Authorized by the Medicare Modernization Act of 2003, the Section 1011 program is set to expire on September 30th. Congress authorized $250 million annually for the program in fiscal years 2005-2008. Two-thirds of the funds are divided among all 50 states and the District of Columbia, based on their relative percentages of undocumented aliens. One-third is divided among the six states with the largest number of undocumented alien apprehensions. As you know, the Emergency Medical Treatment and Labor Act requires hospitals to treat anyone who needs emergency care, regardless of their ability to pay or their citizenship.
      A bipartisan group of 15 U.S. Senators recently urged their fellow Congressional leaders to extend Section 1011 of the Medicare program, which helps reimburse hospitals for emergency services provided to undocumented immigrants. “Section 1011 plays a critical role in helping to stabilize our states’ health care safety net and preserve access to care,” the group said in a letter to leaders of the Senate and its Finance Committee. “We hope that you concur and include a two-year extension of Section 1011 in this year’s Medicare bill.”
      In total, providers received over $58.1 million in Section 1011 funds for services furnished during FY 2005 and $192 million for services furnished during FY 2006. As of May 23, 2007, more than 15,766 providers from across the United States have enrolled in the Section 1011 program. Texas has been one of the program’s largest beneficiaries. With an undocumented population of well over 1 million persons and counting, providers in Texas have earned nearly $45 million in Section 1011 reimbursement during FY 2008.
      TrailBlazer Health Enterprises, LLC, was selected to process enrollment applications and make payments to providers under the Section 1011 program. TrailBlazer accepts original, hard copy applications from providers enrolled in the Medicare program and from providers who want to seek Section 1011 reimbursement but do not wish to enroll in the Medicare program. Only Medicare participating hospitals are eligible to enroll and receive reimbursement from Section 1011. If you are not currently enrolled in the program, the application process and other detailed information regarding Section 1011 is available at www.trailblazerhealth.com/section1011/.

Please contact your member of Congress and urge them to continue this program for an additional two years and to be sure to include the reauthorization of Section 1011 in the ‘Medicare package’ that Congress will consider before September 2008. 

Even though these two meetings are almost upon us, there is still time to register. We welcome any and all rural hospitals and home health staff or executives to attend these TORCH–sponsored events. Each offers you a unique opportunity to delve into specific areas such as home care operations and facility replacement and renovation. The cost is nominal and each event offers an informal setting with plenty of opportunities for discussion, questions and networking. Please consider making one or both of these events part of your career development plan this summer.
      This Rural Hospital Facilities Workshop is being co-sponsored by Rees Associates, Inc., and TORCH and will be taking place June 5, 2008 at the Marriott Dallas Las Colinas. We are pleased to make available this workshop designed specifically for rural hospitals that are contemplating either a major renovation project or a total facility replacement. Through the cooperative efforts of Rees Associates in bringing the concept to us and working jointly to develop the program, and their sponsorship generosity, we are able to offer this affordable workshop to provide a wide scope of information to help hospital administrators and trustees make informed decisions about their hospital’s facility needs.
      This all-day workshop has knowledgeable speakers presenting a comprehensive agenda including:

• Strategic / Master Planning - Market Study/Needs Analysis; Debt Capacity Study; Pre-Design Process; Staff/Physician Recruitment Plan
• Public Relations / Outreach Plan - Community Support Plan; Fund Raising Plan; Furniture/Fixtures and Equipment Donation Plan; Land Donation Plan
• Financing - Financing Plan; Options; Financing Implementation
• Design and Construction Process - Architecture, Engineering, Interiors; Furniture, Fixtures and Medical Equipment; Construction and Delivery Options; Commissioning of the Facility
• Occupancy and Post Construction - Celebration Planning; Staff Training; Move-In Planning; Occupancy; Post Occupancy Evaluation

