extremity surgeon at The Brookwood Orthopedic Sports Medicine Institute. For questions, appointments, or referrals call (205) 877-BONE (2663).
Tuesday, November 17, 2015
By: Dr. Thomas Holley, Urology Centers of Alabama
Prostate cancer continues to be a major public health problem in American men particularly those in Alabama. The death rate in Alabama from prostate cancer is too high. One of the particularly disturbing problems has been the lack of early diagnosis in African American men. Since 2007 we have supported a major effort to bring early detection opportunities to the underserved men of our state.
Recent statistics from the Alabama Department of Public Health have shown that the disparity in early stage at diagnosis between black and white men has been eliminated. We are encouraged that the death rate from prostate cancer continues to decline nationwide as well as in Alabama. Of particular interest the death rate among black men in Alabama has declined at an even faster rate.
The physicians of Urology Centers of Alabama are very concerned that the US Preventive Task Force has recommended against prostate cancer screenings. As a result of their recommendations the incidence of prostate cancer has declined over the past few years. Prostate cancer has not gone away it is just not being diagnosed at the same rate. Our fear is that many of the men who were not diagnosed early will be seen in a few years with late stage prostate cancer. This could have been prevented. The physicians at Urology Centers of Alabama continue to be strong advocates of prostate cancer screening as well as innovations to make screening more effective (see notes below).
Some of the challenges in prostate cancer diagnosis and management involves potential over diagnosis and over treatment. One of the areas of importance is trying to determine which men who have had a negative prostate biopsy should have a repeat biopsy. In an attempt to answer that question Urology Centers of Alabama joined with several national and internationally respected prostate cancer centers to study this problem.
The group found that using a methylation intensity-based algorithm performed on the negative biopsy specimens could help predict which men harbored high grade prostate cancer and thus needed to be rebiopsied.
The implication of this methodology could be far reaching by avoiding unnecessary biopsies and in men with positive biopsies segregating likely under graded men from active surveillance candidates.
Urology Centers of Alabama remains committed to excellences in prostate cancer care.
Tuesday, November 10, 2015
By: Susan (Zeisler) Pretnar
President at KeySys Health LLC
You may be thinking ‘Please…spare me another acronym!’. Most practices are already struggling with identifying, securing and maximizing the information technologies (IT) they’ve installed. Needing IT to manage patient relationships seems to complicate what is thought to be a comfortable, face-to-face space between the patient and the caregiver: doctor, nurse or other traditional clinician. So, what do Millenials have to do with patient relationship management (PRM)? They’re the tsunami coming our way. The future health care delivery model is quickly morphing, in no small way due to the digital natives among us.
The IT part of the healthcare story is no longer very clear, especially because of the proliferation of mobile devices and myriad data communication alternatives. The younger the caregiver and the deeper we get into the meaningful use of electronic medical records, the softer the protest at having been dragged into that world. A few are actually starting to see benefits, while others still feel hindrances.
IT has an impact on:
• Market share
• Patient acquisition and retention
• Employee satisfaction
• Brand image
• Profit margins
• Cost reduction
• Organizational efficiency/productivity
All of these things contribute to the practice and to patient relationships. If you are not aware of the potential impact of IT on the items in this list, you probably are not convinced that investing further in IT is a valuable ‘spend’ for your practice. Finding the long term ROI in IT expenditures for operations makes selecting the right ICD10 code seem simple. Until recently, healthcare had few of the characteristics of a ‘market’, including the influence of its users. It appears that a true healthcare market, foisted on us by the totally connected Millenials, may finally emerge. It would be one with standard benchmarks and recognizable comparatives. So, why does this seem to be happening now?
A finger can be pointed at the Millenials in our midst. As a group, they will become the largest demographic in the next 10 years. That means Millenials will represent the majority of the patients in your practice (estimated to be 75%), save for the average geriatric specialist. They have faith in technologies and services that can bypass the traditional doctor or hospital delivery systems. The shear size of their generation means that they will have an impact.
Millenials have already influenced many other industries, as a direct result of their swift adoption of digital gadgets. I say swift because truly the smartphone started it all, and was introduced a mere 8 years ago. Can you name a proven clinical practice or procedure that has been embraced by all of healthcare in less than 8 years? Even for non-Millenials, smartphones, tablets and wearable electronics are ubiquitous in everyday life.
Millenials are disrupting healthcare delivery systems just as they impacted traditional paper media, financial services, and brick and mortar sales of goods and services. They are comfortable getting their healthcare information from Google – and they believe it. Aren’t we all getting just like them? We also want same day appointments, online scheduling and bill payment, electronic access to our medical records and the option to text or email our providers. And, we all assume someone else is handling privacy and security matters.
Providers say that it is not their fault that patients aren’t ‘engaged’, but we may soon be crying that Millenials are pushing us too fast to accept bi-directional communication with them. They believe that their patient generated health data (ugh - PGHD!) is valuable information to share, not just on Facebook, but also with their doctor. They already self-monitor with Fitbits or one of the 40,000 health related apps they can download to multiple mobile devices. This group is questioning the traditions of healthcare: where it is delivered and by whom.
