Signs of Stress: Hospitals Faced with Increasing Nursing Woes

BY JUSTIN VAUGHN, MDIV
Vice President of Anesthesia Compliance, Coronis Health, Jackson, MI

Incoming! The exclamation is not foreign to the ears of those in the military. Those who’ve been under the incessant bombardment of the enemy are well aware that this word of warning means that another munitions round is on its way. From the trenches of WWI to the killing fields of Ukraine, men under arms have had to face the stress of that familiar whizzing sound, signaling the hurtling of yet one more shell toward their position.

This is the essence of real stress—not just the single advent of bad news but the continual barrage of bad news. It seems that this is what hospitals in the U.S. have been experiencing for some time now, and the bad news keeps coming.

Even before the pandemic, there were the incipient stages of the doctor shortage crisis, as well a general increase in financial pressures. And we don’t need to recount the panoply of predicaments endured by the nation’s frontline medical facilities during the darkest days of the public health emergency (PHE). It bears repeating, however, that the COVID crisis continues to have ramifications on the healthcare system long after the peak of the pandemic. Now that the PHE is winding down, hospital board members have been looking forward to a break in the bad mojo and getting back to business as usual. Unfortunately, there is one issue that continues to act as a major stressor for many an American hospital: the nursing crisis.

GAUGING THE SITUATION

According to Forbes Magazine, the U.S. Bureau of Labor Statistics recently reported that more than 75,000 additional nurses will be needed from 2020 to 2030. Employment opportunities for nurses are projected to grow at a faster rate (nine percent) than all other occupations from 2016 through 2026.

So, the need for nurses has been solidly established, but will this need be met? All indications are that, unless conditions change, we may be looking at a long-term problem.

The American Nurses Foundation (ANF) and Joslin Insight conducted a survey of nurses across the U.S. this past November. Over 12,000 individuals participated, and all 50 states were represented. According to the ANF, the survey has a 1.15 percent margin of error.

The nurses completing the survey work in a wide spectrum of settings, including 53 percent employed in acute care hospitals of all sizes. Seventy-two percent of respondents provide direct care to patients, with 78 percent being employed full-time. Four percent of respondents identified as a travel nurse. Importantly, 41 percent of respondents indicated being 55 or older.

FEELINGS OF FATIGUE

The survey revealed several significant findings that will have widespread implications for hospitals’ ability to provide patient care over the long term. Sixty-four percent of nurses reported feeling stressed, with 57 percent identifying with the term “exhausted.” Surprisingly, it is those younger and more inexperienced nurses who “are struggling more with emotional health than their more experienced colleagues.” Nearly one-third of nurses with less than 10 years of experience indicated being “not emotionally healthy.” This is compared to just eight percent of nurses with 41-50 years’ experience.

Ominously, 33 percent of nurses under 35 years of age indicated feeling depressed in the past 14 days, compared to 18 percent of nurses 55 or older. This is a trend that has been identified and monitored since 2021, according to the ANF report.

ROOTS OF THE PROBLEM

We’re all well aware that burnout has been, and continues to be, a significant problem among hospital nursing and other clinical staff. When asked what the prime contributors were to their feelings of fatigue, burnout and low morale, the leading responses from the nurse survey were as follows:

• Not enough staff to adequately do
• their job (38 percent)
• Lack of respect from employer
• (14 percent)
• Too many administrative tasks
• (10 percent)
• Insufficient compensation
• (nine percent)

I was talking with a trauma nurse at a major medical center just recently. She told me that the administration had recently increased the patient-to-nurse ratio, due to an insufficient number of nurses at the facility. That is, there would now be less registered nurses (RNs) for each patient than what prior protocol had allowed. This, of course, only makes it more difficult for her to sufficiently do her job, and patient care is thereby compromised. The role of licensed practical nurses (LPNs) had also been expanded at the facility to fill in the care gap, which may further compromise patient safety.

The scenario described above is no doubt being seen in multiple hospitals in multiple states. To address the problem, some are looking to their legislatures. It is being reported that organizations representing the nursing profession in the states of Washington and Oregon have been instrumental in getting bills introduced that will mandate patient-to-nurse ratios that are in keeping with established standards that stress patient safety. If passed, such bills would mandate either the hiring of sufficient numbers of nurses or the reducing of a facility’s patient volume.

