Legal Affairs: Staying informed: How to avoid liability for exclusionary violations, see page 5
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The Leading Source for Healthcare Business News June 2013 • Volume 10, Issue 3 • $3.50
A trauma center in a backpack see page 14
INDEX ▼ Hospital Headlines...........3 Financial Perspectives.......4 Legal Affairs......................5 Healthcare Properties........6 THA...............................8 Integrative Medicine.......10 Breaking Ground............11 Technology......................14 Special Feature................16
Integrative approaches to low back pain see page 10
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BY MINDI SZUMANSKI PUBLISHER & EDITOR MEDICAL JOURNAL - HOUSTON Please see CEO SURVEY page 12
PRSRT STD US POSTAGE PAID HOUSTON TX PERMIT NO 13187
Medical Journal - Houston
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Episcopal Diocese of Texas finalizes transfer of St. Luke’s Episcopal Health System to Catholic Health Initiatives
The Episcopal Diocese of Texas recently transferred St. Luke’s Episcopal Health System to Catholic Health Initiatives, the nation’s third-largest faith-based health system, officials announced. The transfer of the system, which now will be the St. Luke’s Health System, includes the Texas Medical Center campus, as well as suburban hospital locations in The Woodlands, Sugar Land, Pasadena and The Vintage. In addition, CHI will continue to grow and enhance St. Luke’s significant affiliations with Baylor College of Medicine, Texas Heart® Institute, KelseySeybold Clinic, Texas Children’s Hospital and MD Anderson Cancer Center. Last month, the two organizations announced that they had reached a definitive agreement for the transfer. As
area’s underserved population. In addition, CHI has committed an additional $1 billion for future investment in the health system.
part of the transfer, CHI will contribute more than $1 billion to create a new
Episcopal Health Foundation, which will focus on the unmet health needs of the
The St. Luke’s Episcopal Health System Board conducted an 11-month evaluation process, which included 30 prospective local and national partners, before narrowing the list to three in March and selecting CHI, which operates 86 hospitals and other facilities in 18 states. While it no longer will provide acute-care services, the Episcopal Diocese of Texas has established the Episcopal Health Foundation (EHF), which will focus on parish-based, preventive and primary healthcare. Episcopal Health Charities will continue its fifteen year history as part of the new EHF. t
Medical Journal - Houston
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. . . . . . . . . . . . . . . FINANCIAL PERSPECTIVES
New health insurance coverage notices will be required by most employers starting October 1, 2013 BY REED TINSLEY, CPA, CVA, CFP, CHBC As you know, the primary purpose of the Affordable Care Act (also called the Healthcare Act) was to expand access to affordable health coverage. Central to this is the creation of new Insurance Exchanges, which are being referred to as the Health Insurance Marketplace (or the Marketplace). The Marketplace is intended to provide a competitive private health insurance market where individuals and employees of small businesses can shop for affordable coverage. Every state will have a Marketplace—some will be run by the state, others by the Federal government or a combination of the two. They are currently being set up and are supposed to be up and running by 10/1/13. Open enrollment for health insurance coverage through the Marketplace begins 10/1/13 for coverage beginning 1/1/14. Individuals who don’t have insurance coverage after 2013 may be subject to a penalty.
Depending on their income, individuals who obtain coverage through the Marketplace may qualify for premium tax credits that immediately reduce the premiums they pay for coverage. They may also be eligible for cost-sharing reductions that reduce the amount they pay out of pocket for medical expenses. However, neither the credit nor cost-sharing reduction is available if the individual’s employer offers a health plan with minimum essential coverage that is affordable and meets the minimum value standard. The plan meets the minimum value standard if the plan’s share of the total allowed cost of benefits is no less than 60%. Coverage is affordable if the employee’s share of the self-only premium for the employer’s lowest cost plan doesn’t exceed 9.5% of the employee’s household income. To make sure your employees have the information they need to allow them access to the benefits offered through the Marketplace, starting 10/1/13, employers must provide its employees written notice of the health coverage it offers along
with an explanation of the new Health Insurance Marketplace coverage options. Employees will take this information to the Marketplace when they apply for insurance. Providing notice to employees The notice must be provided to all employees, regardless of plan enrollment status (if applicable) or of part-time or fulltime status. A separate notice does not need to be given to dependents or other individuals who are or may become eligible for coverage under the plan, but who are not employees. Content of the notice The notice must include specific information. The DOL has provided two Model Notices: The first model notice applies to employers who offer a health plan to some or all employees (http://www. dol.gov/ebsa/pdf/FLSAwithplans.pdf). The second model notice applies to employers who do not offer a health plan (http:// www.dol.gov/ebsa/pdf/FLSAwithoutplans. pdf). Employers are permitted to modify the model notices as long as they still meet the content requirements specified in the health care reform law. Timing and delivery of the notice Employers must provide the notice to all current employees by October 1, 2013, though the notice may be provided sooner. Also starting October 1, 2013, new employees must receive the notice at the time of their hire. For 2014, the DOL will consider a notice to be timely provided at hire if it is provided within 14 days of the employee’s start date. The notice must be provided in writing and can be provided electronically if the DOL’s electronic disclosure safe-harbor requirements are met; otherwise, the notice may be provided by first-class mail. COBRA Also in connection with the new exchange notice, the DOL released a revised COBRA Model Election Notice that includes information about the health insurance exchanges. The DOL included a redline document showing the changes made by the revised COBRA notice. http://www.dol.gov/ebsa/ t
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. . . . . . . . . . . . . . . LEGAL AFFAIRS
BY MARY M. BEARDEN AND ALLISON SHELTON, BROwN & FORTUNATO, P.C.
