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On Rounds Physician Spotlight
Hospitals Face More Medicaid Cuts By TED GRIGGS
Dr. Hugo St. Hilaire Triple Threat
Hailing from Montreal, Canada, Dr. Hugo St. Hilaire was trained as a dentist, maxillofacial surgeon and plastic and reconstructive surgeon. But he truly is a triple threat at home, where he is Dad to two-year-old girl triplets and an 11-year-old son.... page 3
Another budget year, another cut in hospital funding. This year’s proposed Medicaid funding cut, $10 million, isn’t the largest Louisiana’s hospitals have faced. But the most recent hit is piled on top of the $254 million in Medicaid cuts hospitals have seen since 2009, said Sean Prados, vice president of the Louisiana Hospital Association. “I think when you look at it in the broader terms of what’s facing hospitals, when you look at what’s happened with the federal healthcare reform, and you look at the sequestration cuts, and you look at what’s happened with the state Medicaid side, and what we’re facing over the next couple of years in reductions and disproportionate share, the funding for hospitals for the next couple of years is going to be a tremendous challenge,” Prados said. Gov. Bobby Jindal’s administration proposed the hospital funding reductions as part of roughly $52 million in healthcare cuts. Half of the cuts are in state funding, and the remainder from the federal government. Sean Prados In announcing the cuts, the state Department of Health and Hospitals said the agency faced a deficit in the current fiscal year, at current operating levels, unless changes were made. Most of the money will come from Medicaid. (CONTINUED ON PAGE 8)
Making the Marriage Work
Alignment & Integration Strategies to Strengthen Physician, Hospital Unions By CINDy SANDERS
ICD-10: Are You Ready? With the rapidly approaching ICD-10 ‘go live’ date of October 1, 2014, medical practices should be well on their way in preparing for the transition ... page 9
… And they all lived happily ever after. In fairytales, the two protagonists manage to overcome many barriers to ultimately ride off into the sunset … presumably for a lifetime filled with sunshine and roses. In the real world, we only have to look to divorce statistics to know that ‘wedded bliss’ frequently dissolves into angry recriminations, mistrust and broken vows. As it turns out, marriage makes for an interesting analogy to the wave of physicians, practices and hospitals rushing to the altar under the new world order of healthcare reform. Thanks to economic strain, the market has seen quite a few shotgun weddings lately. In other cases, such as some ACO affiliate agreements, the parties have opted to cohabitate rather than legally wed. And in some instances, the belief is that the union completes and complements each party to the ultimate benefit of both. No matter how the parties entered the relationship, once the honeymoon phase (CONTINUED ON PAGE 10)
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Dr. Hugo St. Hilaire Triple Threat
By LISA HANCHEy
Hailing from Montreal, Canada, Dr. Hugo St. Hilaire was trained as a dentist, maxillofacial surgeon and plastic and reconstructive surgeon. But he truly is a triple threat at home, where he is Dad to two-year-old girl triplets and an 11-yearold son. Just how does he balance his busy practice between New Orleans and Lafayette with his young family? “A lot of help and understanding. from my wife, Brooke,” he admitted. “She is a nurse, but she takes care of the family right now. That’s the only way this can happen.” In Montreal, St. Hilaire graduated from McGill University Faculty of Dentistry and practiced for a year at the Jewish General Hospital. But, he yearned for something more. “While dentistry was nice, I was always looking for something a little bit more challenging,” he recalled. “So, coming from a dental background, the next step was oral surgery.” At age 23, St. Hilaire came to New York to enroll in oral and maxillofacial surgery at The Mount Sinai Medical Center. During his training, he became interested in reconstructive surgery. “I wanted to do a little bit more complex reconstructive surgery, particularly in the head and neck area,” he explained. He was particularly intrigued by microsurgical techniques used in craniomaxillofacial reconstruction. So, he came down to New
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Orleans to study plastic and reconstructive surgery at Louisiana State University. “LSU has a long history of excellent training in microsurgery, which is what I was interested in,” he said. “So, that’s why I came down here.” St. Hilaire was taught by Dr. Charles L. Dupin and Dr. Robert Allen, both pioneers in microsurgery. When he had just started his residency, Hurricane Katrina hit. “New Orleans shut down at that point,” he recalled. For three months, he studied in Baltimore at Johns Hopkins Medical Center. Then, he returned to New Orleans to complete his training. After finishing at LSU, St. Hilaire went back to Johns Hopkins for a year-
long craniofacial surgery fellowship. Afterward, he returned to New Orleans, where he practices plastic and reconstructive surgery and oral maxilla facial surgery with a subspecialty in cranial facial surgery. About 30 to 40 percent of his practice is in pediatrics. He performs all of the pediatric plastic surgery and craniofacial surgery at Children’s Hospital and Ochsner’s Baptist Medical Center in New Orleans. Shortly after beginning his practice, St. Hilaire met Dr. Darric Baty, a Lafayette-based pediatric neurosurgeon, at a meeting. The two specialists discussed starting a pediatric craniofacial surgery program at Women’s & Children’s Hospital in Lafayette. “It took us about two
years, going back and forth and trying to figure out the right way of doing this,” he said. “This was something new for the hospital. We were persistent, and we were able to establish our program. And, it’s been doing great.” Since starting the program, St. Hilaire has juggled his practice between New Orleans and Lafayette. He spends a few days a month working on complex pediatric procedures in Acadiana. “The rest is a combination of adult craniofacial and reconstructive surgery for cancer or bad injury to the head and neck area,” he explained. “But, I still do general plastic surgery with a focus on microsurgery. So, I do a fair amount of breast reconstruction after cancer using microsurgical techniques, as well as some lower extremity reconstruction. A very, very small portion of my practice is in aesthetic surgery, and that’s mainly by choice.” It was also St. Hilaire’s choice to travel to Lafayette for his pediatric patients. “It’s easy for me to just stay in New Orleans and have patients come and see me,” he said. “But, those families are going through a lot with their babies having to go through surgery. I think it makes it a little easier on the families to stay over there in Lafayette. It’s a nice thing to do, so we can bring the specialty services to them instead of them having to travel for hours.” St. Hilaire obviously has a soft spot when it comes to kids. He and Brooke live in Metairie with their four children – Colby Decker, “CD,” age 11, and 28-month-old triplets Adele, Caroline Kate and Ellie. “They are always excited to see their Daddy,” he said proudly. “It’s awesome. It’s the best part of the day.”
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AUGUST 2013 • 3
Group Tries to Make Obamacare Understandable By TED GRIGGS
More than 120 companies, civic organizations, advocacy groups and healthcare associations have banded together to help Louisiana residents understand Obamacare and its impact. “Basically, we started (it) to get unbiased information out into the marketplace to help people navigate the new Affordable Care Act landscape and to disseminate health and wellness information,” said John Maginnis, spokesman for the Louisiana Healthcare Education Coalition. The coalition provides information on the major drivers of healthcare costs, the importance of personal wellness, and the need for access to quality health- John Maginnis care. The group works with healthcare providers, small businesses, faith-based institutions, employers, community leaders, patient advocacy groups and the public. The coalition partners include everyone from AARP Louisiana, Bunkie General Hospital, and the
Louisiana Academy of Family Physicians to New Orleans Faith Health Alliance and the Vietnamese Young Leaders Association. Maginnis said the coalition serves solely as an education resource and neither endorses public policy nor seeks to create it. The coalition began getting the word out in the third week of March with back-to-back-to back press conferences in New Orleans, Baton Rouge and Shreveport. The group also held a conference in Lafayette, and events are set for Aug. 14 in Alexandria and Aug. 15
in Lake Charles. And the group is picking up new members by the day, he said. One of the latest members, the Louisiana Municipal Association, joined in early July. The LMA’s members are helping push information down to the grassroots level. The coalition is entirely a volunteer effort, Maginnis said. Blue Cross and Blue Shield of Louisiana provided some administrative support and trained about 40 employees to serve as speakers. But that number is also increasing. “We’re undergoing a ‘Train the Trainers’ program for the partners to train their speakers,” Maginnis said. The coalition’s organizing partners, the Louisiana Public Health Institute and Louisiana Healthcare Quality Forum, are coming on board with more speakers every day, he said. It takes only a couple of hours of training for the volunteers, since most generally bring a lot of knowledge to the table. That familiarity is helpful when the Affordable Care Act’s situation changes frequently, Maginnis said.