Let’s look again at the bulleted survey data above, as it may prove helpful to hospital decisionmakers to see this quantification of the reasons behind the growing dissatisfaction among nurses. For example, from the above numbers, one may derive that it may not be as important to raise the wages of current workers as it is to hire additional nurses and to foster a better working environment. The bottom line to this section is the following message: retaining and recruiting a sufficient number of nurses will be a vital mission for many U.S. hospitals over the foreseeable future.

THE PROBLEM MAY GET WORSE

The bad news is that there is more bad news—at least potentially. According to the survey we’ve been discussing, some 22 percent of nurses said they have changed positions in the past six months. As an indication of what hospitals may expect in the future, 19 percent said they intend to leave their position in the next six months, and 27 percent said they are considering leaving. While this is a modest improvement compared to survey results from one year ago, it is still cause for concern.

Of those who intend on, or are considering, leaving their position, 13 percent said they plan to leave nursing altogether. From an anecdotal perspective, one nurse stated, “I have seen many caring people step aside from nursing because they have found it is no longer worth it.” Another nurse echoed this sentiment, stating:

The staffing shortage has gotten even worse and most of the medical staff currently working are burned out and ready to leave. It’s hard to stay positive in this type of environment. I’m at the point where I want to leave nursing, but I am unable to because I’m supporting my family. The report concludes this section by stating, “The effects of burnout are far-reaching, and employers need to heed the warning.” So, unless hospitals intervene, the nursing shortage may continue to intensify. It is, therefore, incumbent on hospital administrators to recognize the severity of the crisis, admit its potential for worsening, and take steps to reverse it. This may include an array of options based on the particular circumstances of each facility. What hospital executives cannot do is sit back and hope for the best.

JUSTIN VAUGHN, MDIV
Justin Vaughn, MDiv, serves as vice president of anesthesia compliance for Coronis Health. Mr. Vaughn has over 20 years of experience in anesthesia compliance and has been a speaker at multiple national healthcare events. He has written two books on compliance-related issues and is the author of numerous articles relevant to the hospital space. Justin can be reached at Justin.Vaughn@coronishealth.com.

from
https://www.coronishealth.com/blog/signs-of-stress-hospitals-faced-with-increasing-nursing-woes/

Under the Microscope: Anesthesia Giant Sued by Feds

Summary

Bigger may not always be better. Sometimes it just makes you the easy target. That’s what one anesthesia “supergroup” has just learned as it finds itself the subject of a federal lawsuit. More importantly, the legal action may have widespread implications for the anesthesia specialty as a whole. 

It’s not a pleasant prospect. Being the focus of special scrutiny can be unnerving and even alarming. We’ve all endured the occasional background or credit check when seeking a job or a loan. And we all find ourselves increasingly subject to camera and software surveillance. These intrusions into our privacy have become fairly routine. But it’s another thing altogether to know that someone is looking into your business practices—especially when that someone is connected to a federal enforcement agency. That’s the position that one of the nation’s largest anesthesia groups now finds itself.

Late last month, it was announced that the U.S. Federal Trade Commission (FTC) filed suit against U.S. Anesthesia Partners (USAP). Originally known as Pinnacle Anesthesia Consultants and headquartered in Dallas-Fort Worth, USAP has now spread into nine other states. Much of this growth over the last several years has been accomplished through a strategy of acquiring other large anesthesia groups in selected cities. Known as one of America’s “supergroups,” USAP boasts over 4,500 providers who serve at over 700 facilities.

As we’ve written in recent alerts, one of the options that hospitals are looking at to contain costs is having such a supergroup to come in and take over the anesthesia contract, which means either pushing out the current group or forcing the existing providers to join the new regime. It matters, then, that the FTC is showing such an interest in the business practices of at least one of these supergroups.

