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PHYSICIAN SPOTLIGHT PAGE 2
Mihir K. Patel, M.D., MSc
ON ROUNDS Surgeons to Patients: Is This Really Necessary? Doctors say sometimes waiting is the best option Before deciding on whether a surgical procedure is necessary, the patient and surgeon should be discussing a pile of questions that could end up being thick enough to cut with a scalpel ... 3
Reimbursement Revisit A look at payment innovation While physicians and facilities have long had to keep up with different negotiated contract rates among payers, the reimbursement landscape has become much more varied over the last few years as a push toward payment innovation has ushered in a host of reimbursement options ranging from shared savings programs to bundled payments to carrotand-stick compensation ... 4
Medicare Math
Or How a 2.3 Percent Raise Became a 3 Percent Reduction By CINDy SANDERS
At first glance, the FY-2015 revision of the Medicare hospital inpatient prospective payment systems (IPPS) by the Centers for Medicare & Medicaid Services (CMS) appears to offer acute care hospitals a 2.3 percent rate increase beginning this month. Dig deeper, however, and it looks more likely that Tennessee hospitals will actually realize less than last fiscal year for providing the same services. “It’s death by a thousand cuts,” explained David McClure, senior vice president for Finance & Medicare at the Tennessee Hospital Association. “What CMS gives you, they find a way to take back.” McClure, who has been with THA for nearly two decades, recently spent several weeks deciphering the 500-plus pages of the IPPS final rule, which was published in the Federal Register in August in advance of going into effect Oct. 1. “The inpatient rule controls the payment to hospitals for about $2.5 billion in the state of Tennessee,” he said. “This inpatient rule continues on with the implementation of provisions in the Affordable Care Act and the American Taxpayer Relief Act of 2012.” On the plus side of the payment equation for Tennessee hospitals, he noted, “The market basket update this year was 2.3 percent. That’s about $60 million.” However, McClure continued, those ‘new’ dollars are quickly offset when looking at reductions and penalties spread out through a number of (CONTINUED ON PAGE 6)
HealthcareLeader
Sandra Ray Administrator, Henry County Healthcare Center By SUZANNE BOyD
Not one to shy away from the unknown, Sandra Ray has taken on many new programs and projects throughout her 30-plus year career. That willingness to take on unchartered territory led her to realize her love of the nursing home side of healthcare. Today, as administrator of Henry County Healthcare Center in Paris, Tennessee, Ray is enjoying the nursing home side of things
while still capitalizing on her talent for new projects and programs as she leads. Ray, who hails from Central Arkansas and holds a Master’s degree in Operations Management from the University of Arkansas, entered the field of healthcare when she went to work at a hospital in Blytheville, Arkansas. Management quickly pegged her as the go-to-girl for special projects as she displayed quite a knack for getting (CONTINUED ON PAGE 9)
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PhysicianSpotlight
Mihir K. Patel, M.D., MSc By SUZANNE BOyD
When West Tennessee Gastro hired Mihir Patel, MD, MSc, in July, there was more than a new doctor in the area. Patel’s addition to the gastroenterology staff meant patients would have access to new technology and new treatments. Born in the Western part of India, where he also received his medical school training, it was Patel’s passion for caring for people that put him on the path to a career in medicine. It was marrying his wife, who grew up in Atlanta, Georgia, after medical school that landed him in Atlanta. “In India, your undergraduate work and medical school are combined and it takes almost six years to complete. You have the option of staying there for residency or going to another country. After considering several options, including staying in India, it was the reputation of the American healthcare system that led to my decision to come to the United States,” said Patel, who completed his medical education in 2005. “The practice of medicine is top notch in America, not only in terms of patient care but also in terms of the technology, innovation and research conducted. Once here, I knew it was where I wanted to practice medicine.” Coming from a foreign country meant Patel had to spend a little more than a year and a half taking exams and getting certified to start his residency training. While completing this requirement, he worked at Emory Hospital as a volunteer health assistant in the emergency department and as a research fel-
low in microbiology developing influenza vaccines. For his residency in internal medicine, Patel headed to the University of Louisville in Kentucky. Since he also had an interest in public health and clinical investigation, he took on the arduous task of pursuing his Master of Science in Clinical Investigation while completing his residency. “My days were spent as a resident and in the evenings I was a graduate student working towards my Master’s degree,” said Patel. By the time Patel completed his residency, he had developed a strong interest in endoscopy as well as continued research, some of which was award win-
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ning. Based on those achievements he matched with a gastroenterology and hepatology fellowship at the Mayo Clinic in Jacksonville, Florida. While at the Mayo Clinic from 2010 through 2013, Patel was involved with research in pancreatic cancer. Using advanced technology, specifically identifying pancreatic cancer from examining the small bowel. “This generated quite an interest in the medical community worldwide and even led to presenting the findings in an international conference,” said Patel. “My interest in pancreatic cancer led me to get advanced endoscopic training on more complex endoscopy procedures.” Patel’s training at the Mayo Clinic as well as during his one year advanced endoscopy fellowship at the Cleveland Clinic in Ohio included endoscopic ultrasound (EUS). This procedure utilizes a combination of endoscopy and ultrasound to evaluate the surrounding organs. He also received training in complex endoscopic retrograde cholangiopancreatography (ERCP) that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts. He is also trained in balloon endoscopy, which is a technique that allows for better visualization of the small bile in evaluating malignancies and small bile lesions. With his advanced procedure training complete, Patel knew he wanted be in a place where he could nurture not only the skills and training he had honed but also be a help to the community. His search led him to of all places, Jackson and the West Tennessee Gastro group
in July. “There was a strong need for the type of advanced procedures I was trained to do,” said Patel. “My wife and I liked Jackson and while we had offers other places, it was the people of Jackson that made it the place for us. We really liked the people and the community.” Since coming to Jackson, Patel has been busy. Bringing procedures such as EUS, Barrett’s ablation and balloon enteroscopy, to Jackson means patients who would otherwise had to have go to Memphis or Nashville can be treated at home. “Just increasing the awareness of what all we can now do here in Jackson is so important,” said Patel. “And there is so much more we can do, from collaborating with surgeons, oncologists and interventional radiologists to building programs for community health and providing more cancer screenings. I want to see us come up with a plan to be a part of community wide health initiative that goes beyond just treating patients in the hospital.” Patel’s research and training has caught the eye of the American College of Gastroenterologists. He was recently invited to serve on the College’s Training Committee, a position he is humbled to fill for the next three years.