The Texas Hospital Home Health Association Conference will take place at the Arlington Hilton Hotel, June 4-5 and is intended for hospital-based home care programs only. The semi-annual event offers information on topics of vital concern to home health directors and hospital administrators alike. THHHA has been providing targeted information to hospitals in the area of home health for many years, but there have been a lot of changes recently with both home health reimbursement and regulations. Those programs that are not up to speed on best practices or finding innovative ways to address these new issues risk falling behind and making home care a service that costs rather than supports the hospital and the local community. The Department of Aging and Disability Services requires home health administrators and alternates to earn 12 hours of continuing education. This conference meets the requirements for this education.
      At the THHHA Education Conference you will learn new information about the following topics:

• Billing
• Infection Control
• Legal Issues
• Regulations
• Coding
• DMEPOS
• Licensure
• Training
• Performance

For more information about either of these affordable educational opportunities, please contact the TORCH office soon at 512-873-0045. We look forward to seeing you at one of our upcoming TORCH or THHHA events.

TORCH is playing a new role in HealthFind for 2008. The Office of Rural Community Affairs has contracted with TORCH to help manage the event this year and we are excited to be even more involved than usual. We hope that you too will play a critical role by participating in this year’s HealthFind, which promises to be both fresh and exciting. This year’s theme is “Where City Meets Country.” Our hope is to put a little country flair back into HealthFind and get maximum participation by all the family practice and internal residency programs in the State of Texas, as well as those physicians who are actively searching for practice opportunities in rural Texas.
       Please MARK YOUR CALENDARS for August 22-23 at the Hotel Intercontinental in Dallas. Plan to participate in this event to recruit physicians for your community. We look forward to seeing you at the rootinest, tootinest, rural HealthFind ever! Look for more information soon about how and when to register. 

TORCH recently sent a letter to the Health Resources and Services Administration regarding the newly proposed designation criteria for primary care shortage areas which are intended to replace the HPSA and MUA/MUP designations. Many rural providers have traditionally relied upon these designations for their Rural Health Clinic status, National Health Service Corps graduates, J-1 Visa Waiver Physicians and funding preferences for other grants and subsidies. These changes are part of a multi-year effort to update and consolidate the manner in which the Feds determine what areas are in most need of additional primary care services.
      TORCH also sent its comments to both the Texas rural Congressional delegation and all rural and community hospitals in Texas for their own review and comment. The deadline for comments to be submitted electronically is May 29th. Here is a copy of the text that underscores the concerns that have been raised by our members as well as some proposed corrections to the rule that would better serve the hospitals and other healthcare providers located in rural Texas:

Thank you for allowing us the opportunity to comment on the proposed methodology for determining Medically Underserved Populations (MUP) and Health Professional Shortage Areas (HPSA) that appeared recently in the Federal Register. It is clear that much thought, time and effort went into the development of an appropriately adjusted ratio that does seem to take into account many of the various complicating factors that make rural healthcare delivery so very challenging.
       As our rural hospitals and rural health clinics in the State of Texas have studied the new methodology that has been proposed by HRSA to replace the former shortage area designations, several concerns have arisen due in large part to the methodology’s effect on areas of extremely low population. Texas is by some standards the second most frontier state after Alaska and the most frontier state in the lower 48. Almost 158,000 square miles of land in Texas is designated frontier. Texas has 27 counties with less than 3,000 residents and another 22 counties between 3,000 and 4,500. For these counties to operate a rural health clinic at even minimal staffing (one physician and one mid-level) it could put them over the 3,000:1 ratio if the population is not properly adjusted or the providers spend the vast majority of their time providing primary care.
       Also, it is important to note that some of these communities have a critical access hospital in combination with a rural health clinic. They may have recruited more than one physician to the community in order to make the call schedule and ER coverage more manageable. A single physician should not be tasked with ER call 24/7/365. That is a sure path to burnout and something that many of even our smallest communities have tried to address proactively. Now those efforts are threatened because of the impact that losing their shortage area designation would have on their RHC status, grant funding, bonus payments and J-1 or NHSC eligibility.
       In our opinion, several different solutions have emerged. First, HRSA should consider exempting areas of extremely low population from the eligibility process and simply confer a shortage designation on any area that also qualifies as frontier. These counties are challenged enough already with maintaining an adequate supply of primary care in remote areas. You could call these areas ‘tier 3’ HPSAs perhaps, but some recognition that such sparsely populated areas are going to constantly struggle with securing needed primary care providers would be appropriate.
       Second, it is debatable whether or not it is the proper time to begin counting mid-level providers at all due to the scope of practice issues that still persist, but at the very least HRSA should consider removing any physician or mid-level provider who works at a free-standing or provider-based Rural Health Clinic from the provider count. This would bring RHC providers more in line with the way that FQHC providers are currently being accounted for. These provider types are extremely similar in nature and no singular issue would be more important to our members than fixing this inequity.
       Furthermore, we would find it favorable if HRSA would discount any primary care provider that has not been practicing in their current location for more than 24 months. To count providers who may not yet be willing to make a long-term commitment to the community contributes to the same yo-yo effect that this methodology was intended to alleviate. Also, ensuring that there is a way to become rapidly designated in the case of a disaster situation or a severe change in the community’s medical personnel would also help to set our members at ease.
      Lastly, we question the agency’s plan to disallow ‘for-profit’ entities from becoming ‘safety-net’ providers. Certainly a for-profit clinic that is the sole-source of primary care services in the community is a better option than no access at all. We always try to remember the greater good and that all providers must make at least enough ‘profit’ in order to be able to continue to provide these valuable healthcare services to their local citizens.
      We hope that you will make these few simple changes to the regulations as written. It will certainly reduce the apprehension that many rural providers have expressed and put less of our members at risk of any unintended consequences. Please contact us if you have any questions about the issues or solutions we have presented.

Larry Krupala, who is now heading the hospital management and consulting division of TMSI, has added the talents of two very experienced former rural hospital administrators to the list of consultants that are available to assist rural hospitals with operational, financial and strategic consulting. In addition to Larry himself, Ernie Parisi and Windell McCord now serve as Senior Hospital Management Consultants, who work with TMSI to assist rural hospital administrators and trustees in addressing a wide array of issues. As you are considering contracting with a consultant, we hope that you will consider using YOUR management and consulting firm, TORCH Management Services, Inc.
      With new TMSI President/CEO Rob Madsen coming on board, Larry Krupala is now free to assist more hospital executives and boards with operations, benchmarking/ performance-related issues and trustee leadership training. Larry’s pedigree includes a very long career as the CEO at Cuero Community Hospital. Larry has also held significant leadership positions at both the state and national level. Larry spent the last 12 years building TMSI into a well-trusted and invaluable rural hospital resource for interim administration and also board and executive-level consulting. Windell McCord has been assisting rural communities maintain access to vital healthcare services his entire 30 year career and retired from Heart of Texas Memorial Hospital in Brady in 2006. Ernie Parisi spent nearly 25 years in rural healthcare and retired from ETMC Quitman in 2007. Mr. Parisi is a long time advocate for rural healthcare issues at both the state and national level.
      Together, Larry, Ernie and Windell are ready to assist those rural hospitals that have a need for either an experienced consultant or administrative expertise on an interim basis. When you are considering how to address a new project, get a better handle on your current status or tackle a nagging problem, you can rely on TMSI to have the talent and the know-how needed to help move your organization forward. TMSI consultants can play a valuable role as the facilitator or ‘change agent’ that is sometimes needed to get the job done right. Call today and find out how outside help can often be the key to success inside your hospital.
      For more information about these and other TMSI services, please contact Larry Krupala at 361-275-3595 or Rob Madsen at 817-372-1305. TMSI is here to serve YOU.