The Allegations

In its September filing, the FTC alleged that USAP engaged in a decade-long scheme to drive up the price of anesthesiology by buying up more than a dozen practices to monopolize the Texas market and by setting prices with other anesthesiology firms. The action was filed against USAP and its private-equity founder, Welsh, Carson, Anderson & Stowe. According to the Washington Post, “the case represents one of the strongest moves by regulators to address complaints that the large doctor practices being built by financial firms are boosting U.S. medical prices.”

“Private equity firm Welsh Carson spearheaded a roll-up strategy and created USAP to buy out nearly every large anesthesiology practice in Texas,” FTC Chair Lina Khan said in a statement announcing the lawsuit. The government also alleges that USAP entered into “unlawful agreements to set prices and allocate markets.” The FTC asserted that such tactics enabled USAP and Welsh Carson to raise prices for anesthesia services, allowing them to rake in tens of millions of extra dollars for these executives at the expense of Texas patients and businesses. According to the FTC lawsuit, USAP’s tactics allowed it to get reimbursement rates that are double the median rate of other anesthesia providers in Texas.

Interestingly, the Washington Post had written a previous article back in June featuring USAP. The column focused on the supergroup’s expansion into Colorado, where internal documents provided insights into some of its business practices. Per the Post, “As in Texas, the company there bought some of the state’s largest anesthesiology firms and then negotiated price hikes.”

The Rebuttal

Company officials have denied that they are engaged in a scheme to wield monopoly power. In statements issued by representatives of USAP, the FTC lawsuit was characterized as “unwarranted.” Derek Schoppa, a USAP physician and board member stated that “the FTC’s civil complaint is based on flawed legal theories and a lack of medical understanding about anesthesia, our patient-oriented business model, and our level of care for patients in Texas.”

In addition, a statement from Welsh Carson related that the company’s rates have not exceeded medical cost inflation. “We are confident we will prevail as the FTC’s claims are without merit in fact or law,” the statement said. USAP and Welsh Carson executives have described the consolidation of doctor practices as a means of creating synergy.

The Takeaways

No one likes being the target of a federal investigation or the named subject in a federal lawsuit. However, it appears that the government is serious about the appearance of creeping monopolies in a given metropolitan area. FTC Chair Khan stated in her press release that “The FTC will continue to scrutinize and challenge serial acquisitions, roll-ups, and other stealth consolidation schemes that unlawfully undermine fair competition and harm the American public.”

Whether or not USAP has acted inappropriately or illegally will be determined in due course. It’s now in the hands of the courts. What matters here for our discussion is what all this may mean for our specialty from a 30,000-foot perspective.

Hospitals want anesthesia services but at a reasonable cost. Anesthesia providers want a place to practice but at a reasonable rate of pay. Sometimes the solution has involved one of these large regional or national anesthesia supergroups, often referred to as “anesthesia staffing companies.” While it is not the purpose of this article to weigh the plusses or minuses of such entities, it is important that our readers are alerted to the larger and long-term implications of the FTC’s current actions against USAP. What does this portend for the future? What impact will this have on the trend toward consolidation? Will hospitals rethink their partnering with an anesthesia supergroup? It will be interesting to see how all this plays out. The forthcoming ruling in the FTC lawsuit will be an early indicator.

If you have any questions on this topic, please contact your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/under-the-microscope-anesthesia-giant-sued-by-feds/

FQHC Coding for COVID-19 Vaccines

On September 11, 2023, the FDA authorized, for emergency use (EUA), the 2023-2024 formulations of the Pfizer-BioNTech and Moderna COVID-19 vaccines for individuals ages 6 months and older. This new formulation includes a monovalent component corresponding to the Omicron XBB.1.5 variant. The FDA simultaneously rescinded the authorization for bivalent vaccines for use in the United States.

The FDA set forth the following guidelines for vaccination by age of the eligible individual:

• 6 months through 4 years: If previously vaccinated are eligible to receive 1 or 2 doses of the new vaccine depending upon the timing and number of previous vaccine doses.
• 6 months through 4 years: If previously unvaccinated are eligible to receive 3 doses of the new Pfizer-BioNTech vaccine or 2 doses of the new Moderna vaccine.
• 5 years and older: Regardless of vaccination history are eligible to receive 1 dose of the new vaccine at least 2 months after the last dose of any previous vaccine.