I bought a smartphone in order to communicate with my grandchildren (text only of course), and to enable me to access business emails from literally anywhere in the world. We’re pushed privately and professionally to adopt the latest technologies. Secure IT belongs in any strategy around patient relationship management. Perhaps it is beyond time for healthcare to accept the meaningful use of technology, instead of quibble over the meaningful use of electronic medical records. As has been eloquently stated by others ‘if we are going to live in interesting times, there is no reason not to embrace them’.
Monday, November 9, 2015
By Jeremy Beck,
Director of Sales and Business Development at Integrated Solutions
Most clinic administrators have lost sleep wondering if their doctor’s texts are HIPAA Compliant. Is it okay for the doctor to receive and send sensitive patient data over their phone? What if they lose their phone?
So, are your doctor’s text messages secure and compliant? The answer under the HIPAA guidelines is yes as long as “administrative, physical and technical safeguards exist that ensure the confidentiality, integrity and security of electronically stored or transmitted private health information.” This statement might be even more confusing to you so let’s look below at somethings that might make this a bit clearer.
WHY ARE TEXT MESSAGES NOT SECURE?
- You Use SMS For Your Phone or Tablet
o First, you likely use SMS for your phone or a tablet. SMS stands for Simple Message Service and is the underlying protocol that all text messages use. The primary transmission methods (protocols) used for SMS are not encrypted
- Text Messaging is, By Default, Not Secure
o Text messaging by default is not sent or received in a secure manner although some cellular providers provide additional security methods. In other words, the messages can be intercepted and read as plain text.
WHAT CAN YOU DO ABOUT IT?
- Create Solid Clinic Rules
o In order to safeguard against PHI data loss on these devices and to safeguard messages sent and received via text messaging, clinics need to have policies in place stating guidelines for what is acceptable use on portable devices and what to do in case of a breach.
- Encrypt it
o The clinic should protect the transmission of data by encrypting it. There are many good products on the market that will provide secure text messaging as well as the ability to delete the data from a portable device should it become lost or stolen. Encrypting mobile devices like Apple, Android and Windows can be accomplished by using a 3rd party application such as Wickr, Gliph, MeOnCloud or WhisperSystems. These applications can help for SMS encryption and can help to ensure that patient data is protected.
- Erase the phone
o Your doctors and staff might not like this response but applications need to be in place so that smartphones and tablet data can be remotely deleted. If the phone or tablet is lost or in question you can delete the data remotely.
By Bill Cockrell,
President - Cockrell, Egeland and Associates, LLC
Thirty plus years ago, when I first got into medical practice management, I was the practice administrator for a small primary care group. Right before he left, the previous administrator had purchased a business card sized listing in the yellow pages (yes, once people really used the paper version). It simply listed the practice, the physicians, the address and phone number – that’s it. When I started, I was told one of my first jobs was to write a letter of “apology” to the Medical Society for using “advertising” to attract patients. It’s commonplace now but, at that time, no professionals (doctors, accountants, and even attorneys) talked about themselves in ways that could be construed as marketing. Yes, things have indeed changed.
Today, it’s hard for physicians to market themselves on television because all the good slots are taken up by attorneys. Kidding of course but, the reality is that medical marketing does occur, even if a physician doesn’t lift a hand. It’s through insurance carrier provider network listings, hospitals pushing their physician networks and other organizations with something to gain. On top of the normal channels, anything that appears on social media, whether it deals with a practice or not (for example, waiting too long to see the doctor, poor bedside manner or even big game hunting), is a form of marketing, positive or negative. Finally, go on any major insurance provider’s website, including Medicare, and plenty of information on patient satisfaction, quality and cost, among others, are easy to find.
So, does it matter if a practice markets itself? Yes. Absolutely yes. As stated, there’s a lot of information out there. However, explanations on what the information means, is lacking and, often, clear only to those who put it together for their needs. On the CMS (Medicare) Physician Compare website, it states “CMS has continually worked to make the site function better, improve the information available, and provide useful information about physicians and other health care professionals who take part in Medicare. This ongoing effort, along with the addition of quality measures on the site, helps Physician Compare serve its two-fold purpose:
Provide information to help consumers make informed decisions about their health care and create clear incentives for physicians to perform well.”
Consumer information includes what “CMS indicated that the first measures available for public reporting on Physician Compare would be the 2012 PQRS GPRO measures collected via the GPRO Web Interface for groups of 25 or more eligible professionals.”
This will not be limited to larger groups of course but, despite the intentions of CMS, when it’s hard for us to understand what PQRS measures mean, what happens when that information gets in the hands of a consumer who has only a government explanation to help them understand it. Now, what do we do? We educate (market). By being proactive in showing our own data, patient satisfaction or any sound quality data we help the patient understand what the information represents and how to use it. That’s called productive marketing through education. We can even use provider data and explain what it means. And, on top of the information, we can use the same information to target populations groups based on demographics or referring physicians based on the type patients they care for.