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The coalition’s website, LHEC.net, also helps groups with their own educational efforts. Groups can click on the “request a speaker” tab, and fill in some information, such as the name of the organization and the type of event group and a volunteer will get in touch about the event. The website also contains simple but detailed explanations for some of the most commonly asked questions, such as: Will my premiums go up because of healthcare reform? Many people are likely to see rates increase. But the good news is that the changes mean thousands more Louisiana residents will have health coverage. “The challenge comes from the fact that insurance companies must take all customers, no matter their health condition. It costs us more to cover people with pre-existing conditions. That’s why rates will go up for everyone. Also, health insurance companies can no longer charge different rates for people of different ages. Young and old people will all be put into the same pool when we set insurance rates. That means many younger people will see their rates go up; older people will likely see them go down. Plus, the new law says all plans must include more benefits. That means we will add to all plans such things as: ER services, maternity care, mental health, lab services, pediatric care, and vision services. You may not have had these benefits in your original plan. More benefits add to the cost of plans.” The website also touches on major changes the Affordable Care Act will bring about in 2014, including the elimination of annual limits; preventing insurers from denying coverage because of pre-existing conditions; the requirement that everyone buy insurance; and the penalties if one does not. The site also contains information on how small employers will be affected by the changes, where to get help navigating the health insurance marketplace and the major drivers of healthcare costs. The latter include an aging population, rising rates of chronic disease, lifestyle factors and personal health choices. “There’s a tremendous void of information surrounding the act. If you look at recent polls done by Kaiser Family Foundation, 67 percent of the uninsured in the United States say they don’t have enough information about the ACA to understand how it will impact their lives,” Maginnis said. “You can miss deadlines. You can miss opportunities. There’s a lot at stake, and we’re just trying to contribute.”
For more information, go to LHEC.net, call 1-855-871-5497, or email LHEC@bcbsla.com.
Concussions: When in Doubt, Sit Them Out BY LISA HANCHEY
With football season just around the corner, Louisiana’s athletes are getting their bodies in tip-top physical condition. But, before the first practice, concussion management specialists have gotten a head start on protecting players’ brains. About a month before the games begin, Tommy Dean, founder and managing member of Concussion Solutions, LLC, begins performing neurocognitive evaluations on players at 38 high schools in the Acadiana area. Over Tommy Dean the course of a year, the national board-certified athletic trainer will clear over 4,000 athletes to play sports ranging from football to golf. His diagnostic tool of choice is ImPACT® (Immediate Post-Concussion Assessment and Cognitive Testing). This software allows him to evaluate a player’s brain prior to the first practice. “People are looking for a definitive way to diagnose everything,” Dean explained. “And, I really don’t think there’s a lot of that out there, particularly when it comes to the brain. ImPACT does
not diagnose concussion. But it does provide you with an objective tool to help make a sound clinical decision.” During the first few minutes of the 30-minute test, Dean asks players demographic questions, then tackles their health histories, including any headache or seizure activity. Afterward, athletes undergo a 20-minute video game-style computer test which measures functions like processing speed, attention span, reaction time, working memory and cognitive efficiency. At the end, test-takers receive a baseline score. “If they sustain a concussion later, we are able to post-injury test them on the same piece of software,” Dean said. “The test gives you an apples-to-apples objective comparison to what your normal brain function is and what your everyday symptomology is. In my opinion, ImPACT is, by far, the cornerstone of any management program. If you don’t have an objective tool such as ImPACT, then you are doing the same thing you did 20 years ago with concussion management,
which is really just guessing.” One of the misconceptions about concussion is that a player has to lose consciousness. But, that is normally not the case. “Only one out of 10 athletes that get a concussion loses consciousness,” observed Dr. Julian Bailes, chairman of Dr. Julian the Department of NeuBailes rosurgery at NorthShore University Health System in Chicago, medical director of Pop Warner football
and former NCAA and NFL physician. “Ninety percent of the time, they are awake and walking and talking. There are usually no outward and visible signs. So, someone has to really be on the lookout and have a high index of suspicion.” Concussion symptoms include headache, dizziness, confusion and balance problems. Later on, these might advance to sleep disturbance and problems at work or play. So, when a player sustains a head injury, first responders should err on the side of caution. “They should be aware of the symptoms and evaluate any person suspected of even possibly having had a concussion,” Bailes advised. “And, there should be a low threshold for taking them out of that practice or game. They should be very conservative with the management and eager to evaluate players to decide if they think an athlete might have had a concussion. If there’s any doubt, then they should sit that player out.” Athletes sustaining head injuries should be seen by a physician as soon as practicable. Most simple concussions can be managed by a general or family practitioner. “I think it’s important to know that (CONTINUED ON PAGE 6)
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Concussions: When in Doubt, Sit Them Out, continued from page 5 85 to 90 percent of concussions are what we call simple concussions,” Bailes explained. “They resolve within a week to 10 days.” As medical director of Concussion Solutions, Dr. Stephanie Aldret, family medicine and sports medicine specialist, usually sees an injured player within a week of impact. Aldret, along with Dr. Seth Rosenzweig, an orthopedic surgeon, are Credentialed Dr. Stephanie Aldret running concussion tests ImPACT Consultants under Concussion Solutions. Working closely with Dean, Aldret dret explained. “I also think that balance retests athletes with the ImPACT softis important, and doing balancing testing ware, comparing post-injury results with can be kind of fun for the kids. For a lot their baseline scores. She also checks their of us, balance is a new area to be incormemory with SCAT3™ (Sport Concusporated into concussion management in sion Assessment Tool) and balance with Louisiana, even at baseline stage.” BESTest (Balance Evaluation Systems Post-exam, Aldret manages her conTest). “I look at those tests, I look at their cussion patients by having them rest at symptoms and then also do a full neurohome and possibly taking a break from logical exam to see where they are,” Alschool. “If the stress of math or science or
even English is too much for them, and if they get a headache or feel irritable or nauseated, then we take them out of school,” she said. “It’s not too far from the ‘dark closet’ sort of treatment to shut them down until they are without any sort of symptoms.” If symptoms persist for more than a week, then Aldret tries other measures, including supplements such as fish oil, magnesium and vitamins C and D-3. “These are different things that can be used to just sort of theoretically help the brain to recover,” she explained. “And, it actually makes us feel like we are doing something as well.” Once patients are symptom-free, they can ease back into school. As soon as they can handle the mental stimulation, then they can gradually add physical activities. “We start to incorporate slowly back into some physical activity, with first a light jog, then more sprints,” Aldret said. “It takes about a week once they hit that point before we can even look at getting them back into regular play.” When symptoms linger or worsen, patients should consult a specialist such as a neurologist or neurosurgeon. “I think the concussions that don’t resolve or have any other neurological problems are ones that should be referred to a specialist,”
Bailes advised. “Primarily, symptoms which are not going away in a week to 10 days are an indicator that is more than a straightforward or simple concussion.” Scientists are still studying the long-term effects of multiple head injuries. The traditional rule was that after three concussions, a player’s career was over. “It appears that the risk for long-term neurological problems increases once you have over three concussions,” Bailes observed. “So, I think three concussions, especially in close proximity, are kind of a warning. That patient should certainly be seen by specialists and probably held out of play for a longer period of time. “ For Aldret, the red flags are the type of blow and resulting symptoms. “Some the things that I look for is if it takes less and less of a force to cause a concussion and if it takes longer and longer to recover after a concussion,” she said. “Those are some of those things that I look for to disqualify them from collision sports altogether.” In recent years, doctors have recognized that repetitive subconcussive blows can be as dangerous as full-blown concussions. These types of closed head injuries may lead to chronic traumatic encephalopathy (CTE), a degenerative brain disease with symptoms including dementia, memory loss, aggression, confusion and depression. “There’s been research on this chronic traumatic encephalopathy, or CTE, which is really, for the most part, only found in professional athletes,” Bailes explained. “And, we think that it is more related to exposure to multiple concussive and subconcussive blows and so, therefore, it’s exposure-related. We hope that with current more conservative management strategies, the risk of CTE will be eliminated in sports.” For Dean, the most important thing is to make sure that players have fully recovered from a head injury before returning to collision sports. “Nothing except time and rest has really been proven reliable from an evaluation and diagnosis standpoint to a recovery and prevention standpoint,” he said. “In my assessment, our treatment and management are more conservative, but we also have more tools that are being researched that I think will give us a better grasp of how to objectively evaluate and treat the injury moving forward.”