The FDA also approved:

• Comirnarty COVID-19 vaccine (2023-2024 formula) change to a single dose for individuals, ages 12 and older.
• Spikevax COVID-19 vaccine (2023-2024 formula) change to a single dose for individuals ages 18 and older; and, approval for a single dose for individuals, ages 12 – 17 years.

Providers are advised to remove and dispose of all bivalent vaccines in their inventory, even if they are not expired. The Bureau of Primary Care advises health centers that have ordered vaccines through the COVID-19 Vaccine Program to update their stock and wastage via the Health Partner Order Portal which may be found through the Health Center Program Community.

The AMA, in August 2023, approved new vaccine product codes and deleted over 45 previously approved ones to streamline the coding for COVID-19 vaccines. This follows the Vaccines and Related Biological Products Advisory Committee decision that COVID-19 vaccinations be updated annually. In addition, the AMA created one administration code to be used with any vaccine for any patient, regardless of patient age, thereby replacing all previously issued administration codes. The effective date of the new codes coincides with the FDA approval date of September 11, 2023.

With the streamlining of the COVID-19 vaccine code set, the AMA deleted Appendix Q, effective November 1, 2023. Appendix Q and the deleted codes will appear in the CPT® 2024 codebook because the decision to delete them came after the codebook was finalized. Health centers should refer to the AMA website for the most up-to-date information.

As of September 12, 2023, Medicare will no longer pay for the deleted CPT codes. Most state programs and commercial payors are also no longer paying for the deleted CPT codes, and health centers should check with their individual payors.

Medicare will continue to pay FQHCs 100% of the reasonable cost for administering COVID-19 vaccines through the cost report. Health centers should continue to submit administration claims to the relevant Medicare Advantage plan. Check with your payors or vaccine programs for policies specific to your health center.

References:

FDA Updated COVID-19 Vaccines

https://www.fda.gov/news-events/press-announcements/fda-takes-action-updated-mrna-covid-19-vaccines-better-protect-against-currently-circulating

Medicare Learning Network COVID-19 Vaccines

https://www.cms.gov/training-education/medicare-learning-network/newsletter/2023-09-14-oce

CPT Coding Assistant Coronavirus

https://www.ama-assn.org/system/files/cpt-assistant-guide-coronavirus-august-2023.pdf

from
https://www.coronishealth.com/blog/fqhc-coding-for-covid-19-vaccines/

Strike One: Hospitals Must Keep Their Eye on the Ball

We’ve seen this before, but not to this scale. A hospital in New York sees a couple hundred of its nurses go on strike. A similar work stoppage occurs in a Michigan facility; and another healthcare-related walkout is reported down in Texas. These 2023 job actions are seen by many as nothing more than random, localized and one-off occurrences. But what do we do with last week’s historic joint-strike against Kaiser Permanente (KP) facilities in California, Oregon, Washington, Colorado, Virginia and Washington D.C.?

On October 4, over 75,000 healthcare workers walked off the job in a three-day action meant to send a loud message to management. This amounted to the largest strike involving healthcare workers in American history. “Random” and “local” no longer apply.

The Pitch

A spokesman for the Coalition of Kaiser Permanente Unions (CKPU) said that KP employees decided to walk off the job in order to push for higher wages, better benefits and “an end to understaffing that threatens all of us as workers and patients.” Indeed, back in August, the coalition of unions had asked for a $25 hourly minimum wage, as well as increases of seven percent each year in the first two years and 6.25 percent each year in the two years afterward, according to an Associated Press (AP) report.

A spokesperson for Oakland-based Kaiser Permanente, Hilary Costa, also made her pitch to the media, warning that a strike could cause delays in people getting appointments and scheduling non-urgent procedures. She assured the press that the company was working to reconvene bargaining “as soon as possible.”

Short Stop

The work stoppage had been scheduled to run from Wednesday 6 a.m. until Saturday 6 a.m. (PT) of last week. Since it was announced ahead of time that this was to be limited to a three-day demonstration, the apparent intent of CKPU was to get the attention of KP decisionmakers, rather than force their hand by way of a walkout of indefinite duration.