Staying informed: How to avoid liability for exclusionary violations Bulletin, provider liability arises when “an excluded person participates in any way in the furnishing of items or services that are payable by a Federal health care program.” Even if the excluded person did not receive compensation or worked temporarily with the provider through a staffing agency, the provider is still liable.
“Federal health care program,” encompasses any federally funded program, such as Medicare Parts A through D, Medicaid and other state programs, Medicare Advantage, TRICARE, etc. When a person is excluded, the person cannot directly or indirectly furnish services or items payable under such programs, regardless of the form of payment. Payments fromPMfederal MS-Houston Med Jrnl (Nov):7.5x9.312 Island 10/25/12 12:04 Page health 1 Under the Updated Bulletin, the term, care programs may include “itemized
On May 8, 2013, the Office of Inspector General (OIG) issued a Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs (Updated Bulletin) as an update to the previously issued 1999 Bulletin. The Updated Bulletin provides guidance for the health care industry on the scope and implications of exclusions.
If Eleanor isn’t moving, she isn’t happy. There’s skiing, wakeboarding, rock climbing, and the more down to earth activities like biking to the store. When she needed surgery on her ankle, she was worried. She came to UTMB Health and benefited from a multidisciplinary team of surgeons, doctors, nurses, and physical therapists who knew that Eleanor needed aggressive treatment to return to her active lifestyle. They kept her informed at every step.“I’m a Nurse Practitioner. I practice what I preach about staying active and healthy. When it came time for rehab, the people here made sure I stayed with the plan. You get out of it what you put in.”
Exclusion is often seen as the death knell for providers because they can neither directly provide nor indirectly participate in services billed to a federal health care program. Ironically, the OIG does not expressly prohibit excluded persons from owning a health care provider. Such ownership has certain risks, however. When an excluded person owns five percent or more of an entity, the OIG may exclude the entity from federal health care programs.
Providers that contract with or employ excluded persons may incur CMPs up to $10,000 for each service from which payment is sought, can be subject to an assessment of three times the amount claimed, and may be excluded. According to the Updated
Please see LEGAL AFFAIRS page 17
ink muscles, joints and bones. It’s about getting your life back.
The U.S. Department of Health and Human Services established the OIG to identify and correct problems and to ensure efficiency within the Department’s programs. In accordance with these goals, the OIG may exclude individuals or entities who have committed program-related fraud or abuse from federal health care programs. For example, if a health care provider bills Medicare for substandard or unnecessary services, then the OIG has the discretion to exclude the provider. In some situations (e.g., patient abuse or conviction of Medicaid fraud), the OIG must exclude the health care provider.
Exclusions have implications for not only the excluded person but also the health care industry as a whole because other providers must take precautions not to employ or contract with an excluded person. According to the Updated Bulletin, “no Federal health care program payment may be made for any items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person.” Violators, whether excluded or not, may be subject to assessments, exclusion, and civil monetary penalties (CMPs).
claims, cost reports, fee schedules, capitated payments, a prospective payment system or other bundled payment.” Accordingly, excluded persons may not render a service even remotely related to patient care. In fact, excluded persons cannot perform administrative or managerial services for a provider that participates in a federal health
Today, Eleanor is back to her old tricks, which also happened to include kicking up her heels and dancing at a friend’s wedding. Whether it’s working in ortho, neuro, or any aspect of the musculoskeletal system, UTMB has gifted clinicians. These are the doctors and surgeons who teach others their art, using the very latest equipment, technology and techniques.
Left: Nikoletta Carayannopoulos, DO Chief, Orthopaedic Trauma Surgery Center Left: Joel Patterson, MD, FACS, FAANS Chief, Division of Neurosurgery Center Right: Vinod Panchbhavi, MD, FACS Chief, Division of Foot and Ankle Surgery Right: Gregory McGowen, PT, Cert MDT AIB Certified in Vestibular Rehabilitation, Rehabilitation Services The four clinicians featured here are representative of the whole team of specialists spanning our musculoskeletal services.
The University of Texas Medical Branch Member, Texas Medical Center
It’s about getting your life back.Your life. Whether that means gardening, hiking, fishing, playing guitar, typing on a keyboard, extreme sports or just lifting your grandkids, our team is ready to return you to the things you love to do. If something isn’t right, do what Eleanor did. Take charge of your health and call us at 800-917-8906, or go to utmbhealth.com to work wonders for you.
Medical Journal - Houston
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BY BETH YOUNG, CCIM, LEED AP, SVP, COLLIERS INTERNATIONAL
Positive ramifications of the Affordable Care Act on real estate
There are always at least two perspectives regarding any change; and the Patient Protection and Affordable Care Act (“ACA”) is no exception. One very positive viewpoint of the ramifications of the Affordable Care Act is the impact it will
have on the commercial real estate industry, specifically the asset class of healthcare properties. Some of the underlying goals of the ACA include controlling the costs of medical
HealthSouth Offers a Higher Level of Care.