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Wellness Programs in the Workplace: New Rules and Opportunities for Employers By STEPHEN ANGELETTE and KELSEY CLARK
On June 3, 2013, the Department of Health and Human Services (HHS), along with the Departments of the Treasury and Labor, released final regulations concerning the implementation and regulation of wellness programs in private companies. These regulations are continuations of certain 2006 rules that were composed of the Health Insurance Portability and Accountability Act (HIPAA), ERISA, the Internal Revenue Code (the Code), and the Public Health Service Act (PHS Act). The 2013 regulations do not greatly change the substance of the 2006 Regulations; in fact, the regulations remain largely the same apart from an increase in the maximum amount a company can offer as a reward. Prior to 2006, the PHS Act, the Code, and ERISA all contained provisions and regulations pertaining to private employer wellness programs. With the implementation of HIPAA in 2001, HHS was forced to implement HIPAA nondiscrimination regulations into their existing laws governing wellness programs. HHS and the Department of Labor released joint rules on December 13, 2006 that generally prohibited wellness program providers from discriminating against individual participants based on any health factor in health-contingent programs. “Health factors” include health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, or disability. Wellness programs had to be offered to all similarly situated individuals and could not condition a reward on an individual satisfying a standard based on a health factor. HHS recognized that this severely limited the kinds of programs that private employers could offer. In response to this limitation, the 2006 Regulations established an exception for private employers to use in order to avoid violating the non-discrimination regulations while still being able to offer wellness programs that discriminate based on health status. If the companies met the following five criteria, they would not be violating HIPAA: 1. The value of the reward must not exceed 20 percent of the cost of employeeonly coverage.
2. The program must be reasonably designed to promote health or prevent disease. 3. The program must give individuals the opportunity to qualify for the reward at least once a year. 4. The reward must be available to all similarly-situated individuals. A reasonable alternative must be offered to those individuals for whom it is reasonably difficult or medically unadvisable to participate. 5. The plan must disclose the availability of the alternative standard in any plan materials describing the terms of the program. As long as these factors are met, employers can discriminate based on health factors in the implementation of wellness programs and avoid a violation of Federal law. In 2010, the Patient Protection and Affordable Care Act (ACA) was passed by Congress and, among many other things, amended the HIPAA non-discrimination provisions and wellness provisions of the PHS Act to prohibit discrimination against individual participants and beneficiaries of group health plans in eligibility, benefits, or premiums based on a health factor. As a result, HHS had to make changes to the 2006 Regulations so that they would be in line with an exception in the ACA to allow premium discounts, rebates, or modifications in return for adherence to certain programs of health promotion and disease prevention. The 2013 Regulations create a compliant method by which private employers can discriminate based on health factors in the implementation of wellness programs. And like the 2006 Regulations, if the program does discriminate based on health factors, employers have to meet the same five criteria set forth above in order to avoid an outright violation of HIPAA. However, another fairly significant change was made in the new rules: the
Making Louisiana a Better Place to Practice Medicine Since 1878
The 2013 Legislative Session in Review by LSMS Chair of Council on Legislation Keith DeSonier, MD For a few short months every year, legislators gather in Baton Rouge to discuss ideas and concepts that have the potential to impact our lives and livelihoods greatly. As LSMS Chair the only physician of Council on organization that Legislation, Keith represents all special- DeSonier, MD ties in the state, the Louisiana State Medical Society works diligently on your behalf to protect your patients and your practice.
contracted with the health plan. This was passed unanimously.
House Bill 393 - Act 312 - by Representative Andy Anders of Vidalia and Senate Bill 185 - Act 358 - by Senator Ed Murray of New Orleans are companion pieces of legislation requiring that: • all Bayou Health plans use a standard prior authorization form for prescription drugs, • all Bayou Health plans hold open and public meetings when changes are being proposed to their formularies, • all Bayou Health plans standardIn 2013, the LSMS sought passage of ize the credentialing process for five bills. Four of the bills formed a providers and institute set time comprehensive Medicaid reform packperiods with which the Bayou age in an effort to increase transparency Health plans must complete the and decrease the administrative burden credentialing process, and that has been placed on the backs of • all Bayou Health plans standardize physicians. The fifth bill intended to the information that is provided in protect a physician’s right to due process the remittance advice or explanarights and privacy when interacting with tion of benefits when the plans pay the Louisiana State Board of Medical or deny claims. Examiners. House Bill 273 by Representative The Medicaid package was passed, while Nick Lorusso of New Orleans called the due process bill was successful in for greater due process and procedural the House but could not get out of the protections to be implemented by the Senate. LSBME. As mentioned earlier, it could not get out of the Senate Committee Medicaid Package on Health and Welfare after passing through the House. Senate Bill 55 - Act 212 - by Senator Ronnie Johns of Lake Charles requires It would have required raising the quothe Department of Health and Hospirum of the LSBME from two to four tals to provide more transparency in the members (the board is comprised of Bayou Health and Behavioral Health seven members) and ensuring that the Partnership programs by publicly repersonal medical records of physicians porting measures which speak to health did not become a public record in the outcomes, provider claim payments and event a physician was brought before denials, and recipient satisfaction. One the board for an adjudicatory action. side note, not only was this legislation passed unanimously; it was also coauJoining LAMPAC thored by 63 members. To learn more about the LSMS’ legislaHouse Bill 392 - Act 311 - by Repretive efforts, visit sentative Stuart Bishop of Lafayette will lsms.org/advocacy. Also, to join our require that Bayou Health networks political action committee, LAMPAC, reimburse all primary care services visit lsms.org/LAMPAC. You do not provided to newborns within the first need to be an LSMS member to join 30 days of life, regardless of whether LAMPAC. the physician providing the service is
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Louisiana Medical News
AUGUST 2013 • 7
Hospitals Face More Medicaid Cuts, continued from page 1 The hospital association has asked the administration for a detailed explanation, including the projected demand for services by Medicaid enrollees. DHH did not immediately provide those figures, and the agency had not provided them at deadline. However, the agency said it had used recent utilization rates in calculating the cuts. DHH Secretary Kathy Kliebert told The Advocate that she was confident in the projections that showed the funding reduction was necessary. Prados said it appeared that DHH was anticipating higher utilization rates in making the cuts ahead of time. But it looks as though the projected utilization rates are based on historical experience, and that experience may no longer apply, he added. Louisiana’s Medicaid situation has changed. The recently passed state budget means fewer people are eligible for Medicaid. The Jindal administration has made a number of moves to control the program’s costs, including putting Bayou Health in place. The private insurance program covers two-thirds of the people enrolled in Medicaid and was designed to reduce Medicaid costs. The Jindal administration has been reluctant to share that information. But the hospitals are continuing to ask for Bayou Health data. Prados said another factor that could affect the Medicaid costs is that Louisiana’s hospitals have also taken, and are continuing to take, steps to lower those expenses. The healthcare cuts will reduce rural hospitals’ Medicaid funding by a little more than $3 million. Urban hospitals will see a cut of a little less than $10 million. The Medicaid cuts, include: • 2009, estimated at $90 million for 3.5 percent mid-year cut; and 6.3 percent in-patient and 5.7 percent outpatient reductions in August. • 2010, estimated at $46 million for 5 percent mid-year cut; and 4.6 reduction in
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August. • 2011, estimated at $18 million for 2 percent mid-year reduction. • 2012, estimated at $31.3 million for 3.7 percent in-patient and outpatient reductions. • 2013, estimated at $19 million for 1 percent in in-patient and outpatient reductions; $10 million announced in June for current fiscal year. Prados said there is some concern that hospitals may face another round of midyear Medicaid cuts. The hospitals have a lot of the mid-year
cuts in the last five and half years, he said. One reason for that concern: the state budget included $200 million in overdue taxes. The money was included in DHH’s budget. Hospital association members, among others, were concerned about the amount of amnesty payments, not to mention the origin of the numbers. The Legislative Fiscal Office’s chief economist, Greg Tarver, told legislators he had no idea where the $200 million number originated. Prados said it’s too early to figure out what will happen with the amnesty program
Wellness Programs in the Workplace, continued from page 7 maximum reward was increased from 20 percent to 30-50 percent. This allows employers to offer rewards of up to 50 percent of employees’ health insurance hosts if they meet certain wellness goals. Additionally, the new regulations provide employers with greater flexibility when it comes to how they want to set up their programs. As long as employers meet the five criteria in order to avoid HIPAA violations, they can implement their programs however they want.