According to one KP official, the pre-planned event had already created some headway in the addressing of union concerns. Wayne Davis, spokesperson for the large non-profit health system, told the Daily News that there had been “a lot of progress, with agreements reached on several specific proposals late Tuesday.” However, according to CKPU, no deal had been reached at the conclusion of the strike on Saturday. Bargaining discussions were scheduled to resume on Thursday. If no deal is reached, there is the strong prospect of a more protracted union action that could bring financial pain to both sides.

A long strike would be a significant burden for all involved—those living paycheck to paycheck but also the facilities. There are clearly costs that both sides will need to consider.

Out at Home

This issue is not going away. Regardless of which side has the better argument, we are likely to see an increase in work stoppages at healthcare facilities if employees continue to perceive that they are being treated unfairly relative to wages, benefits and working conditions.

According to Nurse.org, the current year has seen a significant rise in nursing strikes, with more and more nurses leveraging their union membership to fight for better pay and safer working conditions. A visit to their website uncovered the following list of pending nursing strikes at the following facilities:

• Cedars-Sinai Marina del Rey (Marina del Rey, California)
• Dana-Farber Cancer Institute-Merrimack Valley (Boston, Massachusetts)
• Ascension Saint Joseph-Joliet (Joliet, Illinois)
• Catherine of Siena Hospital (Smithtown, New York)

Pre-strike picketing and rallies were recently reported in the following locations:

• Hazel Hawkins Memorial Hospital (Hollister, California)
• Allegheny General Hospital (Pittsburgh, Pennsylvania)
• Saint Louis University Hospital (Saint Louis, Missouri)
• Providence St. Mary Medical Center (Apple Valley, California)
• Jackson Park Hospital (Chicago, Illinois)

Nurse.org, asserts that strike pay is considered a type of crisis pay, so nurses are often paid a premium rate for these contracts. The pay is also guaranteed, even if the strike doesn’t happen. Depending on the facility, replacement RNs can easily make upwards of $100 per hour. Strike contracts aren’t just for RNs, either. LPNs/LVNs can make upwards of $80 per hour and CNAs over $50 per hour.

The math is simple: when healthcare workers walk off the job, someone has to pinch hit; but that comes with an increased cost. Hospital administrators will need to be mindful of the potential of such strikes and will need to have a gameplan for mitigating such actions.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/strike-one-hospitals-must-keep-their-eye-on-the-ball/

Why Anesthesia Practices Fail

Summary

There are a number of factors that contribute to the success of an anesthesia practice. The same can be said for a practice’s failure. Today’s article looks at these factors and suggests what works best to keep the group afloat.

It has been the plan and aspiration of every founder of an anesthesia practice that there would be a strong and productive relationship between its providers and the facility administrations it serves. The expectation has always been that the practice would be a source of income and job security for its members. It used to be that when a physician or CRNA joined a practice they could put down roots and become a part of the community. There would always be a need for anesthesia, and so there would always be plenty of work. There was a time when most providers stayed with the same practice until they retired, but this is no longer the case. In the turbulent world of American medicine, anesthesia is no exception: the only constant is change. Like so many other businesses, very few anesthesia groups remain the same, and many simply cease to exist.

Whether a practice decides to become part of a larger entity or no entity at all, the underlying dynamics are the same. Managing a medical practice successfully in the current environment is a complicated and often challenging proposition. Most practices complain that their greatest challenge is generating enough revenue to recruit and retain an appropriate team of qualified providers. In other words, the practice must juggle the service requirements of the clients, the revenue potential of the clinical activity and the capricious demands of anesthesia providers in a competitive market. The successful practices are notable for their favorable location, their effective management and their exemplary customer service, but they are the exception rather than the rule. Curiously, it is not the size of a practice that makes it successful but rather its strategic plan and its commitment to certain key values.

Success and Failure

Without question, the number one reason for failure is financial. There was a time when most providers generated a sufficient amount of revenue from their clinical activities to cover the cost of their income and necessary business expenses. As coverage requirements began to expand and as payer mix has eroded, most practices have had to ask for financial support from the facilities they serve. Hospitals used to respond to such requests with fairly generous subsidies, but now even ambulatory centers are being asked for financial support. Contract negotiations are now often contentious as practices are forced to justify the cost of the requested services.