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Surgeons to Patients: Is This Really Necessary? Doctors say waiting sometimes is the best option By LAWRENCE BUSER
Before deciding on whether a surgical procedure is necessary, the patient and surgeon should be discussing a pile of questions that could end up being thick enough to cut with a scalpel. Is this the right time? What are the alternatives? What if you don’t get the surgery? Do the benefits outweigh the risks? How long will the recovery be? What is the long-term prognosis? How important is my age? And that’s just for starters. Some doctors say a patient should do thorough research on the Internet and make lists of questions before deciding on non-emergency surgery. “I run into this issue a lot, and what I can tell you is patients need to speak up and not be afraid to talk to their doctor and bring up questions,” says William Mihalko, MD, professor and J.R. Hyde Chair of the Joint Graduate Program of Biomedical Engineering at the University of Tennessee Health Science Center. “In our elderly Dr. William Mihalko population when they get into their 70s a lot of times they’re not always proactive in asking the questions they may have.” Mihalko, who also is in the Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, adds, “My advice is that if something doesn’t seem right or they don’t understand something they need to speak up and ask their doctor. There are no stupid questions from a patient. Sometimes there’s that white-coat syndrome or patients get the deer in the headlights feeling or they just forget the questions. I tell patients one of the best things to do is make a list of questions.” Surgery for an older patient carries some special considerations, but doctors say every case is different and decisions must be tailored to the individual. “It’s not so much the chronologic age as it is the physiologic age,” says Timothy Fabian, MD, the Harwell Wilson Alumni Professor and chair of the Department of Surgery at UTHSC. “You can have some 50- or 60-year-olds who are going to do worse than some 90-year-olds because they haven’t taken care of themselves. They might have heart disease or they’ve smoked all their lives. “Is anyone ever too old for surgery? Not really, but it would depend on what the surgery is. If it’s someone 90 years old with the same inguinal hernia he had for 50 years, that would be someone you wouldn’t want to operate on. But if they’ve got an abdominal aortic aneurysm that’s
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getting bigger in size that’s documented and they’re in reasonably good health regardless of their age, then you operate on them.” Mihalko’s specialty is hip and knee replacement surgery, an elective procedure that he says calls for some practical as well as medical decisions. Some patients start thinking about surgery before they actually need it. He once did a hip Dr. Timothy replacement for an othFabian erwise healthy 92-yearold man whose alternative was moving to a nursing home because of his arthritic hip. The surgery allowed the patient to live independently for several more years. But the surgeon emphasizes to patients that surgery is not always the answer. “Just because their X-rays say they have bad arthritis doesn’t mean they have to undergo hip or knee replacement,” Mihalko explains. “It all depends on how it’s affecting their life and everyday activities. If they’re still able to take a walk and get in enough exercise to keep their heart and their lungs fit, then it’s probably not time to be thinking about that hip or knee replacement.” Another reason a patient might want to at least delay such surgery is that the advancements in surgery over the past 15 or 20 years have been unprecedented. There may be a better procedure just ahead. “Surgery is radically different over the last 15 years in almost all areas, and the technological advances have been incredible,” Fabian says. “Almost every area now has some element of minimal invasive approaches to surgery, be it heart surgery, neuro surgery, orthopedics or general surgery. That’s completely revolutionized all of surgery. “It’s happened at some expense,”
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he continues, “but in most circumstances through studies of procedures it’s found to be as effective and safer. In follow-up surveys, in the overwhelming majority, there’s better patient satisfaction with these minimally invasive approaches.” Mihalko adds that the best is yet to come. “Progress in medicine is moving much faster, so if you wait three or four years until it is bad enough to be impacting your life there may be a new procedure out or a new treatment that’s going to significantly benefit you,” the doctor says. “We may have a new treatment we didn’t have when all this started, and once you do a hip or knee replacement you burn the bridge. You can’t go back. “I think too many times a lot of patients get into the mindset that, ‘Well, if I’m going to need it eventually I should just do it now.’ That’s not necessarily the right mindset. There are many 65-yearolds who are not as fit as some 75-yearolds. There are some 75-year-olds who are out there running half-marathons. It really comes down to the individual patient, and we need to treat them that way.”