Wellness Program Implementation The Affordable Care Act intends to create new incentives and build on existing wellness program policies to promote employer wellness programs and encourage opportunities to support healthier workplaces, but it appears that employers are still hesitant to fully implement wellness plans. Around half of employers have implemented some form of wellness plan, but very few wellness programs today come close to the 20 percent maximum reward prescribed in the 2006 rules. In fact, most rewards are in the 3-11 percent range. Additionally, employee participation is very low; only about 20 percent of employees
engage in them. This may be due to a concern that, because of the minimal rewards, the benefits to participating are very small. A recent RAND Study has indicated that most employees only save about $2.38 per month on healthcare costs. The study did not detect any statistically significant decrease in the use of emergency rooms or hospital care, nor did the health of employees substantially improve. RAND reports that employees generally only lost one pound a year for three years, and cholesterol was not greatly lowered. With cost concerns foremost in the minds of employers, there is a rising belief that among employee benefits specialists that improving the health of employees can have a positive effect on costs. For example, a recently released survey by the Archives of Internal Medicine found that obese employee medical costs were seven times higher than average; those same workers file twice the average rate of worker compensation claims and miss thirteen times more workdays. It is a wellknown healthcare truism that 20 percent of the population is responsible for 80 percent of the cost of healthcare. Thus, employers are looking for ways to target the unhealthiest beneficiaries in order to re-
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or what the worst-case scenario might be. The hospitals will have to wait and see, but they should have some idea of what will happen by January, he added. For now the hospitals and the association are working with the agency, he said. DHH has promised the hospital association that the department will work throughout the year to identify other sources of revenue. “So we’ll continue to work with them. The budget is always a work in progress. We’ll kind of wait for details as they become available,” Prados said.
duce the costs of that group’s healthcare. The exceptions for wellness programs provide a potential part of the solution. The difference between now and 2006, when the wellness plan regulations were initially passed, is that the urgency for employers to implement wellness plans is much more compelling for both large and small employers. For employers with greater than 50 full time employees, the ACA employer mandate, recently postponed to become effective on January 1, 2015, requires those employers to provide affordable, minimum value insurance to at least 95 percent of their employees. For smaller employers who are not required to provide insurance in 2014, the ACA provides grants to small businesses (fewer than 100 employees), to implement wellness programs within their companies. The ACA appropriates $200 million for these grants. Implementing wellness programs is a potential route for private companies to cut costs and provide employees with incentives to remain healthy, as well as a recruiting tool for future employees. Aside from the statistics regarding savings and improvements in employee health, employers have repeatedly noted that they feel these programs are good for their companies. RAND’s report stated that there were “small yet promising changes in worker behavior” from programs at 600 businesses. The same study noted that wellness programs are a recruiting and retention tool, and they attract health-conscious employees. Wellness programs also lead to less paid-timeoff for employees because those programs promote preventative healthcare, which in turn leads to less sick days. Employers also told RAND that they felt overwhelmingly confident that workplace wellness reduces medical costs. While the statistical data on wellness plans has not been sufficiently developed to guarantee a net positive result, as American healthcare continues to focus on preventative care and the cost-saving benefits of avoiding hospital admissions, wellness plans may be becoming a valuable option for employers. Stephen Angelette is an associate in the Baton Rouge office of Breazeale, Sachse & Wilson, LLP practicing in the area of healthcare and Kelsey Clark is a law clerk in the Baton Rouge office.
ICD-10: Are You Ready? By BILL HEFLEY, MD
With the rapidly approaching ICD10 ‘go live’ date of October 1, 2014, medical practices should be well on their way in preparing for the transition. With implementation of ICD-10, physician offices accustomed to the 13,000 ICD-9 codes must be prepared to transition seamlessly to a new set of 68,000 codes. More specifically, a physician or billing clerk currently using ICD-9 to properly code the diagnosis of ‘patella fracture’ must choose between two possible codes; when utilizing ICD-10 that number explodes to 480 codes. Yes. Get ready. In 1992 the World Health Organization (WHO) published the International Classification of Diseases, Tenth Revision. The U.S. made modifications to the WHO ICD-10 creating the ICD-10-CM (Clinical Modification) which is the diagnosis code set that will replace ICD-9-CM Volumes 1 and 2. The Department of Health and Human Services (HHS) published a regulation requiring the replacement of ICD-9 with ICD-10 and later pushed back the compliance date one year to October 1, 2014. Farzad Mostashari, MD, the National Coordinator for Healthcare Information Technology, asserted last month that there would be no extension of the deadline. While many physicians see the transi-
Myths Associated with ICD-10 The Go-Live date will most likely get delayed again The only staff members affected will be coders and billing specialists My EMR and PM vendor will be automatically compliant General Equivalence Mappings are a good solution to coding an individual clinical chart After October 1, 2014 payers and clearinghouses will aid practices by automatically cross-walking submitted 9 codes to 10 codes
tion to ICD-10 as an unnecessary burden, other physicians and industry stakeholders believe that the ICD-9 code sets are obsolete and inadequate. ICD-10 codes have more characters and a greater number of alpha characters creating space for new codes and flexibility for future medical advances. ICD-10 has increased specificity that will improve the ability to identify diagnosis trends, public health needs, epidemic outbreaks, and bioterrorism events. In addition, ICD-10 will improve claims processing, quality management and benchmarking data. A successful ICD-10 transition requires exhaustive preparation by medi-
cal practices. Yet recent research by the Medical Group Management Association indicates that only 4.7 percent of practices reported that they have “made significant progress” when rating their “overall readiness level for ICD-10 implementation.” The research was derived from respondents in 1,200 medical practices in which more than 55,000 physicians practice. Preparing to practice medicine in the world of ICD-10 is no small undertaking. It will require time and money. Having an experienced billing clerk “coder” in the practice will no longer be sufficient to generate accurate codes. Simply converting the practice’s ICD-9 superbill to ICD-10 is problematic. Many industry experts don’t see the superbill being preserved at all. The American Academy of Professional Coders (AAPC) recently issued a two page
ICD-9 superbill which when crosswalked to ICD-10 became nine pages long. Another industry consultant sites an example of a two page ICD-9 superbill translating into a 48-page ICD-10 superbill. Preparation for the medical practice begins with internal training and testing of all parties involved in producing proper coding. Administrators must establish a training and implementation schedule; set deadlines; create a project team; identify training resources; perform documentation gap analysis; evaluate and modify the practice’s forms; budget for transition expenses; communicate with practice management (PM) software and EHR vendors; assess hardware and software update requirements; and arrange testing with clinical and billing staff, PM and EHR (CONTINUED ON PAGE 12)
Louisiana Medical News
AUGUST 2013 • 9
Making the Marriage Work, continued from page 1 wears off, both are left to figure out how to navigate this new partnership and work as a team. Of course if that was easy, there wouldn’t be such a high divorce rate. You only have to look back to the rash of mergers and buyouts in the ‘90s to know that many of these marriages between practices and hospitals don’t end harmoniously. So what can you do to beat the odds? Medical News had the opportunity to chat with Ken Hertz, FACMPE, principal with MGMA Health Care Consulting Group, about the keys to creating a lasting union. Hertz, who has nearly 40 years of management experiKen Hertz ence, has held leadership positions with primary care and multispecialty care organizations, as well as large integrated systems. He works with practices and hospitals on strategic planning, integration, operational improvements, compensation, conflict resolution and governance issues.