For all the successes, there are as many failures. Sometimes, administrators grow weary of the ongoing struggle and simply decide to pursue other options. There was a large practice in California that had been serving its primary hospital for 30 years. After repeatedly trying to obtain ever larger subsidies, the administration decided to cancel their contract and hire a national staffing company.

Management and Administration

Sometimes, the financial issues are overshadowed by administrative issues and management challenges. A critical aspect of a contractual relationship between a facility administration and its anesthesia practice is the level of confidence the administrators have in the leadership of the practice. Practice managers are responsible for the consistency and quality of the care provided. The administration should never have concerns about the quality of care or the competency of the providers. A service contract is essentially a wish list. If the terms cannot be met, then the administration has options. If an administration loses confidence in the group’s leadership, the relationship is doomed—no matter how good most of the providers are. Infighting and internal conflicts within the group must remain internal, for the practice must be perceived as a harmonious and collaborative whole.

Ultimately, in the current environment, the strength of a relationship is built on customer service. Anesthesia is a critical service, and anesthesia practices must be quintessential customer service organizations. It used to be that what mattered most was what happened within the four walls of the operating room but now it is what happens outside the O.R. that determines a practice’s success or failure. Anesthesia must not only ensure that every surgical and obstetric patient has a safe and comfortable experience but that it is the quality of the team that make surgeons want to bring their cases to the facility.

It is often some combination of these factors that leads an administration to decide that an arm’s length contractual relationship with a private group practice is no longer a viable solution. This usually explains why the administration will simply decide to employ all the anesthesia providers itself. Such thinking may not result in a perfect solution, but it is usually considered the best option of last resort.

A well-known Harvard business professor, Rosa Beth Moss-Kantor, summarized the three most important qualities of any business partnership in her book, Confidence. They are accountability, collaboration and innovation. When these three qualities define the relationship between the anesthesia practice and its client administration, the relationship will most likely be strong and enduring; but, if one or more of these is missing, then the client’s confidence will be inevitably compromised.  

If you have any questions on this topic, please contact your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/why-anesthesia-practices-fail/

Fiscal Year 2024: New IPPS Provisions Kick in This Week

It must seem strange to many that there is a variance in what is deemed to be the start of a new year depending on whether you’re talking about the normative “calendar year” or the governmental fiscal year. It’s just a bit cumbersome to have two different yearly reboots. However, we must point out that other cultures endure something very similar. While all the nations of the world generally acknowledge Jan 1 as the official beginning of a new year, some ethnic or religious groups will additionally celebrate their “traditional” new-year’s day—which may occur in the spring or fall, rather than winter.

So, there are those around the world who do, in fact, have to keep up with two yearly beginning dates. This would be true of those whose corporate or government positions require them to observe a fiscal year. Hospital administrators would certainly be included among this group. As such, we present this alert as a reminder that your new year begins this week! On Monday, October 1, the 2024 Inpatient Prospective Payment System (IPPS) rules, applicable to acute care hospitals, launched and will remain in effect until Sep 30, 2024.  

Again, as a reminder, the main rule changes starting this week relative to the inpatient setting are briefly summarized below.

Payment Rates

The increase in operating payment rates for general acute care hospitals that are paid under the IPPS is 3.1 percent.

Payment Adjustments

Hospitals may be subject to payment adjustments under the IPPS, including:

• Payment reductions based on various quality reporting programs.
• Payment reductions for excess readmissions under the Hospital Readmissions Reduction Program.
• Payment reduction (one percent) for the worst-performing quartile under the Hospital Acquired Condition Reduction Program.
• Upward and downward adjustments under the Hospital Value-Based Purchasing (VBP) Program.

Low Wage Index Hospitals

CMS will continue temporary policies finalized in the FY 2020 IPPS final rule to address wage index disparities affecting low-wage index hospitals, which includes many rural hospitals.

GME Payments

The new rules include changes to GME payments for training in the new Medicare provider type, the rural emergency hospital (REH) to address the growing concern over closures of rural hospitals. These changes help support graduate medical training in rural areas by allowing these rural hospitals to serve as training sites for Medicare GME payment purposes after they become REHs.

