The first of three regional seminars to inform hospitals about the Medicare and Medicaid survey process was deemed very informative by those in attendance. The meeting was held at the Quality Hotel in Tyler on June 29th and was sponsored by TORCH in conjunction with the Texas Department of State Health Services which provided the faculty and the expertise necessary to create a truly worthwhile program.
      These seminars came about as the result of feedback that TORCH received regarding some recent inconsistencies in the hospital survey process. TORCH Board Member and hospital CEO Nancy Kinkler, TORCH Vice President Dave Pearson and TORCH’s General Counsel Kevin Reed met with the staff at DSHS earlier this year. Together they decided that an off-site educational seminar would be a good way for hospitals to get information and answers to questions that they might not otherwise ask.
      During each of the seminars, staff of the DSHS central office and hospital surveyors will give presentations about the licensure process, proposed licensure rules, hospital survey and certification processes, trauma designation, disaster preparedness, and enforcement. In addition to having the opportunity to ask questions throughout the program, dedicated Q&A time is also available at the end of each meeting.
      We hope that you will take the time to attend one of the remaining meetings: July 18 at the Crowne Plaza Riverwalk Hotel in San Antonio or July 27 in Holiday Inn Park Plaza Hotel in Lubbock. To register, please contact the TORCH office at 512-873-0045.

Want to meet as many healthcare professionals as possible at one place in one day? Want to meet with numerous rural communities, learn about practice opportunities and attend valuable workshops for $100 or less? Then DON’T MISS HealthFind 2006.

What is HealthFind?
HealthFind is an annual rural healthcare recruiting event organized by the Office of Rural Community Affairs (ORCA), with assistance from the Texas Organization of Rural & Community Hospitals (TORCH). It is a unique opportunity to recruit, network, and gain valuable information regarding programs available to rural healthcare professionals and organizations in the state of Texas.
      The event is structured so that healthcare professionals and rural communities have ample opportunity to interact and get to know each other in a casual, family friendly atmosphere. As exhibitors, rural communities set up a booth at the event and provide information to interested healthcare professionals regarding their community and practice opportunity.
      Healthcare professionals have a chance to visit with everyone exhibiting, get information about the different rural practice opportunities available to them, and to schedule site visits with potential matches. Both communities and healthcare professionals may attend any of the workshops provided during the event, with topics ranging from contract negotiations to recruitment tools and rural health financial programs.

Why attend?
HealthFind is the only event in Texas that allows communities to meet with practicing and in-training healthcare professionals who are interested in rural healthcare practice opportunities, giving you access to a large pool of candidates from all over the state. This is a highly cost-effective way to recruit for your community. ORCA keeps the registration fee low at $550, including hotel lodging for two representatives the night prior to or the night after the event. What a great deal: an event that includes lodging in the registration fee! HealthFind also allows you to showcase your community to anyone and everyone in attendance so that you can tell them what makes your community the best place in Texas to call home.

Here’s what a few people had to say about HealthFind 2005:

From a community perspective:
"HealthFind was a cost-effective and convenient recruiting option that provided our hospital and community an opportunity to come together in search of an additional physician to serve as a cornerstone of our health care community. Together, hospital and community leaders continue to pursue promising candidates identified at HealthFind who may ultimately fill this need."
John Phillips
Eastland Memorial Hospital

“The value of HEALTHFIND is that it provides rural providers a rare opportunity to meet and develop relationships with medical students who want to serve in a rural setting. Paying a recruiter to plug a hole is easy, but expensive and mostly ineffective. Anticipating needs, then taking the time to find a person/family that will succeed in your community is the way to go. And HEALTHFIND is the place to start.”
John Henderson
Childress Regional Medical Center

The latest and greatest federal rural health bill is called the Rural Hospital and Provider Equity Act of 2006 or R-HoPE (S.B. 3500). Sen. Craig Thomas (R-WY) and Sen. Kent Conrad (D-N.D), have 17 co-sponsors for their bill that would improve payments to rural hospitals and other healthcare providers. However, neither Texas Senator has agreed to sign on to the bill so far.
      Much of S.B. 3500 would extend or alter rural health care provisions that were included in the Medicare Modernization bill passed three years ago. R-HoPE would remove the DSH cap and create a low-volume adjustment for rural hospitals that have fewer than 2,000 discharges a year and are located more than 15 miles from another hospital.
      The bill also would reinstate additional outpatient payments to rural hospitals and sole community hospitals. The hold-harmless or TOPS payments had been reduced or eliminated by the Deficit Reduction Act of 2005. In some larger sole community hospitals the impact of this provision alone could mean up to $250,000 in additional revenue.
      The legislation also would improve rural health clinic reimbursement. Under current law, RHCs receive an all-inclusive payment rate that is capped at approximately $63. The bill would raise that to $82, comparable to what community health centers receive. The bill would adjust Medicare payments to home health care agencies and assist rural ambulance providers.