Marry in Haste, Repent at Leisure In the current transformational landscape, Hertz has seen a lot of hasty mergers and alignment contracts executed without taking the time for proper due diligence … the ‘chicken little’ syndrome. “I tell people I’m not necessarily sure the
sky is falling or that the world is ending. What we’re dealing with is this funny word called ‘change,’ and some of us can barely say it without stroking out,” he noted. Hertz was quick to add that change is scary, but that’s all the more reason to take time to prepare properly on the front end to ensure each partner stays committed when the relationship hits an inevitable rough patch down the road. He noted the rush to ‘do something’ happens on both sides with physicians worried about the changing regulatory and reimbursement landscape and hospitals snapping up practices before a competitor has the opportunity to grab them. It’s probably wise to note, however, that few couples married at a Las Vegas drive-thru chapel at 3 a.m. make it to their golden anniversary celebration. Instead, many of them wake up the next day with the question of ‘Now what?’ hanging heavily in the air.
Premarital Counseling “It’s like the Yogi Berra line, ‘If you don’t know where you’re going, there’s a good chance you won’t get there,’” Hertz said. “When we work with physician practices and they say, ‘We need to get aligned with the hospital or need to merge with another practice,’ the first thing we ask is why?” It’s important, he said, to really explore what each partner hopes to accomplish through the alignment or merger.
Physicians’ health Foundation oF louisiana
How does each of you define success? Once the ‘why’ has been sufficiently vetted, the attention shifts to the ‘who.’ Hertz said it is essential to honestly evaluate your core values and deal-breakers and then see how those align with your potential partner. “The key to any relationship is you’ve got to understand what makes you tick and what’s important to you … and … you’ve got to understand what makes your partner tick and what’s important to them,” Hertz said. Ultimately, Hertz noted, each party is aligning themselves to a vision. “It’s really critical, I think, that there be a shared vision … and the shared vision can’t be just about money.”
Prenup Chances are not everyone is going to get everything they want in any relationship, but both parties should address the ‘must haves’ and ‘won’t dos’ and write those into the contract. The reimbursement plan, governance structure, conflict resolution protocol, and practice pattern expectations should all be thoroughly discussed on the front end and clearly outlined in the final agreement. Equally, the repercussions for both parties of not living up to the agreement should be spelled out. Making the Marriage Last Although it might seem like the heavy lifting happens in the planning stage, anyone who has been married long knows that once the honeymoon is over, the real work begins. “Each party has to put in a hundred percent. It is the only way this works,” Hertz said. For physicians used to making snap decisions and having their orders carried out, following the maze of corporate protocols that are inherent in most health systems and large practices can be frustrating. For hospitals shifting from a volume-based to an outcomes-based reimbursement model, it can be equally difficult to understand how less truly can mean more. The best antidote for frustrations that build up and fester over time is open communication. Hertz pointed out, “Communication is broadcasting, but it’s also receiving. The notion of two-way communication is critical.”
Not only does there have to be communication, but it must also be meaningful. “Most of the physicians I know were absent the day they taught mind-reading in their training programs,” he said. It does no one any good to have an administrator walk into a physician’s office at the end of the month, tersely tell the doctor the numbers aren’t where they ought to be, and walk out … which Hertz has witnessed. Instead, he said, the two need to work together to figure out where the problem lies and what steps could be taken to fix it. Being open to different viewpoints allows both physicians and administrators to see care delivery issues in a new light. It’s one reason why physician governance is critical to the health of the overall organization. Having physicians involved in planning for the future keeps them engaged in the mission and shared vision. Having a voice, however, doesn’t always mean one party gets their way. Hertz noted, it’s better to hear an honest ‘no’ than a sugar-coated answer that is meaningless. Trust and transparency, he said, are the cornerstones of any good relationship. “Do what you say you’re going to do when you say you are going to do it,” he stated, noting the axiom is equally true for physicians as it is for administrators. Hertz continued, “If I’m a system, and I’m going to pay you based on work RVUs or based on charges or visits or collections or whatever, I need to make sure I can do a really good job of collecting that information; that it is accurate; that it’s timely; and that you trust it. If we don’t trust each other, it doesn’t work so well.” Ultimately, those who have realistic expectations and are willing to put in the work to achieve the shared vision enjoy the strongest partnerships. “You’ve got to know what is going on in the world around you … so you’ve got to be informed. You must do your due diligence. You must know yourself, and you’ve got to do this with your eyes open — wide open — and never assume. Those are the top five things,” Hertz said. “The bottom line is none of this is brain surgery, but there is no silver bullet, no magical answer. It’s darn hard work,” he concluded.
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Louisiana Medical News
BlueBin Bound By LYNNE JETER
Expensive technology not needed. Barcodes are the key. Get rid of the warehouse. And take doctors and nurses out of the inventory control process. In 2009, Charles Hodge gave that advice on ways to streamline hospital supply inventory, when he served as chief procurement officer and vice president of supply chain management at Seattle Children’s Hospital, a major pediatric referral center in Seattle, Wash. At the time, Hodge was in the midst of a four-year journey to implement BlueBin, a smarter inventory process involving barcodes, simple bins and basic wire racks at key traffic areas and points of care. He had developed BlueBin after working in the automotive industry for 15 years, and transferring its lean manufacturing processes to the healthcare industry’s supply management realm. Hodge’s just-in-time inventory system eliminated the hospital’s need for its $5 million, 40,000-square-foot warehouse and millions in inventory. In its first year, the $200,000 system achieved a $2.5 million return, said Hodge. Particularly because the supply management process was new to the hospital industry, executive sponsorship was critical for BlueBin to succeed, said Hodge. “There’s no substitute for executives who are firmly committed to continuous process improvements,” he said. “Make sure you secure their strong support and communicate your results early and often to keep the momentum in place.”
Supply Chain Process Redefined Hodge, the primary architect of BlueBin, may perhaps seem to be an unlikely source of such an innovative, low startup cost supply management system. His career began in 1993, after earning a business administration degree from California State University. An MBA from the same university in 2001 helped him traverse growing roles of responsibility in capital equipment, electronic chemicals, and automotive manufacturing sectors. Before joining Seattle Children’s Hospital and Research Institute, he served as regional director in charge of supply chain management operations for Sutter Health’s peninsula coastal region, and a member of the health system’s corporate strategic sourcing group. “I took the lessons learned from kanban systems and applied them to elements of patient flow and care delivery,” said Hodge. “After I implemented the BlueBin system at Seattle Children’s Hospital, other hospitals started calling me, asking how we did it, and the timing seemed right to start my own consulting firm.” With the BlueBin system in five hospitals across the nation, from brand new to nearly 160 years old, Hodge said consulting groups are keen to learn more about the
kanban conversion from the automotive to the healthcare industry. “For example, Joan Wellman & Associates, the consulting firm for Nemours Children’s Hospital in Orlando, brought us together,” he said. “When hospital leaders start to think about hospitals more like a manufacturing environment, the supply chain bubbles up as a problem because traditional management systems (like the par cart and automation methods) haven’t been changed in decades, and they just don’t work very well. They only work because clinicians and technicians are heavily involved in managing their own supply chains. “Our program says no to that. Get those folks back to the patients, the bedsides, and the families. Let the supply chain do it all, and more efficiently. No inventory. No stat calls. No urgencies. No ‘hey, where is this?’ No off-contract purchases. It saves a lot of money, space and time, and gives that time back to the patient.”