Social Heath Determinants Codes

The Centers for Medicare and Medicaid Services (CMS) finalized a change to the severity designation of the three ICD-10-CM diagnosis codes describing homelessness (e.g., unspecified, sheltered, and unsheltered) from non-complication or comorbidity (NonCC) to complication or comorbidity (CC), based on the higher average resource costs of cases with these diagnosis codes compared to similar cases without these codes.

Wage Index

The new rules finalize the proposal to treat rural reclassified hospitals the same as geographically rural hospitals for purposes of calculating the wage index. Specifically, CMS will include hospitals with §412.103 reclassification along with geographically rural hospitals in rural wage index calculations beginning with FY 2024.

Physician Hospitals

For a hospital to submit claims and receive Medicare payment for services referred by a physician owner or investor (or a physician whose family member is an owner or investor), the hospital must satisfy all of the requirements of either the whole hospital exception or the rural provider exception to the physician self-referral law, commonly referred to as the “Stark Law.” To use the rural provider exception or the whole hospital exception, a hospital may not increase the aggregate number of operating rooms, procedure rooms, and beds above that for which the hospital was licensed on March 23, 2010, with certain exceptions noted in the rule.

Quality Reporting

The Hospital IQR Program is a pay-for-reporting quality program that reduces payment to hospitals that fail to meet program requirements. Hospitals that fail to submit quality data or to meet all Hospital IQR Program requirements are subject to a one-fourth reduction in their Annual Payment Update under the IPPS.

Hospital-Acquired Condition Reduction Program

The HAC Reduction Program creates an incentive for hospitals to reduce the incidence of hospital-acquired conditions by reducing Medicare fee-for-service (FFS) payment by one percent for applicable hospitals that rank in the worst performing quartile on the measures of hospital-acquired conditions. For the full treatment of these and many other changes found in the 2024 FY IPPS rule, please go to https://www.federalregister.gov/public-inspection/current.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/fiscal-year-2024-new-ipps-provisions-kick-in-this-week/

Anesthesia Time in Extended Situations

Summary

How do anesthesia providers account for time spent in cases that contain a delay on either the front end or back end? Today’s alert provides recommended solutions for such scenarios. 

It happens occasionally.  A teacher waits for a delayed parent to pick up the last remaining child at the end of a school day.  The babysitter demands another ten because you arrived home an hour later than arranged.  These temporal disruptions in our otherwise routine schedules are not supposed to occur, but they inevitably do.  Now what?  That’s what many anesthesiologists and anesthetists would like to know.  After all, they, too, are not immune to the caprices of time.

Disturbance in the Force

The surgical schedule is like a well-oiled machine, with patients being ushered in and out on a timely basis—indeed, on a precisely calculated basis—with little room for error.  Utilization experts and OR managers are quite adept at determining which cases will typically take X number of minutes.  As a result, they know when to begin prepping the next patient and thereby execute an efficient turnover rate.  It’s not quite an assembly line process where robotics and automation provide unquestioned predictability, but healthcare facilities do their best to accurately anticipate case timing and transition.

The problem, of course, is that unforeseen events occur.  They are going to happen.  A surgeon arrives 15 minutes late because a previous case ran unexpectedly long, or a surgery had to be canceled because the patient developed an unforeseen issue, or perhaps the recovery “time in attendance” had to be extended due to a lack of appropriate staff.  Stuff happens.  So, what does that mean for the anesthesia provider in terms of billing opportunities?  Let’s take a look at a couple of scenarios.

Delayed at the Start

No one likes a delayed start time.  Whether we’re talking about a five-minute delay of a conference call or a 30-minute delay in a concert performance, people get annoyed at such occurrences.  And the reason why is because people—especially busy people—hate wasting time!  What’s the old saying?  Time is . . . money?  When it comes to business—especially the business of anesthesia—that is most certainly the case.  You are paid, in part, for the number of minutes you’re able to spend on a case.  Well, what happens when you are ready to begin a case but something untoward occurs at the outset that leaves everyone hanging?