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Reimbursement Revisit A look at payment innovation By CINDy SANDERS
While physicians and facilities have long had to keep up with different negotiated contract rates among payers, the reimbursement landscape has become much more varied over the last few years as a push toward payment innovation has ushered in a host of reimbursement options ranging from shared savings programs to bundled payments to carrot-and-stick compensation as applied to quality and efficiency metrics. Rob Lazerow, practice manager for Research & Insight at The Advisory Board Company, recently analyzed some of the payment changes providers are navigating as the healthcare system begins to shift away from a feefor-service model. While the traditional payment method based on volume still makes up the majority of healthcare reimburse- Rob Lazerow ments, Lazerow said it appears the shift toward accountability models is picking up steam … albeit slowly. Lazerow, who is based in Washington, D.C., has created a ‘Field Guide to Medicare Payment Innovation’ (advisory. com). However, he was quick to note the transformation isn’t limited to the Centers
for Medicare & Medicaid Services. “There is a lot of payment innovation happening right now, and it’s happening in both the public and private sectors,” he said. Lazerow added CMS, commercial payers, state Medicaid programs and employers are all experimenting with new payment models in markets across the country. While there is any number of subtle variations within the pilot projects, Lazerow said there are generally three big categories of payment innovation being rolled out at this time — pay-for-performance initiatives, bundled payments, and shared savings reimbursement models. Pay-For-Performance “It’s still a fee-for-service payment, but a portion is withheld and linked to predefined metrics, including process, outcomes and patient satisfaction measures,” he said. “Medicare has a lot of experience here,” Lazerow added of the Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program and hospital-acquired conditions (HAC) penalties. Lazerow said in some cases, it could mean hospitals must invest in performance software or additional manpower to provide the necessary outcomes data … effectively making it cost more to capture the same reimbursement rate compared to the pre-
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pay-for-performance world. However, as Lazerow pointed out, this isn’t a ‘request’ from CMS. These are mandatory programs for all hospitals that accept Medicare prospective payments with two of the three already in place and the HAC penalties set to begin in fiscal year 2015. “We’re seeing pay-for-performance in hospitals and physician practices,” Lazerow said, noting the reimbursement model has spread past the Medicare population. “The challenge then becomes having different payers with different metrics.” Even when broad categories of data collection apply to multiple payers, it isn’t uncommon for each to ask providers to drill down to different outcomes measures within the umbrella category. “As you can imagine, the reporting and compliance burden continues to grow,” Lazerow noted. Bundled Payments Lazerow said bundled payments offer a different take on volume-driven reimbursement by coordinating care among all providers responsible for a patient’s diagnosis, treatment and rehabilitation and inserting a level of accountability into the group dynamic. “In a traditional fee-for-service world, all these providers are paid individually and have no aligned incentives or mutual accountability,” he explained. Although bundled payments are still volume-based … the more you do, the more you are paid … Lazerow said the concept focuses on costs and outcomes. “A bundled payment drives efficiency and quality within a discreet episode of care.” For payers, Lazerow said the reimbursement model creates both savings and price predictability. The sum for the bundle of care is generally less than would have been paid individually to those involved. On the provider side, the reimbursement option helps drive efficiency and care coordination with a goal of having the patient receive the right care in the right setting to maximize outcomes and minimize costs. While Medicare has a big program around bundled payments, Lazerow said this model has been adopted by the spectrum of payers including private employers. Wal-Mart, he noted, has established a bundled payment program around certain cardiac care and orthopaedic procedures. Although most current bundled payment
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programs are designed around specific procedures such as hip replacement or cardiac bypass surgery, Lazerow noted, “We’re starting to hear more interest around medical admissions, as well as the procedures.” Shared Savings Models Although bundled payments might be highly effective for unavoidable care, the concept doesn’t address preventive care. That’s where accountable care models … also known as shared savings … step in to apply population health metrics to mitigate potentially avoidable healthcare spending. The intent with these reimbursement models is typically to spend some in order to save more. “The big focus right now is on shared savings models,” Lazerow pointed out. He added providers work together against a pre-set annual spending target per patient. Unlike past payment experiments based on monthly capitated payments, the shared savings model combines existing fee-for-service payments with a reconciliation process at the end of the year. Providers then share in a percentage of the savings they generate. Best practices and quality metrics are a foundational element to ensure patients aren’t denied necessary care simply to save money. “The overall concept of the ACO is these providers are collectively accountable for the total cost and quality of care for populations of patients over time,” Lazerow stated. From Medicare Advantage plans to self-funded employers, the focus on population health has taken root across the country. While providers also seem to embrace the evidence-based concepts and focus on chronic disease management integral to population health, the financial realities of such programs have proven problematic in some cases. Lazerow noted that of the 32 original participants in the CMS Pioneer ACO program, nearly one-third have left … with seven moving to Medicare shared savings programs, which have a lower risk profile for providers, and three dropping out altogether. “One challenge providers are facing is that sharing 50 cents on the dollar of volumes they are destroying might end up creating a negative financial outcome for the health system,” said Lazerow. “They’re not capturing enough of the savings they are generating.” The Bottom Line Lazerow noted he hears different sentiments from different providers as to which payment innovations they prefer. Some, he added, might like to stay in the traditional fee-for-service model, but that ultimately is unlikely given payer demands for more accountability, increased savings and improved efficiency. “Some providers right now, given their market dynamics, are in a watch and wait mode, but each year we see more and more payers and providers experimenting with accountable payment models,” Lazerow concluded. westtnmedicalnews