Patients and families at HealthSouth Rehabilitation Hospitals hear a lot about a higher level of care. What does this mean to you? Our rehabilitation teams work with patients and their families, providing superior care with quality outcomes to return patients to maximum independence at home and in the community. To a patient recovering from an illness, injury or surgery, a higher level of care means: • Personalized goals for a faster return home • Comprehensive team approach to rehabilitative care • Advanced technologies for the latest treatments • Frequent physician* visits • Three hours of therapy over a day, five days a week • 24-hour certified rehabilitation nursing care For a higher level of care, choose a rehabilitation leader that makes a difference for patients and families. Choose HealthSouth Rehabilitation Hospitals.
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healthsouth.com * HealthSouth provides access to independent private practice physicians, specializing in physical medicine and rehabilitation.
care and providing preventative procedures and wellness care. These goals are very compatible with growing and strengthening a healthcare real estate market. A large cost of medical care is the facilities where patients are treated. The new plan is to keep patients out of expensive hospitals as much as possible. One of the largest trends is the decentralization of healthcare away from hospitals and out into the suburbs. Healthcare systems with good credit are taking more space, and moving more services to outpatient facilities such as medical office buildings (MOB’s) in the communities. Some healthcare systems are disposing of many real estate assets. Healthcare is a very sought-after asset class by both private investors and institutional investors such as real estate investment trusts, commonly known as REIT’s. It all comes down to the yield, and hospitals and medical office buildings with strong-credit tenants are in great demand. A $250 billion sector is seeing a lot of liquidity that 15-20 years ago didn’t exist. Trends point t fewer independent practices and more physicians being employed by hospitals. Many successful private practices are being purchased by health systems; and although this can cause physicians to relocate from neighborhood medical office buildings to on-campus facilities, it is also possible for physicians to stay at their location after the sale of a practice. For example, a specialist such as a pediatrician could find it preferably to become an employee of a hospital that specializes in the health of children, particularly if the doctor can maintain her neighborhood office and the health system takes over her lease obligations that had required a personal guarantee. The fact that the medical building could have a strong-credit tenant like a hospital guaranteeing the lease increases the value of the property for the landlord/investor. In addition to the ACA changes, one of the two strongest trends that will influence the types of medical facilities and where they will be built is the aging population group - those over 65 years of age that will expand by 35% in the next ten years. Since over half of a person’s medical expenses in one’s life are incurred after age 65, a significant portion of all medical care will be given to seniors. And since an additional 30+ million people who were previously uninsured will have insurance available to them in 2014, an additional 91,500 physicians will be needed to treat them. That means more healthcare facilities will be needed to house them. Of all commercial development that is happening in the United States right Please see HEALTHCARE PROPERTIES page 18
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150,000 SF MEDICAL/OFFICE DEVELOPMENT NEAR GRAND PARKWAY ON KINGSLAND BLVD. 23510 Kingsland, Phase I of the development, is centrally located on the northwest corner of Kingsland Boulevard and Cobia Drive. The site was selected based on its close proximity to five major hospital systems, great accessibility to Grand Parkway and Interstate 10 as well as its position within a high growth suburban area.
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• • Excellent location across from future St. Luke’s hospital in Katy, Texas West of Grand Parkway • Great accessibility to Grand Parkway, I-10 corridor, and Katy Mills Mall • Close proximity to four major hospital systems (Memorial Hermann, Methodist, Texas Children’s, and Christus St. Catherine)
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• State-of-the-art building management system • Physician Ownership Available
Medical Journal - Houston
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Important work of Texas hospitals easily shrouded by session politics Special to Medical Journal – Houston BY DAN STULTZ, M.D., FACP, FACHE, President/ CEO, Texas Hospital Association As Texas goes, so goes a unique political voice whose input can only be hampered when we fail to speak with clarity and conjoined conviction.
we worked diligently to ensure the stability of the Texas trauma system by stymieing legislation that would have eliminated the Driver Responsibility Program and the $59 million it generates annually to offset uncompensated trauma care. That funding’s relevance came to light when we clicked on our televisions to see the devastation that rocked West and the response from our amazing Texas hospitals. By speaking as one, Texas hospitals were able to isolate this damaging legislation.
As we plan and map paths to improving the health care system, it is critical that together we lean on what can make Texas great -- conviction in cohesion of voices. John Steinbeck wrote of Texas: “For all
Texas Hospital Association prides itself in the ability to perpetuate a stalwart unification to speak as one for the wellbeing of all Texas hospitals and to ensure the business of health care never divides us
its enormous range of space ... and for all the internal squabbles, contentions, and strivings, Texas has a tight cohesiveness perhaps stronger than any other section of America. Rich, poor, Panhandle, Gulf, city, country, Texas is the obsession, the proper study, and the passionate possession of all Texans.”
from the good we do. That means working together to ensure quality care and a healthy regulatory and business climate for all patients.
