Archive for March, 2012

The Texas Institute of Health Care Quality and Efficiency Board Members Announced

Monday, March 19th, 2012

Last year, the Texas Legislature passed Senate Bill 7 during special session. The legislation was authored by State Senator Jane Nelson to control rising healthcare costs and improve patient outcomes. SB 7 eventually included portions of three bills filed by Sen. Nelson during the regular session: one relating to efficiencies, cost-savings and fraud prevention in Medicaid and the Children’s Health Insurance Program, another to achieve savings in Medicaid and CHIP by re-focusing our healthcare dollars on better patient outcomes; and another allowing health care providers to form collaboratives to better coordinate care, free from burdensome federal regulations. In total, SB 7 is supposed to result in at least $467 million in cost savings.

The bill also included the creation of a new Texas Institute of Health Care Quality and Efficiency. Earlier this month, Governor Rick Perry named Dr. Ben Raimer of Galveston as the Institute’s first chairman and appointed 13 members to the Texas Institute of Health Care Quality and Efficiency’s Board of Directors. The language in SB 7 authorizes the institute to work to improve health care quality, accountability, education and cost to the state by encouraging health care provider collaboration, effective healthcare delivery models and coordination of healthcare services.

Raimer is a board certified pediatrician, and senior vice president and professor at the University of Texas Medical Branch at Galveston. He is a member of the American Academy of Pediatrics, Texas Medical Association, Texas Pediatric Society and Texas Rural Health Association. He is also a member and past president of the Galveston County Medical Society, a public representative for the Texas Health and Human Services Commission Task Force on Local Health Care Initiatives and past chairman of the Texas Statewide Health Coordinating Council and the Health Disparities Task Force.

Among the other board members that were recently appointed, is one health system CEO. Joel Allison is president and CEO of Baylor Health Care System. He is also a member of the American College of Healthcare Executives, American and Texas Hospital associations, Healthcare Leadership Council and Texas Association of Voluntary Hospitals. Other notable appointees with hospital ties include:
· Dr. Steven Berkowitz, founder and president of SMB Health Consulting and a former THA Board Member
· Dr. John C. Joe of Houston, physician and chief medical information officer at St. Luke’s Episcopal Health System and former CEO of Prognosis
· Ronald Luke of Austin, president of Research and Planning Consultants and a past member of the Texas Health and Human Services Council.

The balance of the board is made up of clinicians and healthcare industry experts. Half of the board terms will expire on January 31, 2013 and the other half on January 31, 2015. According to the bill, the Institute itself will expire on September 1, 2017, unless the legislature takes steps to continue it. The board has been given a very broad mandate with regard to its ability to study and develop recommendations around creating more effective healthcare delivery models as a result of increased collaboration and coordination. As such, the Institute will definitely have an impact on the hospitals and the other healthcare providers in Texas. There is no truly rural representative, so TORCH will be making every effort to be involved and keep our members informed about the Institute’s activities and work products.

Primary Election Date Change Reopens Window for More Candidates to File

Friday, March 9th, 2012

With the change in the Texas primary date, a second filing period for candidates was opened up recently under the order of a federal court. Candidates who previously filed also had an opportunity to withdraw with a refund of their filing fee (which is not normally allowed) or file in a different district. The one week second filing window ended Friday at 6 pm, so all of Texas finally knows exactly who is running for State Representative, State Senator and U.S. Representative; and in which district. All hospitals are strongly encouraged to reach out to all candidates running for in their state rep, state senate and congressional races. Ask that all the candidates come by the hospital and even propose a candidate debate at the hospital for staff and the community. Now is an excellent time to get commitments from candidates that they will support laws and policy that protects rural hospitals. Such as approach is more important than ever given the certain cuts hospitals will continue to take.

Redistricting Moves Rural Texas Lines – Primary Election Now a “Go” for May 29

Thursday, March 8th, 2012

The upcoming Texas primary election has finally landed on a date – May 29. And, the three-judge Federal court panel in San Antonio recently issued another set of maps for Texas congressional, state rep and state senate lines. This is expected to be the final word for now as the new maps were agreed to by most of the parties associated with the litigation, including the Texas Attorney General.

The heart of the litigation argument was that the Texas Legislature had drawn the maps in a matter that violated the U.S. Voting Rights Act. It did not give minorities a shot at being elected, especially in new congressional districts, that was proportionate to the growth of minorities in Texas.