The U.S. Department of Health and Human Services is launching the first national print advertising campaign focusing on the quality of care available in the nation’s hospitals.
       The ads, placed by HHS’ Centers for Medicare & Medicaid Services (CMS) in the May 21 edition of 58 major daily newspapers, promote Hospital Compare (http://www.hospitalcompare.hhs.gov), an easy-to-use Web site that helps consumers make well-informed decisions when choosing a hospital. The ads provide scores from two of the 26 quality and patient satisfaction measures on the Web site for a sample of hospitals in the newspapers’ areas. The 26 quality measures allow patients to better understand 10 key aspects of the patient experience.
      “These ads –- and Hospital Compare –- are intended to give consumers more information for making choices about their health care,” said HHS Secretary Mike Leavitt. “This brings us closer to meeting the goal of using new technologies to make the quality of health care services all across the nation more transparent to the public.”
       “The newspaper ads are designed to raise awareness about the important information on Hospital Compare,” said CMS Acting Administrator Kerry Weems. “Patients and their family members can use this information to see how well their hospitals are providing care, and hospitals can use the data to focus on areas where there is opportunity to improve the quality of care.”
      The ads highlight two measures found on www.hospitalcompare.hhs.gov, a Web site that allows users to compare the quality of care provided in nearly 4,000 hospitals across the nation. The newspaper ad, aimed at reaching areas covered by about 1,000 of these hospitals, invites readers to “Compare the Quality of Your Local Hospitals” and contains the following information:

• Percentage of patients at each hospital who always received help when they requested it, as reported by the patients themselves
• Percentage of patients at each hospital who were given antibiotics one hour prior to surgery, as reported by hospitals
• The state average for each of these two measures
• The Hospital Compare ad campaign is the most recent effort by the Department to make reliable information easy to find and raise standards in the health care system. In addition, HHS officials hope the ads –- and the information available at Hospital Compare –- will encourage hospitals to improve the care they provide to patients.

Hospital Compare allows consumers to compare local hospitals on measures that are critical to patients and family members, including quality of clinical care for specific procedures, and what patients say about their hospital experience.
       On Hospital Compare, consumers will find 26 quality of care measures that can be used to compare hospitals to each other, or to state and national benchmarks in addition to information about the care provided to patients with heart failure and heart attack -– or acute myocardial infarction. The newest enhancement to Hospital Compare is the inclusion of 10 patient experience-of-care topics that allow consumers around the country to get a better picture of the quality of care delivered at their local hospitals.
       The patient experience-of-care information available on Hospital Compare is collected through a new patient survey, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. HCAHPS (pronounced “H-caps”) is the first national, standardized, publicly reported survey of patients’ perspectives of care.
       Survey results reported on Hospital Compare cover 10 key aspects of the patient experience, including how often doctors and nurses communicated well with patients, how often patients received help quickly -– one of the features in the newspaper ads –- and patients’ overall rating of the hospital.
       Hospital Compare was created by CMS in collaboration with the Hospital Quality Alliance, a private/public partnership that includes the American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, AARP and the AFL-CIO. Hospital Compare is also supported by other major medical associations, consumer groups, measurement and accrediting bodies, government, and other groups who share a commitment to improving hospital quality.
       To access the Hospital Compare Web site, please visit: www.HospitalCompare.HHS.gov. Other tools are available at www.medicare.gov to compare the quality of Medicare health plans, nursing homes, home health agencies, and dialysis facilities.