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Medicare Math, continued from page 1 provisions in the two acts. Two automatic cuts tied to ACA reduce the market basket index by 0.5 percent and 0.2 percent respectively. The first is a reduction to offset productivity improvements assumed to have been gained through increased efficiency. The second, McClure said, is a general reduction to help pay for the Affordable Care Act that is in place through 2021. “Those two reductions account for about $16 million in cuts,” he noted. “Then in the Taxpayer Relief Act, they have what’s considered a coding reduction. That’s worth about $17.5 million,” he continued. McClure said the rationale behind the 0.8 percent cut is that hospital personnel are becoming better coders. He added that’s probably true considering the number of audits and increased emphasis on coding education. However, McClure continued, the basic premise behind the rationale is flawed since billing is for services rendered … being ‘better’ at coding has no impact on the actual cost of the service provided. With these three cuts in place, more than half of the $60 million increase has already been erased. And, McClure noted, that’s just the beginning. “Probably the biggest change that will happen for hospitals in 2015 comes from the Medicare Disproportionate Share payments,” he continued. McClure explained CMS began implementing a strategy in 2014 to reduce Medicare DSH payments because enrollment in health plans and expansion of Medicaid was anticipated to increase the number of people with coverage. CMS also reworked the formula for offsetting care delivered to the uninsured. The Medicare DSH funding was split into two pools with 25 percent remaining traditional DSH and 75 percent moving to a new uncompensated care pool. “We’re becoming part of the minority now in states that haven’t expanded Medicaid,” McClure noted. “CMS looked at uncompensated coverage rates nationwide and made a decision about how much to cut and how to divide it nationally.” With 27 states opting to expand Medicaid, the uncompensated care pool has been significantly impacted. The net result, McClure said, is that Tennessee is really hit twice … both by not expanding coverage to a large population segment and then by receiving reduced rates for delivering care to that patient sector. “Tennessee will receive 23.8 percent less in DSH and uncompensated care pool payments,” he said. “Under all that redistribution and computations, we will receive $36 million less in Tennessee than we would have under the traditional formula of DSH payments.” He added large, urban hospitals would feel the brunt of those cuts, absorbing approximately $32.5 million of the anticipated $36 million in lost reimbursement. For those keeping up with the math, the reimbursement picture now looks like this — $60 million on the plus side for FY2015 and approximately $69.5 million in new cuts. “Then on top of that, you take
away another 2 percent for sequestration,” McClure continued, noting the automatic spending cuts are currently scheduled through 2024. Monetary Penalties After all the automatic cuts, hospitals must also factor in monetary penalties associated with quality metrics. “From the quality side, there are really three metrics being considered this year — value-based purchasing, readmissions and hospital-acquired conditions,” McClure said. He added the 19 different measures being considered under valuebased purchasing are anticipated to be an economic wash for hospitals in Tennessee. As for the readmissions penalty, McClure noted CMS has increased the area of focus from three in 2014 to five in 2015 with the addition of COPD and elective hip and knee implants. “The cap in the penalty also moves from 2 percent to 3 percent in 2015,” he said. The estimate is that Tennessee hospitals will probably see close to $10 million in penalties this coming year. Similarly, CMS is looking at eight different measures under hospital-acquired conditions and comparing and ranking hospitals nationally. Those in the worst quartile for HACs will see Medicare payments reduced by 1 percent. “We estimate there will probably be 17 or 18 hospitals in Tennessee (that fall in that quartile), and estimate it will reduce those hospitals’ payments by $7 million total,” he said. McClure noted that at the time he spoke to Medical News CMS had yet to publish the final data on hospitals regarding both the readmissions and HAC program but that information was anticipated to be available by Oct. 1. The Bottom Line “When you get to the bottom, bottom line, we would get $25 million less than we did last year,” McClure said of expectations for FY-2015 in Tennessee. That reduction, which equals close to a 1 percent cut from FY-2014, coupled with wiping out the entire 2.3 percent increase touted for FY-2015 means area hospitals will receive about 3 percent less than anticipated this coming year. “Right now we’re in the neighborhood of receiving 92-93 percent of cost … so we’re getting paid less than cost,” McClure pointed out of net Medicare IPPS payments. So how do hospitals keep the doors open? “Hopefully CMS is correct and some of these (newly) insured will come into the hospital and help provide some cash flow and help the hospitals survive,” he said of those joining commercial plans through the federal healthcare marketplace. However, he noted, many of the newly insured are opting for high deductible plans that have a lower monthly costs. “They get federal subsidies for their premiums but not for their deductibles,” McClure continued. “Some folks are having a hard enough time paying premiums. I don’t know how they’ll pay a $5,000 or $10,000 deductible.” westtnmedicalnews
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Conducting Innovative Public Health Prevention Research By LYNNE JETER
TAMPA – Lexington Market-East End, a mini-market located in a historically black “food desert” neighborhood in Kentucky, was once considered an eyesore and unsafe place to shop. Now, it’s the centerpiece of a community driven by new and updated businesses and a stellar example of effective community-based prevention marketing (CBPM) for policy development. The successful overhaul, resulting from The Good Neighbor Store initiative, exemplifies only one project from an impressive track record that helped the Florida Prevention Research Center (FPRC) at the University of South Florida’s (USF) College of Public Health garner $4.35 million in federal funding over a five-year cycle from the Centers for Disease Control and Prevention (CDC) to conduct innovative public health prevention research among population health disparities. “We’re thrilled to receive funding for this particular grant, especially this go-round, because the field was highly competitive,” said Carol Bryant, PhD, distinguished USF Health professor and director of the FPRC. “Congress cut the