In addition, the measure would:

• make loans available to help rural facilities improve crumbling buildings and infrastructure;
• extend a program that provides 10 percent bonus payments to physicians practicing in health professional shortage areas;
• allow physician assistants, nurse practitioners and clinical nurse specialists to prescribe home health or hospice care;
  extend a 5 percent payment increasing reimbursements to home health agencies for rural area care;
• allow marriage and family therapists and professional counselors to bill Medicare for their services;
• require a pilot project providing incentives for home health agencies to use home monitoring and communication technology.

The American Hospital Association, the National Rural Health Association and the American Ambulance Association support the bill, among others. TORCH has been in contact with both Senators Hutchison and Cornyn and we ask that you too take this opportunity to advise their staff about this and other efforts to improve your ability to care for rural Medicare beneficiaries.

As the events of September 11 and Hurricane Katrina have revealed to us, business interruptions do happen, though not always on such a grand scale. A fire, flood, hurricane and tornado are all possibilities for disrupting your hospital operations. The ability to generate revenues could be severely hindered, making it difficult to cover ongoing expenses such as payroll, taxes, loan payments and utilities.
      Business interruption (BI) insurance is designed to help hospitals preserve their revenue stream while recovering from a property loss.For BI insurance to apply, two conditions must be met:

• The cause of the loss must be a covered peril under the policy.
• The loss must occur to an insured property.

One of the overlooked advantages of having BI insurance is that it causes the insurance carrier to expedite finalizing the direct damage to buildings and contents to minimize the BI loss. As long as direct damage loss is under review, the insurer owes the BI coverage while disruption is ongoing.
      Knowing your risks is the best way to determine the type of insurance plan that is right for you.Be sure to identify all the business interruptions your hospital might face, and decide whether or not your hospital can afford the loss of business and the expense of re-establishing it in the event of a disaster.Although not absolutely essential, business interruption insurance can save your hospital from a serious or complete setback due to the reduction in revenue.
      For more information on this and other insurance topics or to discuss your insurance needs, contact HealthSure at 254.773.9814.

As a hospital leader, wouldn’t you like a more efficient way to identify potential areas of compliance vulnerability and risk? TMF Health Quality Institute, the nonprofit designated by Medicare as the Quality Improvement Organization for Texas, wants to make sure you are aware of hospital-specific and statewide aggregate data that are provided for free to your hospital. The data are provided in a quarterly report called PEPPER, the Program for Evaluating Payment Patterns Electronic Report.
      “PEPPER contains hospital-specific data for diagnosis-related groups (DRGs) and discharges that have been identified by the Centers for Medicare & Medicaid Services as at high risk for payment errors,” says Judi McCabe, RN, manager, Hospital Payment Monitoring Program at TMF. “One-third of Texas hospitals have already discovered how useful the report is, but we’d like everyone to know how PEPPER can prioritize findings and provide guidance on areas where a hospital may want to focus their auditing and monitoring efforts.”
      TMF recommends that hospital CEOs and administrators ask their compliance officers, utilization review managers and health information management professionals if they know about PEPPER data and this valuable free information. Find out more at http://www.tmf.org/pepper.
      This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-TX-HPPE-06-25.

Solucient is proud to present the Top 100 Performance Improvement Leaders for the year 2005. Included among them are Goodall-Witcher Healthcare Foundation in Clifton, Christus Spohn Beeville, and Brownfield Regional Medical Center. The study is meant to recognize hospital management teams that have led their organizations to achieve the fastest rate of consistent annual organizational improvement.
      The related hospital-specific report uses a five-year trending methodology to allow a specific hospital team to assess how they are executing performance improvement over time versus their peers. The study revealed that in recent years, the hospital industry's ability to improve performance over time has been minimal, and the challenge health care executives face in aligning their organizations for continuous performance improvement is staggering.
      The winners of the 2005 Performance Improvement Leaders Award made the following gains between 2000 and 2004:

• Went from having more patient deaths, complications, and adverse safety events than expected to having fewer than expected
• Rose from being barely profitable to maintaining a healthy positive profit margin of 5.8%
• Discharged patients two-thirds of a day earlier
• Increased their expenses by only 8%, while their peers' expenses increased 20%.
• Grew their patient volume 5.3 percent, while their peers lost 1.5 percent of their patient volume.

TORCH wishes to congratulate these three fine member facilities and their leadership teams on a job well done.