Let’s say you’ve performed the pre-anesthesia assessment, you’ve washed and scrubbed, and you are now with the patient in the pre-op holding area (PHA) administering Versed in preparation for the beginning of the case.  You next hear that a certain piece of equipment required for the successful conduction of the procedure is on the fritz.  The time it takes to lay hold of a working replacement creates a delay of 20 minutes.  Obviously, in this scenario, there is not much you can do.  Unless you decide to stay with the patient during the 20-minute delay, and there is medical necessity for doing so (based on the Versed administration), you will be unable to bill for this unexpected time delay.

But what if you were already in the OR with the patient when it was learned that the case would face a 20-minute delay due to the equipment failure?  We’ve always said that, once you’re in the OR with the patient, the anesthesia clock can run.  (There is one exception to this that we’ve covered in previous alerts: when you place a post-op pain block or invasive line in between the anesthesia start time and anesthesia induction time.)  So, what happens with this otherwise tried and true rule in the event of a case delay?  Here are some possible ways to proceed:

1. If the patient has already received some type of sedation before announcement of the case delay, and the delay is not sufficiently long to justify removing the patient from the OR, then it would be permissible to count the delay time where you remain with the sedated patient until the surgery can begin.  In such an event, we encourage you to drop a note in the comments section of the record explaining the circumstances of the delay.
    
2. If the delay is long enough to allow the patient to recover from the effects of sedation and the patient is removed from the OR, you could bill time in attendance with the patient until the patient is turned over to other non-anesthesia personnel.  When the case is resumed, you can start the anesthesia clock again once you reenter the OR with the patient.

There may be other scenarios other than those listed above that may occur.  The key is to err on the side of caution in billing anesthesia time in such situations.  Generally, if there is medical necessity for you to be present with the patient during these case delays, that represents care time that a health plan may deem to be appropriate and thus billable.

Delayed at the End

With the rise in case loads and staff shortages that were prevalent during the public health emergency (PHE), we received an increasing number of reports from our clients of cases where the anesthesia provider was being forced to remain with patients either in the OR (because the PACU was full) or in PACU (because of a lack of personnel in that unit) beyond the point when they normally would.  So, what is the provider to do in such a circumstance?

Unless a particular payer has provided written guidance to the contrary, we believe it is entirely appropriate to bill time in either location (OR/PACU) reflecting your continuing presence with the patient caused by delays due to the above-referenced circumstances.  Some of you may recall that the Medicare Claims Processing Manual (MCPM), Ch 12, Sec 50, actually provides a definition of anesthesia stop time.  In addressing anesthesia time, generally, the MCPM goes on to say the following:

. . . and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care.

You are, therefore, allowed to bill anesthesia time until transfer of care.  There is no exception to this allowance listed in the MCPM to account for delays that you occasionally encounter.  Consequently, if your care transfer time is delayed due to the temporary unavailability of PACU space or staff, meaning there is no one to whom you can turn the patient safely over, then you can bill through that time.  Again, you will want to provide a note in the anesthesia record explaining why you had to spend an inordinate amount of recovery time with the patient.

Ultimately, it will be up to the payer to determine how much of this time is reasonable for reimbursement purposes.  Your documentation of the extenuating circumstances becomes especially pertinent when considering that, some time ago, Medicare conducted a study of typical time spent in PACU.  They determined that the average anesthesia time in recovery is 7 minutes.  That doesn’t mean you are forced to stick to that precise amount.  Every case is different, and Medicare knows that; however, it does reinforce the fact that Medicare is watching for habitual outliers as to recovery time.  If, due to current circumstances at your facility, you are routinely forced to spend extended recovery time with your patients, it may raise red flags with auditors.  They may not wish to reimburse you the full time you have claimed.  Indeed, despite the above MCPM excerpt, at least one Medicare administrative contractor (years ago) stated that 15 minutes is the absolute limit for billing post‐surgery anesthesia time—regardless of PACU issues that cause an extended wait. So, ultimately, it depends on whether or not the payer (a) has a policy on this, or (b) agrees with the medical necessity of your extended time claim.

If you have any questions on this topic, please contact your account executive. 

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/anesthesia-time-in-extended-situations/