One Hospital’s Lean Journey When Nemours began its lean healthcare cultural transformation journey in 2008, the executive team huddled to define very specific and focused strategic goals, while also aligning all associates in the organization around those goals. “We’ve achieved great results but still had variation in those results, and we wanted to find something that would really help us catapult our work in a constant quest for perfection in everything we do – the highest quality, no safety errors, a 100 percent engaged workforce. Clearly, we’re focused around quality and patient care and safety, engaged people, and stewardship,” said Mariane Stefano, vice president of service and operational excellence for Nemours, whose healthcare career began “as a nurse, rummaging through supply closets.” As part of this quest, hospital leaders
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Louisiana Medical News
AUGUST 2013 • 11
BlueBin Bound, continued from page 11 began seeking a more efficient and effective management system for medical supplies, the second largest expense for most health systems, accounting for up to 20 percent of hospital costs. They were encouraged to learn about Seattle Children’s Hospital recapturing an estimated 48,000 hours for patient care instead of scavenger hunts for needed supplies. The executive team embarked on a study trip to Autoliv, a manufacturer of air bags and other components for the automotive industry, followed by a “totally fascinating” tour of the Toyota plant in Kentucky to see how lean tools and principles impacted the end product, said Stefano. The team’s next stop: Seattle Children’s Hospital, now a 400-bed pediatric hospital that’s been on a lean journey since the late 1990s. “We saw firsthand how these tools that were being used in the automotive manufacturing industry could easily be applied to a healthcare environment,” said Stefano. “We knew the tools and principals of a lean environment could really help in terms of problem solving, removing waste and inefficiencies from our system, and making sure that everything stays focused on the customer.” When the team returned to the east coast and gathered around the Nemours table, “we knew this is exactly what we needed as part of our organizational transformation journey. We were sold on it once we saw how it worked.” Nemours implemented BlueBin
12 • AUGUST 2013
Louisiana Medical News
three months before the children’s hospital opened last October, a timeline that proved challenging and in hindsight was “way too fast,” said Stefano, primarily because of changes in the vendor and supplier distribution flow. “It was a very fast process and we had bumps in the road,” she explained. “We had to change our main supplier to make sure we had suppliers that would work in this type of Demand Flow system and would be willing to deliver supplies daily rather than weekly, and in the quantity we needed instead of bulk. If we need 10 Band-Aids for a supply unit, that’s now what we get.” The investment of upfront manpower implementing the system “will be recouped 10 times over,” said Stefano. “One, you’re no longer holding inventory so that cost de-
creases; two, the most powerful point of the BlueBin system is that it takes the clinical staff totally out of the supply management work.
Demand-Flow Supply Replenishment Model In early June, healthcare leaders from around the country – Stanford’s Lucile Packard Children’s Hospital, Oregon Health & Science University, UCLA Health, the University of Michigan Health System, and Vancouver Coastal Health – converged at Nemours in Orlando to see BlueBin in action. • A dedicated supply technician uses barcode scanning to initiate the automated supply management process. • Supply areas are stocked with two bins for a particular supply. • The front bin holds a specified level of supplies. • When the last item of the front bin is used, nurses place it in a designated holding area, triggering a replenishment order. • Then, nurses pull the second bin to the front. • Before the second bin is emptied, the first bin’s supplies will have already been reordered, restocked and replaced in the supply area. BlueBin has also been implemented
at Mercy Hospital and Medical Center, Chicago’s first hospital, and Presbyterian Hospital in Albuquerque, NM. “Before we implemented BlueBin, our store rooms were being overused and we weren’t centralizing the purchase of supplies,” said Rick Cerceo, executive vice president and COO of Mercy, a 410-bed acute care facility – Chicago’s first hospital – that transitioned to BlueBin in mid-2011. “Our staff was running out of supplies, which delayed procedures and patient care. This forced nurses to start ordering their own supplies and supply rooms began bulging at the seams because they were so afraid of running out. Now I can say these problems are completely gone; the process has been amazing.” When Martin Health South implemented BlueBin, the rollout schedule began last summer in various ICU areas and concluded in February. “Before, things were just wherever there was a spot for it,” said Linda Landers, a patient care technician in the surgical intensive care unit (SICU) at Martin Health South in Stuart. “Now there’s a flow to it.” Nemours’ Alfred I. duPont Hospital for Children in Wilmington, Del., is the sixth location deploying BlueBin technology.
ICD-10: Are You Ready? continued from page 9 vendors, clearinghouses and major health plans. Providers must be trained on the changes in clinical concepts and the level of detail in ICD-10, so that their documentation supports the ability to code to the highest level of detail. For many specialties, it is highly recommended that physicians take anatomy and physiology refresher courses. Billing staff must increase their knowledge of anatomy and physiology, learn and adopt a completely different coding system and be able to code to the greatest level of detail. Training options include sending staff for offsite training, hiring an outside trainer to come to the practice, online training, webinar training and book-based training. Frequent testing and trial coding for all staff is also highly recommended in the months leading up to the ICD-10 ‘go live’ date. In addition to internal preparation, medical practices must also arrange testing with their PM vendor, EHR vendor, clearinghouse and major health plans. Many PM vendors and EHR vendors will not be ready to meet the October 1, 2014 ICD-10 compliance date. Practices must communicate with their vendors months in advance to schedule software upgrades and testing to assure readiness. If the practice’s PM or EHR vendor is not going to be prepared for the ICD-10 launch, the practice will need to make plans to switch in time for the transition date. Many practices with in-house billing departments will weigh the benefits of outsourcing the practice’s revenue cycle management. Costs associated with the preparation for the ICD-10 transition are not insignificant. Industry experts suggest budgeting $200,000 to $280,000 for an eight-physician practice. Expenses include training,
testing, hardware upgrades and PM/EMR software upgrades. In addition to the onetime costs associated with implementation, many practices will experience ongoing, recurring costs related to the need for increased coding staff, consulting services, subscriptions to print and software-based coding aids and reduced productivity as a result of increase need for documentation and coding complexity. The ICD-10 transition will undoubtedly eclipse Y2K and the HIPAA 4010 to 5010 transition in terms of the impact on the healthcare industry. Unprepared practices will face painful disruptions in cash flow and a chaotic scramble to regain practice productivity. Even well-prepared practices that execute ICD-10 implementation flawlessly will likely experience some disruption in cash flow. Remember, a successful revenue cycle requires every entity in the claims processing chain to be fully prepared for ICD-10. The PM system, EMR system, clearinghouse and payer must all communicate properly electronically and adjudicate ICD-10 claims correctly. Some bugs are inevitable. Practices should have in place a line of credit sufficient to cover three months operating expenses prior to ‘go live.’ Preparation will take considerable planning, time and money and should begin immediately. October 1, 2014 is just around the corner. Bill Hefley, M.D., is President and CEO of MedEvolve, providers of Practice Management Software, EHR, and billing services to thousands of physicians across the US. In addition, he has an orthopedic surgery practice in Little Rock, specializing in minimally invasive surgeries for the knee, hip and shoulder including arthroscopic and joint replacement procedures.
DHH/BHSF Rulemaking The following Rules were published in the July 20, 2013 Louisiana Register. They should also be available at the register website, http://www. doa.louisiana. Cindy Bishop gov/OSR/reg/ regs2013.htm If you have any questions, please contact me. EMERGENCY RULES AND PUBLIC PROCESS NOTICES 1. Disproportionate Share Hospital Payments - Public Private Partnerships - South Louisiana Area: amends the provisions governing disproportionate share hospital (DSH) payments for hospitals participating in publicprivate partnerships to establish payments for hospitals located in the following areas: 1) Houma; 2) Lafayette; 3) Lake Charles; and 4) New Orleans. 2. Disproportionate Share Hospital Payments - Public Private Partnerships - South Louisiana Area: amends the provisions of the June 27, 2013 Emergency Rule to correct the percentage for DSH payments to hospitals located in the Lafayette area. This action is being taken to promote the health and welfare of Medicaid recipients by maintaining recipient access to much needed hospital services. 3. Inpatient Hospital Services - PublicPrivate Partnerships - Reimbursement Methodology: amends the provisions of the April 15, 2013 Emergency Rule in order to revise the formatting of these provisions as a result of the promulgation of the June 1, 2013 Emergency Rule to assure that these provisions are promulgated in a clear and concise manner in the Louisiana Administrative Code (LAC). 4. Inpatient Hospital Services - PublicPrivate Partnerships - South Louisiana Area: amends the provisions governing the reimbursement methodologies for inpatient services provided by non-state owned hospitals participating in public-private partnerships to establish payments for hospitals located in the Lafayette and New Orleans areas. 5. Nursing Facilities - Leave of Absence Days - Reimbursement Rate Reduction: amends the provisions governing the reimbursement methodology for nursing facilities to further reduce the reimbursement rates for leave of absence days. 6. Nursing Facilities - Per Diem Rate Reduction: amends the provisions governing the reimbursement methodology for nursing facilities to further reduce the reimbursement rates for non-state nursing facilities. 7. Outpatient Hospital Services - NonRural, Non-State Public Hospitals - Supplemental Payments: amends the provisions governing the reimbursement methodology for outpatient hospital services in order to revise the qualifying criteria and reimbursement methodology for non-rural, non-state public hospitals. 8 Outpatient Hospital Services - Public-Private Partnerships - South Louisiana Area: amends the provisions governing the reimbursement methodology for outpatient services provided by non-state owned hospitals participating in public-private partnerships to establish payments for hospitals located in the Lafayette and New Orleans areas. 9. Professional Services Program - Public-Private Partnership - Professional Practitioners Supplemental Payments: amends the provisions governing the reimbursement methodology for the Professional Services Program to provide a supplemental payment to physicians and other professional service practitioners employed by a physician group affiliated with certain non-state owned hospitals participating in public-private partnerships.