funding level significantly for this cycle, dropping the number of recipients from 37 to 25. When we saw the recipient list, there were quite a few surprises. Harvard didn’t make it. Neither did the University of Michigan, which has a very strong program. The University of Texas, an original recipient with a terrific program, didn’t make it. This time, we competed against the University of Florida for the first time… such a stellar university.” The list of 24 academic institutions in 25 states became 26 schools when, at the last minute, the CDC added a second Pennsylvania system, making a second exception not to award two prevention research centers (PRCs) in the same state. (Two New York PRCs received CDC grants.) These PRCs will partner with communities to translate research results into effective public health practices and policies that avoid or counter the risks for chronic illnesses, including heart disease, obesity and cancer. “We worked tirelessly to have a very good proposal,” said Bryant, noting team members skipped vacations last summer and worked nights and weekends to finetune it. USF, whose FPRC program has been
continuously funded since 1998, was the only Florida academic institution to make the final list. The USF center’s specialty niche: social marketing. The award “helps USF reinforce its brand equity as a leader in communitybased social marketing and gives us the credibility that allows us to be more effective,” said Bryant. Specifically, the FPRC’s award – $750,000 for the first year – will support research to promote colorectal cancer screenings among underserved populations initially in Hillsborough, Pasco and Pinellas counties, with plans to later expand to other regions of Florida. The project to promote colorectal cancer screenings among the underserved, selected by the Florida Department of Health, begins in October, Bryant explained. “This will be our first time for the center to work very closely with research colleagues at Moffitt Cancer Center, and state, regional and local partners, including the state health department, American Cancer Society, and many other community-based organizations in Tampa Bay’s tri-county region,” said Bryant. “Those partnerships will give us
a fabulous interdisciplinary team. We’ll learn together how to think about applying social marketing to colorectal cancer screening by looking at the entire system.” The USF center will identify groups at high-risk for the disease that are most likely to respond to prevention marketing strategies with changes in behavior and therefore benefit from the tests that can find colorectal polyps or cancer. Colorectal cancer screening is the second leading cause of cancer deaths among men and women in the United States, pointed out Julie Baldwin, PhD, professor of community and family health, who will become the FPRC codirector with Bryant this month as Bryant transitions to retirement in 2016. “Building upon established partnerships, we plan to identify, tailor, implement, and evaluate a multilevel intervention to increase colorectal cancer screening using community-based prevention marketing for systems change,” Baldwin said. “We’re very fortunate to draw upon our team’s expertise in social marketing and community-based participatory research, and our experience in developing and evaluating effective colorectal cancer interventions.
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ICD-10 Delay. PREPARE!!!
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Everything involving the Centers for Medicare and Medicaid Services (CMS) is a moving target. But there’s no denying that ICD-10 is coming. It’s just a question of when. Keep in mind that I am writing this article September 17, 2014. And I would not have been able to write it without the help of my friends at the MGMA Corporate office in Englewood, Colorado, including Robert Tennant, senior policy advisor, and Jeb Shepherd, senior government affairs representative with the MGMA Government Affairs division. The ICD-10 delay gives us an opportunity to take low-cost, highimpact steps to prepare for the new code set. In spite of this time we’ve been given, (October 1, 2015 is the new compliance date) the Medical Group Management Association research suggests that overall industry readiness for implementation continues to lag. The results, compiled through the Association’s Legislative and Executive Advocacy Response Network, indicate that less than 10 percent of practices report making significant progress when rating their overall readiness. As part of the MGMA ICD-10 advocacy efforts, MGMA strongly asserted that comprehensive end-toend testing is a prerequisite to ICD-10 implementation. Through the hard work and advocacy of the MGMA, CMS has announced three separate testing weeks for conducting “acknowledgement” testing for claims using ICD-10 codes. In my April, 2014 article in Memphis Medical News, “CMS Hasn’t Got a Clue,” I pointed out that challenges remain; a back-end link providing payments and automated account records to insurance companies have yet to be built and might not be completed before summer. I quoted from Time, March 10, 2014; “CMS said this is mostly a headache for the insurance companies and providers.” (Thus passing the buck away from CMS.) The wire services, on September 17 reported lax security: “HealthCare.gov, the health insurance website serving more than five million Americans, has significant security flaws that put users’ personal information at risk,” said the Government Accountability Office. It cited more than 20 specific security issues related to who can get into the system, who can make changes in it and what to do in case the complex network fails. (Remember growing up and being told, “Do as I say, not as I do.”?) The CMS’ new deadline (extension)