It is easy to forget the oneness we share as Texans when for 140 days every two years 181 legislators ascend the Capitol steps to conduct the business of lawmaking. It is easy to get mired in divisive politics as some do their best to eke out political footing on the backs of those who ensure care for millions of Texans. Together, we should recognize the many successes and hard work Texas hospitals managed as we wrap up business for the 83rd Texas Legislature to ensure that care continues. Over the last several months,
Together, we worked to ensure less-thanperfect health care bills did not become law. Together, we ensured a safer environment for our emergency departments by enhancing sentencing guidelines for those who assault health care workers. Together, we worked to ensure the state adequately appropriated funds for the Medicaid Disproportionate Share Hospital program, resulting in $300 million in fiscal years 2014 and 2015. I am proud of how we came together these last five months to help shape the future of health care in Texas. Together, we are stronger. t
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Medical Journal - Houston
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CEO SURVEY continued from page 1
. . . . . . . . . . . . . . . How do you anticipate the Patient Protection and Affordable Care Act will impact your system and what are you doing to prepare? Ronald DePinho, M.D., President, The University of Texas MD Anderson Cancer Center: The University of Texas MD Anderson Cancer Center, as a specialized cancer hospital, and 10 other comprehensive
cancer centers, are now required to report outcomes in several domains. Through our Institute for Cancer Care Innovation as well as the Clinical Operations team, we’ve worked with CMS and its contracted agencies (including the National Quality Forum, Mathmatica and the National Committee for Quality Assurance) as well as other cancer centers to develop meaningful ways to measure outcomes for cancer patients. We have several physicians and staff engaged on several committees that have been working almost exclusively on this issue since the bill was passed, and we’re actively testing how to track, measure and report outcomes to ensure we can meet CMS requirements on deadline. As for reimbursement, there is little question
that the net effect of the Patient Protection and Affordable Care Act will be to decrease reimbursements for health care. With that in mind, we are working to understand and reduce our costs of care delivery, improve our efficiency and optimize the outcomes of the care we provide and actively evaluating both new care-delivery and reimbursement models. Maura Walsh, President, HCA Gulf Coast Division: The Patient Protection and Affordable Care Act (PPACA) has already ushered in many changes to health care. The initial stages of implementation focused on re-engineering existing insurance coverage such as allowing adult children to stay on their parents’ insurance plan
until they turn 26, free preventive care and prohibiting insurance companies from rescinding coverage. The next significant milestone in the implementation of PPACA will come in 2014 with the launch of insurance exchanges and the expansion of Medicaid in those states that so choose. It is important to note, Texas will not expand Medicaid as envisioned in PPACA nor will it create a state-run insurance exchange. The federal government will run and operate the insurance exchange for Texans who will need to purchase health insurance. Needless to say, we are preparing for the continuation of a high number of uninsured patients and will stay focused on quality, efficiency and clinical integration.
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Donna K. Sollenberger, executive vice president and CEO, UTMB Health System: As an academic medical center we are studying several ways to help patients and health systems achieve better health outcomes. For example, we are in the process of converting all of our primary care practices to patient-centered medical homes and will be seeking certification for them. We believe that by providing a medical home, we can produce better health outcomes for our patients, one of the stated goals of health reform. And, for years, UTMB has had community health and information programs meant to keep some of our most vulnerable patients out of our emergency rooms. We were early adopters of Community Health Workers,
individuals who visit patients in their home and assure they have the prescriptions, follow-up appointments, transportation and in-home care that will be vital to their full recovery or to the management of their chronic disease. All of our Community Health Workers became certified last year. Another program teaches diabetic patients the importance of a good diet, how to buy the right foods for themselves and their family and how to best prepare those foods. As an industry, hospitals and health systems will need to be developing and piloting programs and delivery systems that will better manage the patient’s health and their care outside of the hospital with the goal of minimizing inpatient admissions. Trevor Fetter, CEO, Tenet Healthcare
Corporation: Providing coverage to the uninsured is an integral component of improving our nation’s healthcare. Through our national perspective of health care in the U.S., we believe the longer term trends – such as the movement towards reimbursement based on quality and value – will continue, and we are strategically positioned to further the growth we have achieved over the last several years. Our hospitals are focused on the critical mission to provide quality care to all of our patients and we are continuously working to improve that high-quality of care through collaborating with physicians, other providers and insurers to reduce costs by increasing care coordination, deploying advanced health IT systems and using evidence-based standards to ensure every
patient receives the best care possible. PPACA will also be implemented or not implemented in different ways in each state and will impact hospitals in unique and varying ways. Communicating with hospital leaders and providing them with resources to provide quality and value is highly important.
What are your thoughts or concerns regarding the transition to Healthcare Information Exchange (HIE) systems? Ronald DePinho, M.D., President, The Please see CEO SURVEY page 18
Medical Journal - Houston
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Integrative approaches to low back pain BY VICTOR S. SIERPINA, MD, ABFP, ABIHM, Distinguished Teaching Professor, Family and Integrative Medicine, UTMB Health Back pain is one of the top five causes for visits to primary care physicians and afflicts an estimated 60-85% of people over the course of their life. My first intense experience with back pain was watching two strong men help carry my father, a hardy heavy equipment and auto mechanic out the front door to a doctor when I was about 8. My dad worked on commission and was the sole support of our family. It was a
except in the situations in which there is a neurological deficit. Even most cases of herniated discs tend to get better with time, not surgical intervention. Newer techniques such as steroid injections can be useful but are not always effective. Most back pain problems defy anatomical diagnosis, and it is usually not necessary to be excessively precise on the cause of chronic back pain. This can be expensive, creates negative expectations, and doesn’t affect the clinical approach. Uncommon causes that always need to be excluded are fractures, inflammatory disease, infections, and cancer. In older patients, osteoarthritis or spinal stenosis are common contributing causes of back pain and even minor trauma can aggravate these conditions.