The final set of boundaries did move some lines from what the Texas Legislature set back during the session and from what the San Antonio court had originally ordered. The new set of maps was spurred when the U.S. Supreme Court overruled the San Antonio court stating the court overstepped its authority by changing lines on its own, rather its authority was to rule on the legality of the lines and then have the state and other parties revise them.

The bulk of the changes in district boundaries are in the areas between the Dallas-Fort Worth Metroplex and the Panhandle, between the Metroplex and Austin, and in the triangle region cornered by Houston, Austin, and South Texas.

An analysis of the new lines indicates that the political strength of rural areas in Texas is not severely impacted. The maps originally created by the legislature and the final set issued by the court leave rural areas with a similar number of U.S. Congress members and State Senators. The rural areas do have two less State Representatives as those slots were moved by the Legislature into urban areas. A case can be made that rural Texas even gained some U.S. House Representatives as Texas gained four congressional seats and three of those have at least one rural hospital in the district. Counter to looking at the pure numbers, there is however an indirect softening of rural representation as many of the districts continue to be a mix of urban and rural; and the urban portion of those districts has grown while the rural portion has not fostering a scenario where the urban areas of the district will elect the reps and drive their agenda.

Based on the new census numbers for Texas, lines were redrawn to balance population in all districts. Here are the target numbers:

Texas 2010 census population = 25,145,561
Ideal district population:
698,488 Texas Congress (36 districts)
811,147 State Senate (31 districts)
167,637 State House of Representatives (150 districts)
1,676,371 State Board of Education (15 districts)

(Note – the State Board of Education lines were not challenged in court)

A side-by-side analysis can be found here listing each rural hospital by city, its current Congressman, State Rep and State Senator as well as the new congressman, State Rep and Senator. People listed in the “New” column are the current holder of the seat and may not be running for reelection. If the “New” column is blank, then it is a newly created Congressional seat with no incumbent.

A look at the actual new district maps can be found here:

U.S. Congressional Districts
State Representatives
State Senators

Associated with the new lines comes an order from the federal court for Texas to hold its primary party elections on May 29. This results in considerable delay from the original March 6 date. The election will come only days after many local and school elections, which are scheduled for May 12.

CAHs Added to the List of Eligible Sites for National Health Service Corps

Thursday, March 8th, 2012

Critical Access Hospitals (CAH) have recently been added to the list of eligible sites where a National Health Service Corps participant can work. There are some other requirements, but the addition of CAHs is another recruitment opportunity for rural hospitals. The Corps has options for full time and part time participants. The full-time program offers up to $60,000 in tax-free loan repayment for two years of service and up to $170,000 for a five-year service commitment. Information can be found at National Health Service Corps.

Trailblazer Ousting Still on the Calendar

Thursday, March 8th, 2012

Trailblazer is still scheduled to exit the Texas scene this summer as the CMS payment contractor after recently losing a bid to continue to provide the services. CMS says the change is part of its plan to reduce the number of Medicare administrator jurisdictions from 15 to 10 by 2016. Highmark Medicare Services will replace Trailblazer in paying Medicare Part A and Part B fee-for-service claims in Texas by late July 2012. Highmark also will handle claims in Arkansas, Colorado, Louisiana, Mississippi, New Mexico and Oklahoma. It now administers claims in Delaware, New Jersey, Pennsylvania, Maryland and the District of Columbia

CMS previously released information that questions can be directed via email to Kathy Markman in the CMS Office of Acquisition and Grants Management or call her at (410) 786-8916.

CRNA Payment Question Striking More Critical Access Hospitals

Thursday, March 8th, 2012

Several Texas Critical Access Hospitals (CAH) report being hit by audits recently where Trailblazer is adjusting downward the allowable on-call time for Certified Registered Nurse Anesthetists. Trailblazer is denying and/or attempting to recover payments from several Texas rural CAHs claiming the payments are for services not clearly deemed an “allowable cost” under Medicare. The hospitals contend the charges are have been deemed allowable in the past and no CMS rules have changed. The hospitals can appeal the issue, but that can take years and is costly. Plus, Trailblazer appears to be supported by CMS in its position.

The most recent incident involves Otto Kaiser Memorial Hospital in Kenedy. Hospital CEO Nathan Tudor and TORCH recently made a complaint to US Congressman Ruben Hinojosa who represents the Kenedy area. And, CMS has actually responded to Hinojosa’s office on the matter stating they do not consider CRNAs to be on the list of providers where stand by or on-call time is paid for. The CMS contention is that CRNAs are specifically defined separately in CMS rules from a clinical nurse specialist and therefore do not qualify as a “clinical nurse specialist” referred to in the on call payment coverage list.