for implementing ICD-10 for physician practice adoption of the diagnosis component known as the “Clinical Modification (CM)” is October 1, 2015. After that date outpatient claims will need to be coded with one of approximately 69,000 codes, an increase from 13,000 codes in ICD-9-CM. CMS also indicated that all HIPAAcovered entities (providers, health plans and clearing houses) would be required to continue to using ICD-9-CM through September 30, 2015, even if they were already prepared to move to ICD-10. CMS has agreed to comprehensive end-to-end testing that includes returning a remittance advice. The testing weeks will be November 17-21, 2014; March 2-6, 2015; and June 1-5, 2015. CMS says, “We specifically hope designating these three weeks will help to generate an increased interest,” but reiterates that acknowledgement testing is permitted at any point prior to October 1, 2015. Some of you may remember the Comedy Series, “Sanford and Son,” staring Redd Foxx, which ran from 1972 to 1977. In the TV series his wife, Elizabeth, was deceased. During the show if some event occurred that had an impact on him, Fred would hold his chest as if he’s having a heart attack, look up toward heaven and say, “Ut oh, this is the big one, hold on Elizabeth honey, I’m coming to join you.” I hardly missed an episode of “Sanford and Son.” You might want to hold your chest. In 2008, MGMA worked with Nachimson Advisors, LLC, on a study, to try and come up with the ICD-10 cost impact on individual provider practices. In 2014, after a six-year period with a group of consultants, they noted a substantial change in those cost estimates. To determine the practice variable, they estimated costs for small, medium and large practices. Individual practice size was based on variable factors such as specialty, vendor and software. To be consistent, this is how the size of the practice was defined. A small practice is comprised of three providers and two administrative staff. A medium practice is comprised of 10 providers, one full-time coder and six administrative staff. A large practice is comprised of 100 providers, 64 coding staff comprised of 10-full time coders and 54 medical records staff. (CONTINUED ON PAGE 10
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Doctor’s Orders By TIM NICHOLSON
I sat in the parking garage, phone to my ear, breaking bad news to the doctor/ client on the other end of the line. He, most likely standing just outside a patient exam room, showed me what might be a healer’s most valuable trait. The business I’ve run for the past 10 plus years is winding down. Like a patient with a chronic condition that doomed it to a half-life, it would never be its former self or a better self. I’d made the decision
to close it. The past couple of years had been an experiment to see if there was a cure for what ailed the business. There were efforts at giving away the day-to-day to those closer to the client and presumably the culture. There were also the sometimes successful but short-lived efforts to build another business from within it. And of course, the ill-fated attempt to become better at managing the business and less of being the business. None of these inhouse remedies would do more than treat
Sandra Ray, continued from page 1 people on board with new projects and programs. She got her first taste in geriatric care when she headed the opening of a geriatric psychiatric unit. When the hospital built a new facility that was attached to the existing structure, Ray got the assignment to renovate the older facility to house a nursing home. “I basically started from scratch in the old facility,” said Ray. “There were no policies, staff and not even any furniture, so I pretty much had a blank canvas to work with. Once things were up and going, I realized that running a nursing home was my calling so I got my Nursing Home Administrator license.” When the hospital went from being a county-owned facility to corporate owned, Ray decided to make a change herself. “A friend who was a human resource person in Henry County told me about an opening at Henry County Healthcare Center for a nursing home administrator and decided to apply. I had really liked working for a non-profit county owned healthcare system and the opportunity to do so again was too good to pass up,” said Ray. “I have also fallen in love with the Paris area. It has a great culture and offers so much that I hate that I did not discover it sooner in life because I would have loved to have raised my two boys here.” Today, Henry County Healthcare Center is a 136-bed facility that provides skilled and intermediate care with an emphasis on rehabilitation services through the Plumley Rehabilitation Center. “A lot of people think we are just a nursing home but we offer a lot more,” said Ray. “Many of our patients are young and are in our facility due to things such as on the job injuries, strokes, or car accidents. We provide high quality specialized programs that help people rebuild their lives and are far more than just a long-term care facility.” Ray will admit that today’s center is not the one she took over in 1998. “The hospital system had recently taken over the nursing home and everything needed to be overhauled. There were no processes in place, no programs, the interior needed remodeling and we needed staff experienced in working in a long term care environment,” she said. “Once again it was like starting with a blank canvas, we had to start with the basics: training, education, setting up programs, hiring staff and westtnmedicalnews
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remodeling the facility. I salvaged what I could, made the changes and improvements required to ensure we provided the patient-centered level of care needed. It took about two years to accomplish.” During her time at Henry County, the Healthcare Center has seen other improvements. The hospital’s foundation provided funding to build a state of the art rehabilitation gym, which is a part of the Center’s Plumley Rehabilitation Program. A full-time geriatric nurse practitioner has been added to the center’s staff. “This is unique for our industry,” said Ray. “But having a nurse practitioner onsite means our patients get a higher level of hands-on care and monitoring without leaving the center that also helps prevent hospitalizations and complications.” The Healthcare Center was one of only four facilities in Tennessee to be recognized by the American Health Care Association in its Quality Initiative Recognition Program. The program recognizes nursing centers that meet one or more of the programs four quality initiative goals. These goals look at turnover, customer satisfaction, reduced hospital readmissions and reducing psychotic drug use in the facility. Henry County Healthcare Center will be honored at the AHCA’s symposium in Austin, Texas. In her 34 years in management, Ray says she has had a lot of time to tweak her management style but says one thing that has resonated with her is that you are only as good as your team. “I have put together a team of people with integrity and an unstoppable quest for excellence which is what I have as well. We stress the mission, the values and the vision of this organization,” she said. “Most of our managers have been here 10-15 years and we are very proud of our low turnover rate because it’s not the norm in the industry. I think we have created a positive work environment. We believe there is no job that is more important than another and that what one does or doesn’t do in their job affects everyone.” Ray says she has two great passions, her job and music. Having taken piano lessons since she was seven until she was in college, Ray says her ability to play has evolved over the years. She is the accompanist at her church, First Baptist, which feeds not only her love to play the piano but also her desire to serve others.