At the TORCH Board meeting in June, questions were raised regarding the ability of a Medicare Advantage Private Fee For Service (PFFS) Plan, such as PacifiCare, to deem hospitals as participating providers when treating PFFS enrollees. Board members wanted to know if there was any sort of exemption or appeals process for hospitals that intended to remain an out-of-network facility.
      Jennifer Claymon, JD, of Davis & Wilkerson, looked into the matter and offers the following advice. A PFFS plan deems a provider a “participating provider” when the provider renders services to a patient that the provider also knows is enrolled in a PFFS Plan and the provider either possesses or has access to the terms and conditions of participation. It is important to note that the provider is not required to offer medical care to a PFFS Plan enrollee. However, once the provider has knowingly chosen to render services, the provider is deemed a participating provider from then on.
      If a provider renders services, but the requirements to be deemed have not been met, then the provider will be designated a “non-contracting provider.” There are only a few cases where this may happen. For instance, the provider had no knowledge, prior to rendering services, that the patient was a member of a PFFS Plan. Either because the patient failed to inform or was uncommunicative.
      However, most hospitals try to determine payment information prior to rendering services. Medicare requires PFFS insurance cards to state that the provider will be deemed a participating provider and will then be subject to the terms and conditions available on the website. Therefore, your only real option is to refuse treatment. In the case of emergency patients, you could also defer any request for insurance information until after the patient has been treated, but you must continue to inform all other inpatients and outpatients that the hospital does not participate in the PFFS Plan.
      The research was unable to locate any appeals process or other method to reverse being deemed a participating provider under any of the PFFS Plans. However, each PFFS plan’s terms and conditions should be consulted to determine if an appeal is possible.
      PacifiCare was approved on July 5, 2005, to offer a PFFS Plan under Medicare Advantage. Providers may balance bill the patient up to 15% of the PFFS Plan payment rate, in addition to any co-payments, deductibles or coinsurance described in the terms and conditions. Jennifer wanted to ensure that TORCH members were aware of their ability to bill the 15% amount. It won’t remove your deemed status, but it may reduce the financial impact of providing services to these Medicare Advantage beneficiaries. TORCH members can call Davis & Wilkerson for further information: 1-800-969-0614.

I have sincerely appreciated the opportunity to serve as the Chairwoman of the Board of Directors for the Texas Organization of Rural & Community Hospitals for the past two years. It is hard to believe that my term of office is just about over. Our beloved organization continues to evolve, improve and overcome tough challenges. TORCH will continue to progress under the able leadership of Mr. James Buckner, CEO of the Uvalde Memorial Hospital who assumes the Chair on July 1, 2006. I look forward to serving with Jim and the rest of the Board of Directors as I move into the role of Past Chair.
      I’m proud of the fact that as TORCH continues to grow, so does our status as a leading advocate and resource for policymakers in Texas and in Washington, DC. Ultimately, the strength of TORCH can be found in its proud membership of rural and community hospitals. Every year we appeal to you to renew your membership in TORCH and to invite those who are not currently participating to join our cause. All rural hospitals in Texas benefit when we have a strong active membership. I want to thank each of you for your support. At TORCH, we always do our best to demonstrate our sincere appreciation to our dedicated members through the programs, services and representation we provide.

• The TORCH Open Forum is a highly accessible networking tool that many administrators have come to rely on for helpful information and advice;
• The Voter Voice online advocacy system has helped to streamline member involvement in both our state and federal grassroots initiatives;
• We continue to develop timely and relevant education programs like the brand-new Hospital Survey Regional Seminars and the TORCH Leadership and Management Institute;
• Add to that the steady improvement to our legacy services such as our Insurance Programs, the Annual Texas Conference of Rural and Community Hospitals, and www.torchnet.org.

TORCH will continue to introduce new ways to collaborate and ensure that your hospital receives an exemplary return on its investment. The efficient and effective management of the organization insures financial stability and strength to assure members of the value of their membership. As you know, addressing the specific needs of Texas’ rural and community hospitals in a manner that is consistent with the desires of the membership has been my number one goal. I’m proud to have been one of TORCH’s honorable stewards and I hope that you too will become more involved in the life of this great organization.
Sincerely,
Jan Reed

Workplace coverage has been the standard. Two disparate voices agree it's time to replace it.
From the Los Angeles Times - June 25, 2006
Ronald Brownstein/Washington Outlook

