CMS Outpatient Regulation Comments Due This Week

The Centers for Medicare and Medicaid Services (CMS) is accepting comments on the its proposed rule outlining changes to the CY 2011 hospital Outpatient Prospective Payment System (OPPS).  Included in the proposal are significant issues related to the normal operation of small rural PPS and critical access hospitals, and it is very important that CMS receive many comments outlining the issues important to them. The NRHA has developed a sample letter pertaining to the following proposals that will have a significant impact on rural hospitals. Please review, personalize, and submit your own letter using the sample above.  Of course, feel free to modify or expand as you deem appropriate. Please click here to submit your comments: Search for "CMS-1504-P" and follow the directions for submitting.  The deadline for comments is Tuesday, August 31, 2010 at 5 pm Eastern. More information on the issues covered: Physician Supervision In its 2010 Outpatient Prospective Payment System (OPPS) final regulation, CMS issued what it stated as a "clarification" of existing law requiring that all hospitals provide 24 hour "direct physician supervision" of certain outpatient therapeutic services in order to receive proper Medicare reimbursement.  In actuality, this "clarification" amounted to a significant change in the way hospitals operate, imposing levels of supervision never previously required. In early 2010, this decision resulted in an outcry of nationwide and state associations, individual hospitals, and even Congressional offices.  Faced with this overwhelming chorus of disapproval, CMS announced it would delay its decision for Critical Access Hospitals (CAHs) until January 1, 2011.  So, in its most recent proposed rule outlining changes to the 2011 OPPS, CMS has developed a new plan. CMS has proposed to require, for a list of specific outpatient therapeutic services (included in the link below), direct physician supervision at the initiation of service, after which point the supervising physician can move to "general supervision" guidelines and pass the supervising duties on to a mid-level practitioner.  Though this change may relieve some of the burden on certain hospitals, its benefits are not likely to be realized for rural hospitals, who face significant barriers in staffing physicians. Hospital Emergency Department Transfers CMS has been set on a course of implementing notions of transparency in quality reporting for hospitals, especially since the creation of the Hospital Compare program. Hospital Compare makes available to the public a "report card" of quality on various quality indicators, primarily Congestive Heart Failure (CHF), Acute Myocardial Infarction (AMI), Pneumonia and Surgical Care Improvement Project Process of Care measures. A valid criticism of these measures have been that due to small volumes, many of these indicators are not beneficial to rural hospitals in actually assessing and reporting the content of what these facilities actually do. To the credit of small, rural hospitals (especially since CAH's are not required to report), the vast majority of rural hospitals do participate and publicly report Hospital Compare data. The proposed OPPS rule adds a set of measures covering "Emergency Department Outpatient Transfer Communications" in a hospital setting. These measures are applicable to a wide range of patients and NQF endorsed. Pay for Performance and Value Based Purchasing are probable changes on the horizon for Critical Access Hospitals (CAH). Therefore, CAHs need to pro-actively help shape regulated rural-relevant measures that demonstrate improvements in patient care. Without significant comments in support it is unlikely that this measure will be adopted. If it is adopted this will set the precedent for measures that speak to the unique nature of rural, in an environment where the focus of reporting outcomes is increasingly important. Why this measure is relevant to rural and should be included:

  • Due to the nature and coordination of care typical in rural settings, this is a great measure of quality.
  • It assesses the quality of key patient information communicated from an ED to the referral hospital. (See the following link for more information on the measure: Klingner, J, Moscovice, I. Rural Hospital Emergency Department Quality Measures: Aggregate Data Report 2008-2009. (Data Summary Report No.8). Minneapolis, MN: Flex Monitoring Team; May 2010.)
  • This is an ideal opportunity to improve nurse and physician hand-offs from the ED to inpatient units, other hospitals and health care facilities, and reduces adverse events.
  • Research indicates that seamless communication between the ED and long-term care facility is a common challenge for rural providers.
  • Patient safety studies have identified the Emergency Department as the location within a hospital that has the highest percentage of preventable and negligent adverse. Size and geography increase the importance of organizing triage, stabilization, and transfer in rural hospitals.
Definition Specifications The definition of the measure is as follows:
  • Numerator = Number of information elements sent with transfer patients in seven components
  • Denominator = All ED patients transferred to another acute facility
Seven components of the measure include every communication touch point and collectively, should improve continuity of care: 1.       Pre-transfer: Nurse communication with the receiving hospital and physician communication with receiving physician 2.       Patient Identification: Name, address, age, gender, significant others contact, and insurance 3.       Vital Signs: Pulse, respiratory rate, blood pressure, oxygen saturation, temperature, glascow score, etc. 4.       Medication-related: Medications given, allergies, and medications from home. 5.       Administrative or practitioner generated: History and physical, exam, history of current events, chronic conditions, physician orders and plan 6.       Nurse Information: Assessment/interventions/response, impairments, catheters, immobilizations, respiratory support, oral limitations, etc. 7.       Procedures and Test: Ones performed and results sent Click here for the table from the proposed rule of measures under consideration.

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