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Fortunately, most of the time, a back ache or sprain is self-limiting, within a few weeks responding to initial rest, progressive exercise and stretching, mild pain management such as anti-inflammatories, muscle relaxants, and acetaminophen, physical measures such as heat, ice, or analgesic salves. Some patients respond well to massage, chiropractic, or osteopathic manipulation so these referrals ought be considered along with such helpful modalities as physical therapy and water therapy. Acupuncture is also useful and should always be considered for chronic back pain. Chronic low back pain is a challenging condition to treat as well as to live with. Surgery is usually of limited benefit
The most troubling cases faced by physicians are those patients disabled from, or seeking disability because of their chronic back pain. While there are certainly legitimate conditions that cause back pain related disability, it turns out that psychosocial and occupational factors play an import significant problems role in how chronic back pain is perceived and experienced. Many of those disabled from low back problems have significant depression or other psychiatric problems, lack social support, and are prone to substance dependence. Studies have shown that predictors for disability from chronic low back pain include inappropriate attitudes and beliefs about back pain, poor or maladaptive coping strategies, high levels of emotional distress, fear avoidance beliefs, resistance to Please see INTEGRATIVE MEDICINE page 19
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Advanced Centers for Surgical Education completes $4 million state-of-the-art facility Advanced Centers for Surgical Education (ACSE) recently opened a state-of-theart education, training, research and development center. The 10,000-squarefoot-facility, located at 2001 Hermann Drive on the campus of the Victory Medical Center, houses 17 customizable training stations as well as classrooms and conference spaces. Built inside unused space on the campus of Victory Medical Center, Linbeck Construction began work in January of 2013. Designed by architecture firm Page Southerland Page, the privately funded, $4 million project includes top-of-the-line
Texas. We will provide an upscale array of services for medical educators and surgical professionals from around the world,” said Michelle Heinrich, CEO of Advanced Centers for Surgical Education. Advanced Centers for Surgical Education is a division of The Woodlands-based Victory Healthcare, a leading network of specialized surgical hospitals. “We advance our commitment to providing superior surgical care through the opening of this truly unique educational facility. Victory has long been dedicated to bringing the latest technology to our hospitals and now we will be an active participant in advancing technological breakthroughs,” said Robert N. Helms, Jr., Victory’s Chairman and CEO. “We not only practice
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Advanced Centers for Surgical Education (ACSE) new state-of-the-art education, training, research and development center. lights, monitors and software from leading medical technology company, Stryker. This equipment is not available in any other facilities or hospitals in the city of Houston. Through an exclusive relationship with BioEthical Anatomics, a privately held tissue bank, ACSE provides full access to high quality cadaveric tissue that meets rigorous ethical and quality standards. Fully equipped with the latest in imaging, robotic, endoscopic and audiovisual equipment, the facility can be reserved for use by clinicians, surgeons, medical device companies, healthcare organizations and students. The venue provides a one-ofa-kind space for medical professionals to enhance their skill sets and educate students and colleagues. It also provides a first-class venue space for medical device manufacturers to conduct product training for in-house sales representatives and outside clinical groups. “We are excited to open this brilliantly planned facility across from the Texas Medical Center. Our center is one of only a few in the US and the only one of its kind in
medicine, we teach it,” added Helms. Advanced Centers for Surgical Education offers the following services: • State-of-the-art training and education • In-house tissue bank for all specimen needs • 17 customizable training stations • Three conference/didactic rooms • Secure setting for research and development • Fully customizable audio/visual capabilities • Complete program management • Professional/certified staff to fully assist with programs • Continuing education programs, including CMEs • Full concierge service including flights, hotel, transportation, dining and entertainment Strategically headquartered across from the Texas Medical Center on the campus of Victory Medical Center Houston, ACSE also has satellite facilities in Austin as well as other Victory Healthcare locations in Beaumont, Fort Worth, Hurst, Plano and San Antonio. t
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Medical Journal - Houston
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A trauma center in a backpack
For the U.S. Navy, providing trauma care for Marines and sailors deployed in remote locations poses a daunting challenge. When a person suffers major trauma — a bullet or shrapnel wound, a serious head injury, a severe burn — rapid access to high-level medical care can literally be a matter of life and death. But Navy and Marine Corps personnel often suffer such injuries in places and situations where such care may be many hours away. What’s needed is a way to make the clinical expertise and capabilities of a critical care center available to patients while they’re being evacuated. And that’s why the Office of Naval Research has teamed up with biomedical scientists from the University of Texas Medical Branch at Galveston to develop the Automated Critical Care System. The concept behind the ACCS is simple; it’s intended to be a “cruise control” for critical care, able to automatically sense