the symptoms or frankly simply mask the condition. So, I started a series of letters and phone calls to those who’d become part of my family. Most humored my description of what was going on for a moment before quickly asking, “what’s this mean to my whatever it is/was we’re doing together?” I get that. It’s always been about the customer. But this one was different. “So, how are you doing?” he replied. “You know you’ve helped to bring my practice into the 21st century.” I thanked him for that and began to apologize for the inconvenience my closing would create for his business. He interrupted, “This is business. You have great ideas. First, you have to take care of yourself. I want you to trust your instincts and ignore what other people say.” A lump formed in my throat. I’d imagined how many times he’d offered similar advice to a young mother. That’s part of what pediatricians do, right? And considering that he sees 30 plus moms and their children each day and has for twenty-plus years, he probably knows what works and what doesn’t. He’s treating the child and in some measure the mom. She second-guesses herself in response to a mother-in-law’s comment, something a teacher has said, or some child-expert on television. “You’re
not doing this right” or “that’s not how we did it in my day.” And she starts to doubt herself. He turns the doubt around. So Dr. Bubba Edwards, thanks for your bedside manner – empathetic and hopeful – and for extending your wisdom to me. You captured in a moment what I’d sought to find for the past couple of years. While the things we tried were sincere and genuine efforts they ran counter to what my intuition was telling me – it said, “It’s okay to be the brand and to let talented others lift it. They’ll rise, too.” I didn’t listen then but I’ll have to now, doctor’s orders. So Doc, thanks for indulging me these past two years as West TN Medical News has allowed me to share thoughts regarding the medical community’s use of social media. What men and women like you and Dr. Edwards do each day is invaluable. And while they say that Dr. Google is the most popular “physician” on the Internet, it’s still you the patient most trusts. Hey, you don’t have to practice medicine alongside “him” but you can use Facebook, Twitter, Pinterest or Instagram to remind them of something he can’t do, care. Tim C. Nicholson is the President of Bigfish, LLC. Find him on twitter @ timbigfish or email tim@gobigfishgo.com
OCTOBER 2014
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GrandRounds
ICD-10 Delay, continued from page 8
West Tennessee Heart & Vascular Center Earns Award
The estimated costs for medical practices to convert to ICD-10 were released in 2008 and then again in 2014 as follows: • 2008 Study Small practice - $83,290 Medium practice - $285,195 Large practice - $2.7 million • 2014 Study Small practice - $56,639 - $226,105 Medium practice - $213,364 $824,735 Large practice - $2,017,151 $8,018,364 Based on a few budgets of some of the practices I work with, using seven variables, the most outstanding cost was payment disruption. For each size practice, almost 50 percent of the costs in the budget were payment disruption. About two years ago, in an article I wrote for Memphis Medical News, based on my understanding and after talking with some of my colleagues in different parts of the country, I said, “Set up a budget and I suggest you meet with your banker, because with all the pieces involved you absolutely have a cash flow issue with your practice that could be substantial.” In light of this, the old cliché holds true for CMS, “Do as I say not as I do.” Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood. For more information contact Bill at j.william.appling@ outlook.com.
The West Tennessee Heart & Vascular Center at Jackson-Madison County General Hospital has achieved the highest award offered by the American College of Cardiology for highrisk heart attack patient treatment. The ACTION Registry-GWTG Platinum Performance Achievement Award was bestowed only to those hospitals that maintained a performance measure score of 90 percent or better in the treatment of acute myocardial infarction (heart attack) patients for eight consecutive quarters, ending in the last quarter of 2013. This is the third major quality recogni- Back row: Heidi Hill, Emily Garner, Jeff Young, Mark Bedwell, Ken Boroughs, Dr. tion West Tennessee Heath Broussard, Dr. John Baker, Scott Sweat, Dr. Jackie Taylor; Front row: Kellie Mollie Taylor, Dana Velotta, Tammie Todd, Kimberly Wood, Paula Taylor, Heart & Vascular Center Garrett, Mandy Powers. has received this year. Earlier the hospital received national recognition for its echocardiography services and won reaffirmation for the highest level of accreditation from the Society of Cardiovascular Patient Care. West Tennessee Heart & Vascular Center’s compliance with standards outlined by the American College of Cardiology and the American Heart Association as well as strategies for streamlined processes of transferring patients from nearby facilities were factors that boosted the platinum score the hospital received. ACTION Registry–GWTG is a partnership between the American College of Cardiology and the American Heart Association with partnering support from the American College of Emergency Physicians and the Society of Cardiovascular Patient Care. ACTION RegistryGWTG empowers health care provider teams to consistently treat heart attack patients according to the most current, science-based guidelines and establishes a national standard for understanding and improving the quality, safety and outcomes of care provided for patients with coronary artery disease, specifically high-risk heart attack patients.
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OCTOBER 2014
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West Tennessee Healthcare Receives Healthier Tennessee Workplace Award
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The Governor’s Foundation for Health and Wellness has named 73 businesses and institutions across the state including West Tennessee Healthcare, as Healthier Tennessee Workplaces. This new program recognizes organizations that encourage and enable employees to live a healthy lifestyle both at work and at home. Healthier Tennessee Workplaces have certified that they have a wellness program in place that does the following: encourages and enables physical activity in the workplace; offers healthy eating options at work; provides a tobacco-free environment and helps with tobacco cessation; encourages and enables employees to monitor their own health through regular health risk assessments, screenings or check-ups; rewards and recognizes employees for participating in health and wellness activities and achieving health improvements. Places of employment can apply at any time throughout the year. The designation is granted for one full year with an opportunity to renew on an annual basis. Those organizations interested in becoming a Healthier Tennessee Workplace should apply at www. healthiertn.com/workplace .