REDECLARED EMERGENCY RULES 1. Behavioral Health Services - Physician Payment Methodology: continues the provisions of the April 20, 2013 Emergency Rule which amended the provisions governing the reimbursement of physician services rendered in the LBHP in order to establish a distinct payment methodology that is independent of the payment methodology established for physicians in the Professional Services Program. 2. Crisis Receiving Centers - Licensing Standards: continues the provisions of the April 20, 2013 Emergency Rule which adopted provisions to establish licensing standards for Level III crisis receiving centers (CRCs) in order to provide intervention and crisis stabilization services for individuals who are experiencing a behavioral health crisis. 3. Home and Community-Based Services Waivers - Children’s Choice - Allocation of Waiver Opportunities: continues the provisions of the April 20, 2013 Emergency Rule which amended the provisions of the September 20, 2010 Emergency Rule in order to correct a formatting error within the Section. 4. Home and Community-Based Services Waivers - Support Coordination Standards for Participation: continues the provisions of the August 20, 2012 Emergency Rule which amended the December 20, 2011 Emergency Rule in order to clarify the provisions governing support coordination services rendered to participants of OAAS-administered waiver programs. 5. Inpatient Hospital Services - Neonatal and Pediatric Intensive Care Units and Outlier Payment Methodologies: continues the provisions of the August 20, 2012 Emergency Rule which amended the March 1, 2011 Emergency Rule governing the reimbursement methodology for inpatient hospital services to revise the formatting of these provisions in order to ensure that the provisions are promulgated in a clear and concise manner. 6. Inpatient Hospital Services - Nonrural, Non-State Hospitals - Reimbursement Rate Reduction: continues the provisions of the August 1, 2012 Emergency Rule which amended the provisions governing the reimbursement methodology for inpatient hospital services to reduce the reimbursement rates paid to non-rural, non-state hospitals. 7. Inpatient Hospital Services - State Hospitals - Reimbursement Rate Reduction: continues the provisions of the August 1, 2012 Emergency Rule which amended the provisions governing the reimbursement methodology for inpatient hospital services to reduce the reimbursement rates paid to state-owned hospitals. 8. Medicaid Eligibility - Medically Needy Program - Behavioral Health Services: continues the provisions of the April 20, 2013 Emergency Rule which amended the December 20, 2012 Emergency Rule to further clarify the provisions governing covered services. 9. Medical Transportation - Emergency Ambulance - Reimbursement Rate Reduction: continues the provisions of the August 1, 2012 Emergency Rule which amended the provisions governing emergency medical transportation services to further reduce reimbursement rates. 10. Outpatient Hospital Services - NonRural, Non-State Hospitals and Children’s Specialty Hospitals - Reimbursement Rate Reduction: continues the provisions of the August 1, 2012 Emergency Rule which amended the provisions governing the reimbursement methodology for outpatient hospital services to reduce the reimbursement rates paid to non-rural, non-state hospitals and children’s specialty hospitals. 11. Outpatient Hospital Services - Public-Private Partnerships - Reimbursement Methodology: continues the provisions of the April 15, 2013 Emergency Rule which amended the provisions governing reimbursement for Medicaid payments for outpatient services provided by non-state owned major teaching hospitals participating in public-private partnerships which assume the provision of services that were previously delivered and terminated
or reduced by a state owned and operated facility. 12. Outpatient Hospital Services - Small Rural Hospitals - Low Income and Needy Care Collaboration: continues the provisions of the December 20, 2011 Emergency Rule which amended the provisions of the October 20, 2011 Emergency Rule in order to clarify the qualifying criteria. 13. Outpatient Hospital Services - StateOwned Hospitals - Reimbursement Rate Reduction: continues the provisions of the August 1, 2012 Emergency Rule which amended the provisions governing the reimbursement methodology for outpatient hospital services to reduce the reimbursement rates paid to stateowned hospitals. 14. Psychiatric Residential Treatment Facilities - Licensing Standards: continues the provisions of the August 20, 2012 Emergency Rule which amended the provisions governing the licensing of psychiatric residential treatment facilities (PRTFs) in order to revise the licensing standards as a means of assisting PRTFs to comply with the standards. NOTICES OF INTENT 1. Adult Day Health Care - Repeal of Licensing Standards: repeals the licensing provisions governing adult day care center services as these provisions were revised and repromulgated in Part I, Chapter 50 of Title 48 of the Louisiana Administrative Code. 2. Early and Periodic Screening, Diagnosis and Treatment - School-Based Nursing Services: continues the provisions of the March 20, 2012 Emergency Rule which amended the January 1, 2012 Emergency Rule to clarify the provisions governing EPSDT school-based nursing services. 3. Family Support/Subsidy Services Repeal of Licensing Standards: repeals the licensing provisions governing Family Support/ Subsidy services as these provisions were revised and repromulgated in Part I, Chapter 50 of Title 48 of the Louisiana Administrative Code. 4. Intermediate Care Facilities for Persons with Developmental Disabilities - Reimbursement Rate Reduction: continues the provisions of the July 1, 2012 Emergency Rule which amended the provisions governing the reimbursement methodology for non-state ICFs/DD to further reduce the per diem rates. 5. Personal Care Attendant Services Repeal of Licensing Standards: repeals the licensing provisions governing personal care attendant services as these provisions were revised and repromulgated in Part I, Chapter 50 of Title 48 of the Louisiana Administrative Code. 6. Respite Care - Repeal of Licensing Standards: repeals the licensing standards governing Respite Care services as these provisions were revised and repromulgated in Part I, Chapter 50 of Title 48 of the Louisiana Administrative Code.
FINAL RULES 1. Home and Community-Based Services Waivers - Community Choices Waiver: amends the provisions governing the Community Choices Waiver to add two new waiver services, to incorporate a new service delivery method, and to clarify the provisions governing personal assistance services. 2. Intermediate Care Facilities for Persons with Developmental Disabilities - Non-State Facilities - Reimbursement Methodology: continues the provisions of the August 1, 2010 Emergency Rule which amended the provisions governing the reimbursement methodology for non-state ICFs/ DD to restore the per diem rates paid to private providers who have downsized large facilities to less than 35 beds and incurred unusually high capital costs as a result of the downsizing. 3. Nursing Facilities - Standards of Payment - Level of Care Determination: repromulgates the June 20, 2013 final Rule which amended the provisions governing the standards for payment for nursing facilities to clarify level of care determinations in order to correct a typographical error. 4. Personal Care Services-Long-Term Reimbursement Rate Reduction: continues the provisions of the July 1, 2012 Emergency Rule which amended the provisions governing the reimbursement methodology for long-term personal care services to reduce the reimbursement rate. 5. Professional Services Program - Anesthesia Services - Reimbursement Rate Reduction: continues the provisions of the July 1, 2012 and July 20, 2012 Emergency Rules which amended the provisions governing the reimbursement methodology for anesthesia services to reduce the reimbursement rates. 6. Professional Services Program - Family Planning Services - Reimbursement Rate Reduction: continues the provisions of the July 1, 2012 and February 20, 2013 Emergency Rules which amended the provisions governing the reimbursement methodology for family planning services to reduce and adjust the reimbursement rates.