and respond to a patient’s condition with appropriate intravenous fluid support and emergency drugs. The reality is a bit more complicated; it’s a “system of systems” that will continuously take vital data with noninvasive monitors, determine the proper therapeutic support for a particular type of trauma, and deliver fluid and drugs in precise quantities intravenously. “We’re working with trauma surgeons and intensive-care specialists to translate bestpractice principles and rules for emergency and critical care into computer algorithms,” said UTMB professor George Kramer, principal investigator on the project. “We’re providing those systems with input from the new generation of non-invasive ‘smart monitors,’ which can detect a wide variety of vital information, including data that previously required invasive catheters and blood sampling. Finally, we’re supplying fluid therapy with compact, highly efficient pumps that are just entering the market.” The entire package is expected to be no larger than a backpack, making it possible to use it to support casualties in the limited space available inside a crowded aircraft or ground transport. Marine Corps
requirements specify that it be able to autonomously manage a critically injured casualty for up to 6 hours. According to Kramer, the ACCS will be able to operate in both “decision assist” and “fully automated” modes. In the first, the system will provide treatment recommendations that can be accepted or rejected by a local medic or telemedicine caregiver; in the second, it will manage the casualty without human input. “We want to greatly reduce the work load on the caregiver, making it possible for him or her to care for multiple casualties during an evacuation,” Kramer said. “We also believe our technology could make a critical difference in a mass-casualty event, when there aren’t enough caregivers to go around.” In a civilian trauma center, a full team of doctors and nurses often begins treating a trauma victim within minutes of injury. But the treatment of combat casualties and civilian trauma care are not as different as it might seem, said Dr. Bill Mileski, a coinvestigator on the ACCS project, director of the UTMB emergency department and
chair of the ten-member panel developing ACCS treatment algorithms. “The fundamental clinical challenge is the same: assessment, stabilization and resuscitation by individualizing therapy to the specific mechanism of injury and patient status,” Mileski said. “We’re addressing that challenge in our system by developing trauma care algorithms that draw on years of experience and state-of-the-art best practices.” UTMB is in the first year of a four-year $2 million ONR development contract on the ACCS. UTMB researchers have been laying the groundwork for the system with Navy- funded physiology and biomedical engineering studies since 2001. Four Galveston-Houston startup companies have formed around UTMB inventions related to smart monitors and computerized decision support for trauma care. “While this project seems revolutionary, it’s really evolved over 12 years,” Kramer said. “It’s exciting to see all that work finally coming together into something that could make a real difference for trauma care and be applicable for wounded warriors.” t
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Medical Journal - Houston
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What you need to know about preand post-payment EHR audits
By Dr. David Nilasena, Chief Medical Officer, Centers for Medicare & Medicaid Services’ Southwest region An eligible professional, eligible hospital or critical access hospital that attests to receive an incentive payment for either the Medicare or Medicaid electronic health record incentive program may be subject to an audit. The Centers for Medicare & Medicaid Services and its contractor, Figliozzi and Co., will conduct audits on Medicare and duallyeligible (Medicare and Medicaid) providers who are participating in the EHR incentive programs. Medicaid providers participating in the Medicaid EHR incentive program will be subject to audits by the states and their contractors. Pre- and post-payment audits CMS will begin pre-payment audits in 2013,
starting with attestations submitted during and after January 2013. The pre-payment audits don’t replace pre-payment edit checks that have already been built into the EHR incentive p r o g r a m s’ systems to detect inaccuracies in eligibility, reporting and payment. Pre-payment audits will be random and may target suspicious or anomalous data. Providers selected for pre-payment audits will have to present supporting documentation to validate their attestation data before CMS releases their incentive payment. CMS, through its contractor, will also conduct post-payment audits during the course of the EHR incentive programs.
Providers selected for post-payment audits will be required to show supporting documentation to validate their submitted attestation data. Preparing for an audit To be prepared for a potential audit, providers should have on hand electronic or paper do cu ment ation that supports their attestation. If they are selected for an audit, providers will also need to produce do cu ment ation that supports the values they entered in the attestation module for clinical quality measures. Hospitals should also maintain documentation that supports their payment calculations. For more guidance on what documentation to retain for audits, see the “Supporting Document for Audits” fact sheet: http://www.cms.gov/
Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/Downloads/EHR_ SupportingDocumentation_Audits.pdf Audit results Providers found ineligible for an EHR incentive payment based on their prepayment audit will not receive payment. In the case of post-payment audits, the payment will be recouped when a provider isn’t found to be eligible. CMS may also pursue additional measures against providers who attest fraudulently to receive an EHR incentive payment. Starting in 2013, providers found ineligible for their incentive payment will also face a payment adjustment beginning in 2015. Providers should always accurately report and properly document to avoid payment penalties. Audit materials Additional audit materials can be found on the educational resources page of the CMS EHR incentive programs website under the title “Audit Information and Guidance”: http:// www.cms.gov/Regulations-and-Guidance/ L e g i s l a t i o n / E H R In c e n t i v e P r o g ra m s / EducationalMaterials.html t
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LEGAL AFFAIRS continued from page 5
. . . . . . . . . . . . . . . care program. Even filling a prescription written by an excluded person is a violation.