If a provider / practice wants to thrive, what about gathering the information that’s out there already, verifying or adding to it through their own data and presenting it in an educational format to patients and providers is a real option. We’re not talking about contact information or cost. We’re talking about our own results and information. We’re not bad mouthing others, we’re truly educating. Of course, we’re going to benefit from the marketing element but, if a provider really does provide high quality care, in a cost efficient manner, it seems the provider, the payer and, most importantly, the patient, wins. That’s a pretty good outcome. The proliferation of data to the patient is happening whether we like it or not. Isn’t it better to manage the process rather than have it manage you?
The marketing prescription:
Gather your own, provable data
Learn what else is available about you
Repackage it in an understandable format
Identify the targets to get the information to
Deliver the message.
That’s marketing – no apology needed.
By: Brandon Schirg, Michael Staley
This blog was originally posted at Waller Healthcare Blog on 10/29/15 and modified on 11/3/15 for this publication.
On Monday, President Obama signed a two-year, $80 billion budget deal that raises the national debt limit as needed through March 2017 and pushes off the possibility of a government shutdown until after a new Congress and President have been elected.
Of particular concern to hospitals and other providers, the legislation will impact Medicare payments to hospitals by codifying the Centers for Medicare & Medicaid Services (CMS) definition of provider-based (PBD) off-campus hospital outpatient departments (HOPDs) as those locations that are not on the main campus of a hospital and are located more 250 yards from the main campus and limiting reimbursement to new off-campus HOPDs in the future.
The big winners seem to be hospitals with existing PBD HOPDs since they will be grandfathered in under the higher existing reimbursement model. They have the government to thank for giving them what many will call an unfair competitive advantage and the government to thank for new uncertainties surrounding their future growth and expansion. MEDPAC’s recommendations released earlier this year recommended not grandfathering in existing PBD HOPDs.
The biggest losers may be hospitals with PBD HOPDs currently incomplete that were under development or construction at the time the law was signed. The loosely worded law could ultimately be interpreted by CMS to eliminate their eligibility to receive reimbursements at the HOPD rate starting in 2017. The costs for those projects have already been incurred and communities and patients (especially in rural areas) will likely soon be asking lawmakers to help them prevent the government from picking winners and losers through an arbitrary deadline by striking the grandfathering clause.
Requirements for new off-campus HOPD locations to enter into new provider agreements leave the industry with many unanswered questions related to the following:
• Will the Medicare hospital conditions of participation apply to these locations?
• If outpatient surgical locations are required to enter into new provider agreements, will it be the provider agreement that is typically signed by ambulatory surgery centers (ASCs)? If so, does that mean the ASC conditions for coverage apply to the location, as well?
• If the outpatient location is treated as a physician clinic, what CMS coverage rules will apply to that location?
• If new provider agreements are required, will hospitals end up with multiple provider numbers?
• If new provider numbers are issued for the outpatient locations, will CMS allow larger healthcare companies to have the reimbursement payments that are paid to those new numbers deposited in a central bank account? Currently, CMS will allow this approach with amounts that are paid to Medicare Part A numbers but refuses to take that same approach with Medicare Part B numbers.
• How will the Medicare successor liability provisions apply to these new provider agreements?
• How will the effective date be determined for these new locations? For example, if an outpatient surgery department is treated as a new ASC, the location typically has to pass a CMS/accreditation survey before it can participate in Medicare. Would that apply here?
• Does Congress agree with CMS’s position that the 250-foot requirement for on-campus status is measured from the front door of the facility?
The legislation is likely to impact hospitals' physician-alignment strategies and reduce incentives for hospitals to buy physician practices and other ancillary service lines which many hospitals and health systems have done to expand networks and meet the Affordable Care Act's push for coordinated care.
The Federation of American Hospitals’ spokesman said the change in payment method to HOPDs is reasonable, thinking the current payment method was flawed and being exploited.
The American Hospital Association, meanwhile, said the proposed cut in funding to HOPDs is an untested idea which "may endanger patient access to care, especially among patients who are sicker, the poor, minorities and seniors who often receive care in hospital outpatient departments. Moreover, rural communities will be most adversely impacted, as hospitals will no longer be able to help physicians in these communities continue to provide access to their patients."
President Barack Obama stated, “Evidence suggests that in recent years, billing of many ambulatory services has been shifting from physicians’ offices to the usually higher paid hospital outpatient department setting, increasing Medicare spending and beneficiary cost-sharing.”
It is important for lawmakers in the U.S. House and Senate to hear directly from industry-related constituents as the new law is implemented at the agency level.
Staley is senior policy adviser at Waller (wallerlaw.com). He served as chief of staff for former Rep. Spencer Bachus (R-Ala.) from 2007 to 2014 and now works as a federal and state contract lobbyist, splitting time between Alabama and Washington, D.C.