Legislative Affairs content is provided by Checkmate Strategies, publisher of Health Care Information Services. All content © Checkmate Strategies and Louisiana Medical News, LLC. For more information, readers may contact Cindy Bishop at 225.923.1599 or P.O. Box 80053, BR, LA 70598, or send email to destiny362@aol. com. Our website is www.checkmatestrategies.com
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In the News Lafayette General Health Announces Leadership Positions LAFAYETTE – With the addition of University Hospital and Clinics, Lafayette General Health’s Board of Trustees recently announced changes in leadership. The acquisition of University Hospital & Clinics by Lafayette General Medical Center prompted the founding of an official health system, David L. Lafayette General Health Callecod (LGH). The health system owns or manages five facilities and has affiliations with Opelousas General Health System, Abbeville General Hospital, American Legion Hospital – Crowley, Savoy Patrick W. Gandy, Jr. Medical Center and Franklin Foundation. As part of the System implementation, several leadership positions, job duties and titles have expanded or changed. David L. Callecod, Dean Ducote FACHE, is now the President/Chief Executive Officer of Lafayette General Health. Patrick W. Gandy, Jr. is the new Executive Vice President and Chief Executive Officer of Lafayette General Medical Center. Callecod’s main focus will now be on system initiatives for LGH, while Gandy’s focus is directed at management of Lafayette General Medical Center. Jared Stark is the new Chief Executive Officer of University Hospital & Clinics. Additional LGH system leadership roles have been announced: Roger Mattke is now Senior Vice President and Chief Financial Officer. Gordon Rountree, now Senior Vice President, is General Counsel and Chief Legal Officer. Dean Ducote, Vice President, is in charge of Operations and Support Services, and
Edwina Mallery, Vice President, is Chief Information Officer. Paul Molbert, Vice President, is now in charge of Network Development and the Accountable Care Organization, and Carolyn Huval, Vice President, is now in charge of physician recruiting. In medical roles, Ziad Ashkar, M.D., and Amanda Logue, M.D., will also have health system oversight. Dr. Ashkar is Chief Medical Officer and Dr. Logue is Chief Medical Information Officer for LGH. Several of the aforementioned positions share a dual role of focusing on both hospital and system-wide initiatives. The goal is to implement a core set of values and standards that permeate each facility within the system to offer consistent, compassionate service. The Lafayette General Health brand should be one the public associates with advanced medical treatments and excellence in patient care.
to, and respect for Jerry Fornoff for his interim role in past months in preparing Dauterive Hospital for the recent transition of ownership. Jerry has been a true team player and a good friend of Progressive Acute Care. He will continue to serve as a consultant to Progressive Acute Care in several future ventures and projects,” Rissing adds. Fox assumes the role as CEO of Dauterive Hospital July 22, 2013. He is currently completing service on behalf of Progressive Acute Care as CEO of Oakdale Community Hospital in Oakdale. Bill Fox comes to Dauterive Hospital following a healthcare career that spans more than three decades. He earned his Bachelor of Science in Healthcare Administration from Western Kentucky University in Bowling Green, Kentucky and his Master of Science in Healthcare Administration from Trinity University in San Antonio, Texas.
Bill Fox Named Dauterive CEO
Brown to Serve as Moss Administrator
NEW IBERIA- Bill Fox, a member of the Progressive Acute Care corporate leadership team, has been named to the position of Chief Executive Officer for Dauterive Hospital in New Iberia. Progressive Acute Care is the Louisiana based parent corporation Bill Fox that recently purchased Dauterive Hospital. Dan Rissing, Progressive CEO made the announcement of Fox’s appointment while commending interim CEO Gerald Fornoff for his leadership and dedication during the hospital ownership transition period. “We welcome Bill Fox as an integral member of our Dauterive Hospital leadership team and as a man highly respected and credentialed in the development and strengthening of hospitals in their market area. At the same time, we express our great appreciation
LAKE CHARLES- Larry Graham, CEO and President of the Lake Charles Memorial Health System has named Bernita Loyd Brown as Administrator of the W.O. Moss Memorial Health Clinic. “Bernita was the obvious choice when it came Bernita Loyd Brown to selecting the right person to lead the Moss campus forward,” Graham says. “Her leadership and experience speak for themselves, and her passion for the patients of Moss is unmatched. She will ensure her staff meets the medical needs of the community they serve.” In her role as Administrator, Brown will oversee the day-to-day operations of the Moss campus including the urgent care clinic, various outpatient clinics, diagnostic department and pharmacy.
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Connrmed speakers: Gregory D. Frost and Clay J. Countryman from Breazeale, Sachse & Wilson, L.L.P. and Tony Brooks from Horne LLP. 14 • AUGUST 2013
Louisiana Medical News
In the News LAMMICO Names New Marketing Representative
the people of the many communities we serve, “ Roberson commented. “Our experience, reputation, and history in the provision of home health care to the people of our service area in southeast Louisiana serves as the foundation from which we will provide Hospice care,” she adds. Roberson reports that Modern Hospice will offer a range of in-home hospice services using a multidisciplinary team approach that includes the services of nurses, doctors, social workers and clergy in the provision of care. Services will be individually tailored to the specific needs of the patient and their family situation and will include pain manage-
ment, physical, occupational and speech therapy, assistance with medical supplies and equipment, dietary counseling, continuous home care during crisis times, and bereavement services. Respite care workers will also be provided as needed for the relief of primary caregivers. “The services of a Hospice answer a special calling in a time of great need by patients and their families, “ Roberson states. “In our service through Modern Home Health and Hospice, we will combine a very high level of skill, training, and experience with true human compassion in our care of our patients,” she adds.
METAIRIE- Louisiana Medical Mutual Insurance Company (LAMMICO) has named Terry Burrows to join the company as a marketing representative, covering the areas of Central and Southwestern Louisiana. Burrows will be responsible for leading customer service initiatives Terry Burrows to develop new business while sustaining existing relationships with healthcare providers in a wide area. Headquartered in Lake Charles, Louisiana, Burrows will service the city and surrounding areas within Calcasieu Parish, and extend into Lafayette and Baton Rouge. “We are impressed with Terry’s energetic approach to our team-oriented sales efforts,” said Eric Mason, LAMMICO’s Marketing Director. “His strong leadership skills and effective decisionmaking will help LAMMICO policyholders and potential new insureds in a large area of the state.”
nouncement for the newly purchased Hospice. The hospice will be called Modern Hospice with headquarters in Hammond. Stagg also announced that Hope Roberson, RN, has been named Administrator for the Hospice service. Roberson currently serves as Administrator for Champion’s Modern Home Health service, a position she will continue to hold in addition to her Hospice role. The addition of the Hospice service will compliment Champion’s home health services already in existence in the same service area. “We’re most excited to provide this important and much needed service to
Tudor Named ‘Rising Star’among Healthcare Executives DERIDDER-Becker’s Hospital Review is pleased to recognize Nathan Tudor, CEO of Beauregard Memorial Hospital in DeRidder a “Rising Star” among healthcare leaders under the age of 40. The publication named 25 healthcare executives under the Nathan Tudor age of 40 who have excelled as healthcare leaders. According to the review, the administrative leaders recognized have made considerable accomplishments early in their professional lives, and have shown promise to continue succeeding throughout their careers in healthcare. The leaders recognized were collected through peer nominations and editorial research. There were no fees involved and no one can pay to be included on this list. Leaders were under 40 years of age at the time of their nomination. Mr. Tudor joined Beauregard Memorial Hospital in December 2012 as the Chief Executive Officer. He previously served as administrator and CEO of Otto Kaiser Memorial Hospital in Kenney, Texas, a position he held for about two years. Prior to that, he worked with various hospitals in Texas, Arkansas and Tennessee.
Hospice to Serve Southeast Louisiana Region HAMMOND - Champion Management, LLC, a provider of healthcare services across the Southern United States, has announced it has begun providing Hospice services across its South Louisiana service area as of July 1st. John Stagg, President/CEO for Champion Management made the an-
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AUGUST 2013 • 15
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