To determine which employees and contractors to screen, the provider should assess each job title and contract and verify what items and services are payable by a federal health care program either directly or indirectly. Anyone providing such an item or service should be screened. The
health care programs.” Thus, providers should screen nurses from staffing agencies, physician groups that cover emergency rooms, and billing or coding contractors. Since the 1999 Bulletin, the OIG had received questions about the difference between the
The OIG maintains a List of Excluded Individuals and Entities (LEIE). The LEIE provides details on the person or entity excluded and allows the search to be verified through the use of a social security number or employer identification number. In the future, the LEIE may be searched by the person’s/entity’s National Provider Identifier. The Updated Bulletin focuses on the proper screening steps that providers should take in order to avoid liability. The OIG recommends that providers regularly search the LEIE and document the name searches they conduct in order to verify the results of potential matches. The OIG recommends screening new employees and periodically screening current employees. Providers can decide how frequently to conduct screening, but since the OIG updates the LEIE monthly, the OIG advises providers to screen monthly to minimize potential liability. A contractor may conduct screening for the provider, but the provider should monitor the contractor to ensure that the contractor performs the checks properly. Even if a contractor performs the screening, the provider remains liable.
use LEIE since it provides greater detail about the excluded persons. The Updated Bulletin also addresses questions regarding the proper use of sanction databases, such as the National Practitioner Data Bank (NPDB) and the Health Care Integrity and Protection Databank (HIPDB). On April 5, 2013, NPDB and HIPDB combined into one database that reports malpractice and similar adverse findings and actions. While providers can refer to NPDB, the OIG advises using LEIE to conduct exclusion screening. With respect to unanswered concerns providers may have relating to potential liability, they may use the OIG’s Provider Self-Disclosure Protocol to disclose concerns and find a solution. Also, when an excluded person or a provider is unsure whether an arrangement violates the law, they may submit a request for a binding OIG Advisory Opinion, which will inform them if the arrangement does in fact violate the law.
greatest risk of liability occurs “for those persons that provide items or services integral to the provision of patient care because it is much more likely that such items or services are payable by the Federal
General Services Administration’s System for Award Management (SAM) and the OIG’s LEIE. SAM includes both LEIE and debarment actions by other federal agencies. Accordingly, providers should
In light of the OIG’s updates, health care providers now have additional guidance to ensure compliance with exclusionary rules. The Updated Bulletin not only replaces and supersedes the 1999 Bulletin, but it also advises providers regarding the most effective screening methods and ways to avoid liability. Finally, the Updated Bulletin provides resources for self-disclosure and encourages providers to submit exclusionary inquiries. t
Medical Journal - Houston
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. . . . . . . . . . . . . . . now, 50% of it is for healthcare real estate. Patients will continue to have the options of receiving specialized preventative procedures and wellness care that is offered by centralized hospitals. They will also benefit from specialists who will be found in smaller outpatient facilities where they can share ideas and resources while having access to the latest technology and being closer to the patient. Emergency medical clinics and surgery centers are already located and expanding throughout cities.
in neighborhood medical office buildings and retail-based clinics such as those set up in some pharmacies like CVS. Currently, about 44% of retail clinic visits occur when patients cannot see their regular doctors, like weekday evenings and weekends. The number of patients visiting retail clinics has rocketed from 1.48 million in 2006 to 5.97 million in 2009; more than a fourfold increase according to a new study by Health Affairs. Another study predicts that retail clinics are expected to grow by 133% in the next five years. Strong healthcare employment growth is expected to increase more than 70% in the next 7-10 years.
Patients are learning to expect shorter wait times and lower costs at community facilities. Most “triage” work will be done
About 65% of retail clinic patients do not have a primary care physician, but about 71% have Medicare, Medicaid, or commercial health insurance. This provides plenty of incentive for some of the nation’s biggest retailers to expand
in Houston to accomplish this objective.
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Donna K. Sollenberger, executive vice president and CEO, UTMB Health System: UTMB is a member of Houston Healthconnect that will enable us, through electronic medical records, to “talk to” another hospital or medical care provider, reducing duplicate or unnecessary tests, as well as saving patients and systems time, effort and money. We will be joining a Houston area pilot project that focuses specifically on uninsured and Medicaid patients this summer. The health information exchanges will have a particular benefit to patients as they will be able to share their healthcare information to multiple care providers, even if they are not in the same system. This will result in better and safer patient care. UTMB is hopeful that other area health systems join Healthconnect to share information and costs to operate the system.