When organized labor's most inventive union president and the Republican lawmaker in line to chair the powerful House Ways and Means Committee are both touting the same revolutionary idea, it may be time to bend an ear.
       Andrew Stern, the liberal president of the Service Employees International Union, and conservative Rep. Jim McCrery (R-La.), favored to succeed Rep. Bill Thomas (R-Bakersfield) as head of Ways and Means if Republicans keep control of the House, don't agree on much.
       But both believe it's time to replace the central arch of the American healthcare system: the link between health insurance and work. Their arguments may represent the opening notes of the first significant domestic debate of the 2008 presidential campaign.
       The connection between health insurance and employment dates to World War II.
       After President Franklin D. Roosevelt imposed wage and price controls, companies could not compete for workers by offering bigger paychecks. Instead, they provided richer benefits, including health insurance. After the war, the big unions reinforced the trend by bargaining for health coverage in their contracts with major employers.
       Congress cemented the connection between work and health coverage in 1954 by creating a generous tax subsidy for employer-provided coverage. Employers that provide health insurance for their workers can deduct the cost of the premiums as a business expense, the same way companies write off the wages they pay to workers. But although workers pay taxes on the wages they receive, Congress decided they would not be taxed on the value of the insurance their employers purchased for them. That subsidy encouraged employers to shift more of a worker's total compensation from wages to health benefits.
       Linking health coverage to work had other benefits. It created insurance pools that shared risk between workers who were young and old, healthy and sick. And it allowed employers to handle the headache of administering insurance plans, rather than requiring workers to bargain directly with insurance companies.
       With all these advantages, the employer-based system grew enormously over the last half a century. Today, more than 174 million workers and their families receive health insurance on the job.
       But the system is cracking. As the cost of insurance rises, fewer small employers are offering it. Almost all large employers still provide coverage. But more of them argue that the rising cost is hurting their ability to compete against companies from other countries that spread the cost more broadly through government-provided healthcare.
       As these pressures have converged, the share of Americans who receive coverage at work has fallen in each of the last five years — from nearly 64% in 2000 to just under 60% in 2004. Most experts project continued declines. Stern sees in these trends the writing on the wall.
      "We have to recognize that employer-based healthcare is ending; it is dying before our very eyes," he said at a recent forum sponsored by the Brookings Institution think tank.
       Stern didn't endorse a specific plan to replace employer-provided coverage. But he flagged the obvious two options: a government-run, single-payer healthcare regime versus a system that would require individuals to purchase insurance with subsidies from government and, perhaps, mandated contributions from employers.
McCrery, not surprisingly, prefers the latter option, minus the employer mandate.
In an essay published this month in the new journal Democracy, Jason Furman, a visiting scholar at New York University and former economic policy aide to President Clinton, said that tax policy would be the key to any shift away from the employer-based healthcare system.
       The existing tax subsidy for insurance, Furman said, perversely benefits upper-income workers more than lower-income ones. The reason is that under the progressive income tax, the affluent pay higher tax rates on their income. So it would cost them more than low-income workers if government taxed the value of employer-provided insurance.
       Furman wants to reverse that equation. He says that if government eliminated the current tax subsidy for employer-provided coverage (which costs Washington about $200 billion a year), the savings could fund a tax credit that would help all Americans purchase basic health insurance. That structure, he said, would provide the biggest subsidy to the least affluent.
      "We should spend less subsidizing more expensive insurance … for higher-income people and spend more to help moderate-income families obtain the health insurance they lack," Furman wrote.
       A first step, he said, might be to limit the amount of insurance employers could provide tax-free, and to use the savings to fund coverage for some of the nearly 46 million uninsured.
       Any system that affects as many people as employer-based health coverage won't be changed quickly, nor should it be.
      "We have to work incrementally toward getting to a point where we can slowly shift insurance from the workplace," McCrery said.
       Likewise, most big-business executives aren't clamoring to jettison their role.
"We're not giving up on this system and saying it needs to be thrown out," said John J. Castellani, president of the Business Roundtable, which represents the nation's largest companies. "We think it can be improved from both a cost and quality standpoint, and that's what we are focusing on."
       The critics haven't assembled an irrefutable case against the employer-based system; refurbishing it might well make more sense than dismantling it. Any replacement system would need to guarantee affordability and preserve the sharing of risk.
       But the tough, thoughtful questions from such voices as Stern, McCrery and Furman are an encouraging sign that the nation finally may be ready to reexamine a healthcare system that costs too much and covers too few.