By JOSEPH NIXON, printed in the Wall Street Journal; May 17, 2008; Page A9

When Sam Houston was still hanging his hat in Tennessee in the 1830s, it wasn't uncommon for fellow Tennesseans who were packing up and moving south and west to hang a sign on their cabins that read "GTT" - Gone to Texas.
       Today obstetricians, surgeons and other doctors might consider reviving the practice. Over the past three years, some 7,000 M.D.s have flooded into Texas, many from Tennessee.
       Why? Two words: Tort reform.
       In 2003 and in 2005, Texas enacted a series of reforms to the state's civil justice system. They are stunning in their success. Texas Medical Liability Trust, one of the largest malpractice insurance companies in the state, has slashed its premiums by 35%, saving doctors some $217 million over four years. There is also a competitive malpractice insurance industry in Texas, with over 30 companies competing for business. This is driving rates down.
       The result is an influx of doctors so great that recently the State Board of Medical Examiners couldn't process all the new medical-license applications quickly enough. The board faced a backlog of 3,000 applications. To handle the extra workload, the legislature rushed through an emergency appropriation last year.
       Now many of the newly arriving doctors are heading to rural or underserved parts of the state. Four new anesthesiologists have headed to Beaumont, for example. Meanwhile, San Antonio has experienced a 52% growth in the number of new doctors.
       But if tort reform has been a boon - and it is likely one of the reasons the state's economy has thrived in recent years - it was not easy to enact.
In one particularly grueling fight in the legislature in 2003, an important piece of a reform bill went down to a narrow defeat in the state Senate after a single Republican switched his support to vote against it. Republican Gov. Rick Perry was so incensed that he bolted out of his office in the Capitol, sprinted into the Senate chamber, and vaulted a railing to come face to face with the defecting senator.
       That confrontation fizzled, however, and before long Texas succeeded at enacting two simple but effective reforms. One capped medical malpractice awards for noneconomic damages at $250,000, changed the burden of proof for claiming injury for emergency room care from simple negligence to "willful and wanton neglect," and required that an independent medical expert file a report in support of the claimant.
       This has allowed doctors and hospitals to cut costs and even increase the resources devoted to charity care. Take Christus Health, a nonprofit Catholic health system across the state. Thanks to tort reform, over the past four years Christus saved $100 million that it otherwise would have spent fending off bogus lawsuits or paying higher insurance premiums. Every dollar saved was reinvested in helping poor patients.
       The second 2003 reform cleaned up much of the mess surrounding asbestos litigation by creating something called multidistrict litigation (MDL). This took every case in the state involving a common injury or complaint, like silicosis or asbestosis, and consolidated it for pretrial discovery in one court.
       One judge now makes all pretrial discovery and evidence rulings, including the validity of expert doctor reports, for all cases. This creates legal consistency and virtually eliminates "venue shopping" - a process by which trial lawyers file briefs in districts that they know will be friendly to frivolous suits. Trials still occur in plaintiffs' home counties.
       More change sailed through the legislature in 2005; tort reform had become popular with voters and lobbying against it was ineffectual.
The 2005 reform created minimum medical standards to prove an injury in asbestos and silica cases. Now plaintiffs must show diminished lung capacity in addition to an X-ray indicating disease.
       In sum, these reforms have worked wonders. There are about 85,000 asbestos plaintiffs in Texas. Under the old system, each would be advancing in the courts. But in the four years since the creation of MDLs, only 300 plaintiffs' cases have been certified ready for trial.
       And in each case the plaintiff is almost certainly sick with mesothelioma or cancer.
       No one else claiming "asbestosis" has yet filed a pulmonology report showing diminished lung capacity. This means that only one-third of 1% of all those people who have filed suit claiming they were sick with asbestosis have actually had a qualified and impartial doctor agree that they have an asbestos-caused illness.
       In the silica MDL, there are somewhere between 4,000 and 6,000 plaintiff cases. In the four years since the cases were consolidated under the MDL, 47 plaintiffs have filed a motion to proceed to trial based on a medical report indicating diminished pulmonary capacity. Of those 47, the court has certified 29 people as having diminished lung capacity. This, too, is less than 1% of all the "silicosis" claims made in Texas. No one has proven the real cause of his illness to be silica, as no case yet has been certified for trial.
       Before the asbestos and silica MDLs were created, nonmalignancy plaintiffs settled with defendants for anywhere between $30,000 to $150,000 per case. No one knows how many bogus cases were settled in the state with large cash payments. Lawyers who specialized in defending those cases say there were tens of thousands.
       The full costs of large settlements and runaway malpractice suits may never be known. But it is clear that the costs were paid for by consumers through the increased price of goods, by pensioners through diminished stock prices, and by workers through lost jobs. Another group often overlooked is those who are priced out of health care, or who didn't receive charity care because doctors were squeezed by tort lawyers. Frivolous lawsuits hit the uninsured the hardest.
Texas recently became home to more Fortune 500 companies than New York and California. Things are trending well for the Lone Star State.
       Anecdotally, we can see that while doctors are moving in, trial lawyers are packing up and heading west. They're GTC -- Gone to California.