. . . . . . . . . . . . . . . University of Texas MD Anderson Cancer Center: A robust Health Information Exchange is essential for patient with cancer who travel great distances for care, so this is a tool that will impact a large number of our patients and others across the nation. MD Anderson’s Institute for Cancer Care Innovation has a subcontract through RTI International and the Office of the National Coordinator for Health Information Technology to develop a plan to work through the technical and policy challenges of sending structured patient data from our patients to direct-enabled personal health records. We’re looking at how patients could potentially take their medical records from their MD Anderson patient portal, called myMDAnderson, to their personal health records, where patients can also collect other health information online, like records from other doctors’ appointments or lab results or data from blood pressure monitors and glucose monitors. MD Anderson will be conducting a test in a development environment to create a work plan that outlines best methods, any technical issues, and proposed solutions. The work plan can then be used by RTI and the ONC to help guide other institutions that are also making the transition to healthcare information exchange systems, and it will also give us important information about how best to move forward as we better our own electronic medical record systems. Maura Walsh, President, HCA Gulf Coast Division: HCA supports the exchange of data between providers to manage the health of our shared patients. HCA is investing in several technologies across the company and
Trevor Fetter, CEO, Tenet Healthcare Corporation: Tenet is an early adopter of health information technology, having first begun laying the ground work in 2005 for its health information technology initiative, IMPACT (Improving Patient Care through Technology) – well before others in the industry began to embrace health IT. Tenet’s goal is to use the data the technology generates to streamline processes and produce new insights and intelligence for continual improvements in healthcare quality at lower costs. Tenet’s IMPACT program aims to install an electronic health record and a personal health record in each of Tenet’s 49 hospitals by 2015, providing the right information when and where it’s needed to improve the care of every patient who seeks treatment at all of the company’s facilities. To date, 26 hospitals have satisfied federal criteria for meaningful use and have qualified for
into the “Provider” space. Walmart has unveiled plans to have primary care services in rural markets in five to seven years. The opinions of patients are becoming a deciding factor in the design of new healthcare facilities. Surveys to learn what the patient thinks will become more and more common. Hospitals want developers to share in the risk of real estate and become more vested in the design, look and feel – not just to please the patient, but to help control costs and increase success in a competitive industry. At a meeting in San Diego last week, Vincent Cozzi, chief investment officer with Ventas and Lillibridge Healthcare Services Inc., called the trend “investing with hospitals rather than investing in real estate.” t
incentive payments under the American Recovery and Reinvestment Act. All of the remaining hospitals are on target to complete core implementation by mid2014, with ongoing implementation of components of EHRs for many years to come. As an early adopter of health IT, Tenet’s goal is to use the data the technology generates to streamline processes and produce new insights and intelligence for continual improvements in healthcare quality at lower costs. Through Tenet’s health IT efforts and through the secure use and sharing of health information, hospitals across its network already are seeing results, including:
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More complete and accurate patient health information and improved care delivery in both in-patient and ambulatory settings. Better coordination across the entire continuum of care. Improved and secure information sharing with patients and other caregivers. This aligns with national goals to empower patients, making them more responsible for their own health. Use of innovative technologies and shared protected health information (PHI) to help physicians, nurses and other clinicians combat chronic disease with informed, preventive care delivery. Improvements will include earlier diagnoses, reduced medical errors and lower costs. Reduced paperwork and improved workflows.
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As part of its HIT initiative, Tenet is in the initial stages of establishing an HIE. Thus far, roughly one-third of Tenet’s hospitals are connected. As more connections are in place with third-party EHRs, Tenet expects the numbers to increase significantly in the coming years. t
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continued from page 12
. . . . . . . . . . . . . . . change, and family reinforcement of illness behavior.
Focus on exercises that strengthen core muscles of abdomen and back, walking regularly, and keeping a healthy body weight. Again, give them handouts. Our EPIC electronic medical record has a wonderful library of patient educational materials including diagrams and
addition to the usually prescribed antiinflammatories and muscle relaxants. •
Avoid prescribing opiates or other addictive medications unless absolutely necessary. For chronic pain, have the patient sign a pain management
Inactivity leads to a vicious cycle of disuse, deconditioning, stiffness, medication dependency, and further chronic pain. Work related factors predicting disability include low work status and low job satisfaction, jobs with high physical demands with inability to modify work, and overall poor working conditions. Insurance, workers’ compensation, and disability benefits factor into settlements as well and in countries without these safety nets in place, there are very low rates of disability from back pain compared to the US.
Prescribe as appropriate integrative approaches such as acupuncture, massage, chiropractic, osteopathy, physical therapy, aquatherapy, mind-body and relaxation techniques, and exercises. These ought be tried for most cases for at least a year before considering spine surgery referral, in the absence of red flag neurological symptoms such as incontinence, numbness, or weakness in the legs.
It turns out that education and self-care can play a major role is managing back pain and preventing disability. Here are some tips for advising your patients how to live better with back pain: •
Remain active and carry on as normally as possible, being mindful that in most cases staying active may hurt but will not cause harm. Encourage them to lift properly by bending their knees and keeping the back straight. Patient information hand-outs are useful.
or getting controlled substances from other providers. This program is easy to access once you learn how to use it and helps keep patients honest. Such violations break their pain management contract and give you the option to discontinue prescribing controlled medications for an offending patient. Google PAT Texas or go to the website athttps://www.texaspatx.com/ Login.aspx?ReturnUrl=%2fdefault.aspx
detailed explanations on back exercises. •
Recommend stretching exercises for the back such as yoga, tai chi, Pilates, or other specific low back exercises.
Consider prescribing herbal antiinflammatories such as curcumin, ginger, boswellia, Zyflamend ™ in
contract to minimize the potential for abuse. Check urine drug screens randomly to monitor compliance and to detect other drugs of abuse or possible diversion. Utilize the Prescription Access for Texas (PAT) program sponsored by the Department for Public Safety to check if patients are using multiple pharmacies,
Do not recommend imaging studies in most cases of chronic low back pain. . Many expensive studies such as MRI show bulging discs and other abnormalities even in normal people without back pain so are not cost effective or necessary, and are rarely helpful in management. Evidence-based protocols also recommend not to order imaging in acute back pain without trauma for at least 6 weeks as most cases will resolve and imaging does not add to quality or type of care. t Portions of this were previously printed in the Galveston Daily News.
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