The official reply submitted by CMS to Congressman Hinojosa’s office:

CMS policy is to only allow on call costs of clinical nurse specialists and NOT for CRNAs. The statute and regulations clearly limit the pass through payment to CAHs for specific emergency on call providers, including ER physicians, ER PAs, NPs and clinical nurse specialists (CNS). Throughout title XVIII, the statute clearly uses the terms CRNA and CNS separately.

A certified nurse specialist is defined in 1861(aa)(5) as:
(B) The term “clinical nurse specialist” means, for purposes of this title, an individual who (i) is a registered nurse and is licensed to practice nursing in the State in which the clinical nurse specialist services are performed; and (ii) holds a master’s degree in a defined clinical area of nursing from an accredited educational institution.

Separately, a certified registered nurse anesthetist is defined in 1861(bb)(2) as:
(2) The term “certified registered nurse anesthetist” means a certified registered nurse anesthetist licensed by the State who meets such education, training, and other requirements relating to anesthesia services and related care as the Secretary may prescribe. In prescribing such requirements the Secretary may use the same requirements as those established by a national organization for the certification of nurse anesthetists. Such term also includes, as prescribed by the Secretary, an anesthesiologist assistant.

Section 1842(b)(18) defines Practitioner

The term “practitioner” means any of the following
• Physician assistant;
• Nurse practitioner;
• Clinical nurse specialist;
• Certified registered nurse anesthetist;
• Certified nurse midwife;
• Clinical psychologist;
• Clinical social worker;
• Registered dietitian; or
• Nutrition Professional

Accordingly, had the statute wanted to include CRNAs in the list of practitioners for whom a CAH can be paid based on the reasonable costs of having them “on call,” the statute would have (and could have) specifically included CRNAs in the list.

The only recourse from the new CMS position is most likely a bill in Congress to override CMS. TORCH is in communications with Representative Hinojosa’s office about that possibility.

Medicare Advantage Growing in Rural Areas

Thursday, March 8th, 2012

The saturation of Medicare Advantage (MA) continues to grow in rural Texas and across the country, and with that growth, a financial challenge is being presented to rural hospitals, especially Critical Access Hospitals (CAH).

According to a white paper from the RUPRI Center for Rural Health Policy Analysis at the University of Iowa College Public Health Department, enrollment in Medicare Advantage plans has more than tripled over the last five years, with an enrollment of more than 1.5 million beneficiaries in March 2011. Nationwide, the uptake has almost doubled to more than 12.1 million beneficiaries. Sixteen percent of rural Medicare beneficiaries were enrolled in the MA program during 2011, while 26 percent of Medicare beneficiaries were enrolled nationally. Although traditional fee-for-service Medicare continues to have the largest share of Medicare beneficiaries, the percentage of Medicare beneficiaries enrolled nationally in MA has grown significantly over the last five years, from 13 to 26 percent. There is no specific data for Texas, but the percentages are believed to be similar or slightly behind in rural areas.

The challenge for CAHs is that Medicare Advantage payments are not subject to the cost settlement. CMS considers Medicare Advantage to be private insurance, which is technically correct even though Medicare purchases it. This is very similar to the situation that Texas faced with the conversion of Medicaid in rural areas to HMO managed care. Fortunately, TORCH was able to gain state legislation that requires the Medicaid HMOs continue to pay rural hospitals their cost. There is not a similar law at the federal level for Medicare managed care and gaining such legislation is highly unlikely given that Medicare Advantage actually dates back to the 1970s. TORCH has pushed for such requirements, but with no success. As older Americans convert to MA, not only do Critical Access Hospitals potentially lose “cost” on the patient payment (receiving the negotiated rate rather than 101 percent of allowable cost), but the number of Medicare days in a hospital drops impacting overall CAH payments.

The federal government is not the only entity pushing more beneficiaries into Medicare Advantage. As of January, the State of Texas is transferring retired state employees who are on both Medicare and the state’s retiree insurance into one single Medicare Advantage plan. Retirees can opt back into the two plans, however, they are being enticed to stay in the single MA plan with premium savings and some expanded benefits. This was done as a budget savings move and will contribute to some more MA coverage in Texas.