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SOUTHCOMM Chief Executive Officer Chris Ferrell Chief Financial Officer Patrick Min Chief Marketing Officer Susan Torregrossa Chief Technology Officer Matt Locke Chief Operating Officer/Group Publisher Eric Norwood Director of Digital Sales & Marketing David Walker Controller Todd Patton Creative Director Heather Pierce Director of Content / Online Development Patrick Rains West TN Medical News is published monthly by Medical News, Inc., a wholly-owned subsidiary of SouthComm, Inc. ©2014 Medical News Communications. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Medical News will assume no responsibilities for unsolicited materials. All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes.
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GrandRounds West Tennessee Gastro Welcomes Sufiyan H. Chaudhry, MD Gastroenterologist Sufiyan H. Chaudhry, MD, has joined the West Tennessee Gastro staff in Jackson. Dr. Chaudhry was formerly a consultant gastroenterologist with the University of Tennessee Medical Group in Memphis. He served as staff gastroenterologist at Dr. Sufiyan H. Methodist University HosChaudhry pital, and as an advanced procedures consultant for endoscopic retrograde cholangiopancreatography (ERCP) and luminal stenting at Regional Medical Center and Methodist University Hospital Memphis. He also served as assistant professor in the Division of Gastroenterology and Hepatology at the University of Tennessee Health Science Center Department of Medicine. He is specially trained in various advanced diagnostic and therapeutic endoscopic procedures, including endoscopy, colonoscopy, advanced ERCP, percutaneous endoscopic gastrostomy, endoscopic dilation, endoscopic luminal stents, esophageal motility, and capsule endoscopy. He has also been treating patients with complicated inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Dr. Chaudhry completed his Gastroenterology and Hepatology fellowship training at the University of Tennessee Health Science Center in Memphis with 1 year dedicated for ERCP training. He completed his internship and residency training in internal medicine at the University of Tennessee Health Science Center in Memphis. He received his medical degree from King Edward Medical University, Lahore, Pakistan. He has received board certification in gastroenterology and internal medicine. He is a member of the American Society of Gastrointestinal Endoscopy, American College of Gastroenterology, and the American Gastroenterology Association.
Baptist Memphis Wins Pharmacy Award
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The Department of Pharmacy at Baptist Memorial Hospital Memphis was recently presented with the Innovative Health-System Pharmacy Practice Award by the Tennessee Society of Health-System Pharmacists. The award is given annually to a pharmacy department staff in a hospital with more than 100 beds in recognition of efforts which advanced the level of pharmacy services within the past two years. By making this move pharmacists in the flagship hospital are more visible, more involved and are a more immediate service to nurses and ancillary staff. The inpatient staff assists with providing services to the ambulatory care center, stem cell center, cardiac services as well as offsite physician practices. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer. westtnmedicalnews
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OCTOBER 2014
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We did it !
Earns Highest Award from American College of Cardiology
The West Tennessee Heart and Vascular Center of Jackson-Madison County General Hospital has achieved the highest award offered by the American College of Cardiology for high-risk heart attack patient treatment. The ACTION Registry-GWTG Platinum Performance Achievement Award was bestowed only to those hospitals that maintained a performance measure score of 90 percent or better in the treatment of acute myocardial infarction (heart attack) patients for eight consecutive quarters, ending in the last quarter of 2013. This is the third major quality recognition West Tennessee Heart and Vascular Center has received this year. Earlier the hospital received national recognition for its echocardiography services, and won reaffirmation for the highest level of accreditation from the Society of Cardiovascular Patient Care. “The American College of Cardiology and the American Heart Association commend West Tennessee Heart and Vascular Center for its success in implementing standards of care that are critical in saving the lives and improving outcomes of heart attack patients,” said James Jollis, MD, FACC, ACTION Registry-GWTG Chair and Professor of Medicine and Radiology at Duke University Hospital. West Tennessee Heart & Vascular Center’s compliance with standards outlined by the American College of Cardiology and the American Heart Association as well as strategies for streamlined processes of transferring patients from nearby facilities were factors that boosted the platinum score the hospital received.
“We treat more heart attack patients than any other hospital in Tennessee. As this award shows, it is not how many we treat, it is
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“Our hospital receives heart attack patients transferred from all over West Tennessee. Our team strives to improve the time it takes to get heart attack patients into our care where our cardiologists can start treatment immediately,” said Deann Montchal, vice president of hospital services. West Tennessee Heart & Vascular Center provides complete cardiovascular care, from open heart surgery to state-of-the-art minimally invasive procedures. Outreach clinics in Dyersburg, Lexington and Paris, provide patients consistent care from our cardiologists who connect them to the Center’s services in Jackson.
how well that matters
OUR SCORES
most to us.” – Deann Montchal Vice President of Hospital Services.
wthvc.org
99.3% 99.3% 99.3% 99.8% Overall AMI Performance Composite
STEMI Performance Composite
NSTEMI Performance Composite
Discharge AMI Performance Composite
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