Mr. Nixon, a former member of the Texas House of Representatives, is a senior fellow at the Texas Public Policy Foundation.

Trustees are stewards of a community’s most precious resource … the health of its citizens. High performing boards realize community focus is indeed their overall mission. THT’s 2008 Annual Conference will provide speakers and topics to equip trustees with practical tools and the opportunity for multiple peer networking engagements. Included in the Annual Conference are the Founders’ Award Luncheon, the ceremony for honoring Recognized Trustees and the Texas Healthcare Trustees Foundation’s Silent Auction.
      The Governance Institute will be presenting a pre-conference session titled Governance Tools: Board and Management Working Together from 8 a.m. – 3 p.m. on Thursday, July 24th. This full-day session begins with a discussion of targeted topics for the development of successful boards and concludes with facilitators Luanne Armstrong and Mike Wirth, two governance experts, analyzing case studies and current issues within your own hospital. Topics to be covered include strategic planning, quality oversight, conflict-of-interest, compliance, governance planning and board communications.
      Also on Thursday, THT will hold its Public Hospital Orientation and Refresher. Are you new to the board and want an overview of the essentials? Or perhaps you are a current trustee who would benefit from a refresher. Attend this one-day session to learn the basics of trusteeship. Topics to be covered include trends, agendas, conflict-of-interest, finances, medical staff, strategic planning and patient safety. Kevin Reed, Fletcher Brown, Larry Krupala and Bill Parrish will teach all you need to know in this fast-moving overview of hospital governance issues.
      The next two days are dedicated to the latest and greatest topics that hospital trustees need to understand in order to be an effective leader in today’s environment: board performance, physician recruitment, leadership, advocacy, marketing and more. TORCH member hospitals receive the complimentary THT-member rate for all of the scheduled events, so please take advantage of this arrangement.
      Also, congratulations to Lucille Rochs, trustee of Hill Country Memorial Hospital in Fredericksburg. Lucille will be honored by HOSPAC Most Valuable PAC Player, AHAPAC/HOSPAC 2007. TORCH is pleased to co-sponsor this important trustee education program. For more information, go to www.tht.org.

West Texas is the place to be this summer for the Annual Education Convention and networking events at the Northwest Texas Hospital Association. This year’s agenda includes information on Cost Reports, IRS 990 Issues, Recovery Audit, HRSA/HPSA Issues, UPL, Physician Employment, Performance Improvement, Collections Management, Contract Negotiation, and Updates on Legislative and Congressional Issues with a planned presentation by Senator Duncan. Watch your mail for the brochure and registration information.

Dr. Josie Williams has been a member of TMA's board of trustees since 2001 and a member of the association's Council on Legislation and Council on Socioeconomics. Williams also has been a TMA delegate to the American Medical Association's House of Delegates.
       In addition to her involvement with the TMA, Williams is director of the Rural and Community Health Institute at the Texas A&M Health Science Center and assistant professor in the Department of Internal Medicine at the medical school.
In her medical career, Williams has been a physician in private practice, a hospital administrator, a military nurse, a nursing administrator and an assistant professor. She earned her medical degree from The University of Texas Health Science Center at San Antonio, and her nursing degree at Sparks Memorial Hospital School of Nursing at Fort Smith, Ark. Williams completed her undergraduate studies at Texas A&M University.
      "Our state faces many health care challenges, from the high number of uninsured people to overall wellness concerns," said Williams. "TMA has to continue its leadership role in helping tackle those problems, to improve the health of all Texans."
      TMA is the largest state medical society in the nation, representing more than 43,000 physician and medical student members. It is based in Austin and has 120 component county medical societies around the state.