Because of the historic low number of lives covered by MA in rural areas, a negotiated payment versus “cost” has not been an issue, but that will be changing with the growth of MA. Rural hospitals should become more acutely aware of the situation and are encouraged to take caution when negotiating with Medicare Advantage companies. Hospitals also need to educate community leaders and citizens of the potential long-term negative financial impact on the local hospital from increases of Medicare Advantage saturation.

Two Percent Medicare Payment Cut Looms in the Background

Thursday, March 8th, 2012

The Doc-fix, rural extenders and reduced bad debt issues associated with the passage of the Middle Class Tax Relief and Job Creation Act of 2012 last month have overshadowed and, almost pushed out of sight, an impending two percent cut in Medicare payments to all providers, including all hospitals. Lingering provisions from the failed Congressional budget super committee last fall are a slew of cuts to many areas of the federal budget including defense and an automatic Medicare provider cut. The super committee was tasked with coming up with budget cuts in a range of $1.2 to 1.5 trillion across a ten-year span. They did not, which triggered some automatic cut provisions tied to the debt ceiling increase vote from last August. At the top of the list is the Medicare payment cut which goes into effect on January 31, 2013.

Now eleven months away, there is some small talk in the halls of Congress of trying to stop some of the automatic cuts. Most of the talk centers on defense spending, but hospitals need to take every opportunity to talk to their Congressman over the next few months about the impact of further Medicare cuts, especially in view of the bad debt cut.

Texas Prison System Goes Beyond UTMB and Texas Tech for Healthcare

Thursday, March 1st, 2012

The Texas Prison Board went beyond their long standing health care system with the University of Texas Medical Branch and Texas Tech last month by voting to contract with Huntsville Memorial Hospital to provide a portion of the Texas correctional health system. With a $46.8 million dollar contract spanning 3-and-1/2 years, Huntsville Memorial will provide nine beds for inmates at its facility, emergency room care, imaging services, day surgery and physician services. The prison system maintains this will save money, especially with regards to transporting inmates from Huntsville area units to UTMB in Galveston. UTMB has threatened for several years to no longer provide inmate care, claiming to lose money. Texas Tech has not asked to be relieved from their correctional health care duties.

While the Department of Corrections is not currently seeking proposals from other hospitals near prison units, they are clearly looking for regional replacements to UTMB. Rural hospitals near prison units that may have an interest in providing inmate care should make that interest known to the state’s prison system. Letters of interest should be addressed to:

Brad Livingston
Executive Director
Texas Department of Criminal Justice
P.O. Box 99
Huntsville, TX 77342-0099

A copy should also be sent to:
Texas Board of Criminal Justice
P.O. Box 13084
Austin, TX 78711

Notes from the Field

Thursday, March 1st, 2012

Comments from Don McBeath, TORCH Director of Government Relations

It is with some weight on my heart that I report to you that I fear rural hospitals are slowly losing their sympathy status in Washington. Rural hospitals have long been able to touch a sensitive nerve as consensus was every town should have a hospital and no politician wanted to directly or indirectly contribute to a hospital closure. However, as Congress and Washington have turned into a “balance the budget at all cost” fury, hospitals in general (and even rural hospitals) have been put on the target list. I attribute this to several things including a growing attitude among politicians that the health care and hospital industries have long been evasive about how they operate and how much money they are making. Mix in the fact that most leadership in Washington is from urban areas and a realization that politicians are not at much risk by turning their backs on rural areas, and you have recipe for disaster for rural America. There is also a growing sentiment that if local communities want their hospital to survive, they should provide more local support. That is fine if your hospital is one of the lucky few to be situated in an oil or gas field, but that is not the case for most of the rural hospitals in Texas.

We make the argument every day that it is good public policy for the federal and state governments to develop and maintain policies that help keep our rural hospitals open. We talk about the food, fuel and fiber coming from rural areas. But, at the end of the day, for most of the elected officials it is all about where the votes are. And, they are not in rural areas.

Organizations like TORCH, the National Rural Health Association, and others will continue the fight because it is the right thing to do. Sorry to use a worn out phrase, but “the squeaky wheel gets the grease” and we need to throw a little sand on the axle so the wheel squeaks louder!

The involvement of rural hospital CEOs, staff, board members and the local elected officials is critical more than ever. When we ask you to make a call to DC or Austin, you can’t just assume some other hospital CEO will do it. Please take every opportunity to educate your local county judge, mayor and school superintendent to what is going on. And please, seize every chance you can to talk to your congressman. TORCH regularly delivers the message, but you are the story!