From Modern Healthcare - June 12, 2006

As the federal government pushes the healthcare industry to adopt pay-for-performance measures, rural hospitals could have an advantage over their urban counterparts in one area: working collaboratively to improve the overall health of their community populations.
       Similar to the electronic health-record movement, the pay-for-performance initiative can be both complicated and costly, which places a burden on hospitals, especially rural hospitals that have fewer patients and resources. One area where experts say rural hospitals could thrive is in their ability to use their strong set of connections in engaging other community players to improve the health of the area's population.
       While rural hospital leaders recognize that a pay-for-performance model to measure quality outcomes is imminent, they say it's too early to assess progress because the movement is in its infancy and many rural hospitals are not yet equipped with electronic systems to report data.
      "Pay-for-performance is a payer-driven initiative," says Tim Size, executive director of the Rural Wisconsin Health Cooperative, Sauk City. "We're in a reactive mode, and haven't had anything to react to yet," he says of rural hospitals.
Terry Hill, executive director of the Rural Health Resource Center in Duluth, Minn., says one of his organization's goals is to educate rural hospitals on this issue.
      "There is no question that this is where the federal government is going," Hill says. "What we're trying to tell rural hospitals is you have to develop capacity to measure your information and get ready for pay-for-performance."
       Bruce Behringer, assistant vice president for the division of health sciences at East Tennessee State University, Johnson City, says some rural hospitals are connected to larger systems that already have some measures in place. But embracing pay-for-performance will continue to be difficult for the small hospitals that do not have such affiliations and struggle with budgetary issues. "The graveyard of hospital administrators is filled with people who spent money on health information technology that didn't work in the past," Behringer says. "There are ways to measure quality without running through computers, but the types of data that the CMS is talking about are virtually impossible to collect without being automated and integrated."
       As rural hospitals learn more about traditional pay-for-performance initiatives, they might consider a concept that was introduced in the spring 2006 edition of the Journal of Rural Health and discussed at the National Rural Health Association conference in Reno, Nev., in May. Rural hospitals, with their well-established communitywide relationships, could lead efforts to involve other community players such as local businesses, clinicians, schools and employers in improving a population's overall health.
       The article emphasized that "the issue is not whether or not rural hospitals should be in charge, but whether or not rural hospitals have a collaborative leadership role to play." David Kindig, one of the article's three authors, says factors besides healthcare are needed to keep a community healthy. "Ten years ago, most people were still in the mode of thinking that healthcare is the most important determinant," says Kindig, who serves as professor emeritus of population health sciences at the University of Wisconsin School of Medicine and Public Health. "The social factors, like education, income and individual behaviors could be right up there with medical care in terms of their impact on health outcomes." Kindig acknowledges that "the jury is still out" on how well this concept will work, especially given that connecting different sectors in the community is not an easy task. "You really need people talking to each other from the school board, the community board, and the county board on maximizing the balance portfolio across these sectors for population health improvement."
       Hilda Heady, executive director of the West Virginia Rural Health Education Partnerships-Area Health Education Centers, says it is possible for rural hospitals to work with other members in the community to improve a population's health. The purpose of Heady's group is to help retain West Virginia-trained health science graduates in underserved rural West Virginia by creating partnerships with the community, higher education, healthcare providers and governmental bodies.
      Rural communities are very accustomed to having to collaborate because there are limited resources," Heady says. If applicable, rural hospitals should link with the higher education institutions in their states, Heady says. In West Virginia, medical students in state-supported schools are required to complete three months of their training in any discipline in a rural community. "When you look at resource-limited communities, you don't have the luxury of thinking in silos," Heady says. "You have to collaborate to survive."
       Size, who served on the Institute of Medicine's Committee on the Future of Rural Health, worked on a report that culled the six quality aims the IOM introduced in its publication Crossing the Quality Chasm in March 2001. Those aims -- safety, effectiveness, patient-centered care, timeliness, efficiency and equity -- can also be applied when trying to improve rural health, where the entire community is seen as the patient (consequently, the committee changed "patient-centered" to "community-centered"). Size says community leaders in business, faith organizations, public education and local government can work collaboratively to improve the overall health of a community.
       Size, Kindig and third author, Clint MacKinney, outlined steps for rural hospitals to start promoting population health awareness and to establish collaborative efforts, such as adding board members with interests or expertise in population health measurement and improvement, including public health professionals, educators and economic development experts. Hospitals can also devote a periodic board meeting or a portion of every meeting to review available population health indicators, and create a "population health" subcommittee of the hospital board to explore opportunities for hospital partnerships with other community organizations. "Health status is overwhelmingly not a function of healthcare but of (individual) behaviors and socio-economic conditions," Size says.
       Behringer, who supports the idea, says hospitals have both an economic interest and social responsibility in a community. "If in fact a hospital in a rural community -- which is typically the largest employer -- can take the benefit from being funded by tax dollars, there should be some sense of relationship between what happens in the quality of that hospital and the community," Behringer says.