By:  David M Jackson

Attention to detail often becomes more central to success when dealing with an issue or idea, rather than a tangible product or service.  Historic American Author Louis L’Amour said “There will come a time when you believe everything is finished. Yet that will be the beginning.” This can be applied to politics in the sense that many corporations, small businesses, and associations may believe the work stops within the legislature or with campaigns. While keeping a pulse on legislative action can play a major role in all market sectors, many battles can be lost in the administrative rules process as well.  There are 187 state agencies in Missouri that write rules and regulations to implement the laws in Missouri Revised Statutes (RSMo) passed by the General Assembly or through initiative petition.

Twice a month, Missouri’s Secretary of State publishes the Missouri Register. This contains proposed rulemakings by departments and agencies that are then subject to public comment and a hearing.  With 24 editions and over 1200 pages of proposed rules and regulations over the course of one year, it is easy to see why attention to detail is so important. A major component of the rulemaking process is the role of the Small Business Regulatory Fairness Board (SBRFB), which is charged with ensuring state agency rules and regulations do not create an unfair burden for small businesses.

A recent example of this can be seen in a rule published in November of 2008 by the Department of Social Services (DSS) that required all MO HealthNet providers to contract with a Patient Safety Organization (PSO) at the request of the Center for Medicare & Medicaid Services (CMS).  On January 3, 2012, the Department of Social Services proposed to rescind this rule after the Missouri Ambulatory Surgery Center Association (MASCA) filed suit for not properly engaging the SBRFB to analyze the impact this would have on small businesses.  Ambulatory surgery centers (ASCs) add considerable value to Missouri’s economy, with a 2009 statewide economic impact of $841.5 million, including more than $42 million in tax payments and employment of 1,800 full time workers. Additionally, for every dollar spent in the ASC sector of the state economy, $2.35 worth of economic value is created in the state.¹

Patient safety and convenience is the centerpiece of the ASC business model, as surgery centers strive to provide high quality medical care at lower costs with lower infection rates.  A recent national study found that seven-day mortality rates were 25 per 100,000 outpatient procedures at ASCs, compared to 50 per 100,000 in hospital outpatient departments. ¹ Therefore, a regulatory mandate by the Department of Social Services for ASCs to contract with PSO’s could be a cost burden with little to no added value to the quality of care. Most importantly, the Department of Social Services skipped a vital step when they bypassed the SBRFB and neglected the impact this mandate might have on ASCs in Missouri.

This recent victory by the Missouri Ambulatory Surgery Center Association gives new meaning to free enterprise and quality health care in our state.  With a strong lobbying voice and regulatory oversight, all corporations, small businesses, and associations can prevent state and federal government from implementing costly requirements that could be passed on to consumers.  It is MASCA’s mission to continue advocating for free enterprise and competition in the legislative and regulatory environment that will lead to lower costs and high quality care for Missouri patients.

Link to January 3, 2012 edition of Missouri Register:

http://www.sos.mo.gov/adrules/moreg/current/v37n1/v37n1.asp

Source: [1] Oxford Outcomes (2010). ASC Impact Analysis.

After drawing attention through a series of articles in the St. Louis Post Dispatch regarding lack of disciplinary powers and transparency within the Board of Healing Arts (BOHA), the legislature took it upon themselves to ensure BOHA had the necessary tools to stop providers who were a threat to patient safety.  Despite the delayed filing of legislation, contested hearings, and heated floor debate, Rep. Ellen Brandom (R-Sikeston) and Sen. Kevin Engler (R-Farmington) were successful in passing SB 265 on Thursday evening that overhauls the powers of the board.

In representing a large portion of the physician community, we worked with this bill through each stage of development to ensure that the granted powers were reasonable and not a comprehensive punishment to loyal and trustworthy medical professionals.  Specifically, a key provision was removed in the opening weeks that would have placed extensive and burdensome requirements on any physician prescribing controlled or non-controlled substances.  Additionally, the Missouri State Medical Association worked continuously to remove controversial sections regarding civil penalties, gross negligence, and the conditions of emergency suspension powers.  See below for a few key provisions that were Truly Agreed to and Finally Passed in HB 265, sponsored by Rep. Jason Smith (R-Salem).

• Transparency:  334.001- Patients will be able to see the schools a physician attended, disciplinary action by other state medical boards, limitations of practice, any final discipline by BOHA, and if a case brought to BOHA is pending in the administrative hearing commission or any court.
• Disciplinary Action: 334.099- BOHA will have the power to initiate a contested hearing to determine if a provider is unable to practice his or her profession with reasonable skill and safety to the public. 
• Emergency Suspension: 334.102- The Board can apply to the administrative hearing commission for an emergency suspension or restriction of a license for causes involving habitual intoxication, sexual misconduct, abuse of controlled substances, or other conduct that the board may constitute as a serious danger to the health, or welfare of a patient or the public.  The AHC must process the application within five days to determine if there is reasonable cause for an emergency suspension and hold a hearing within 45 days.
• Internet Prescribing:  334.108- Various requirements are added to ensure there is a valid physician-patient relationship established for all medications prescribed over the internet. 

Missouri’s action on physician discipline laws was featured in Amednews this week. Read the full article HERE.

In the final hours of the 2011 legislative session, Senator Rob Schaaf, M.D. (R-St. Joseph) was able to negotiate the passage of health care transparency legislation in Senate Bill 62.  Under RSMo 376.1190, health insurers will be required to provide policy holders with specific cost information that includes deductibles, copayments, and any coinsurance that the individual would be responsible for paying.  All of this information will be made available through a web-based program for patient convenience.

“The Ambulatory Surgery Center Advocacy Committee (ASCAC) advocates for increased transparency in health care to ensure that patients and providers have access to important information when making health care decisions and to help create a more efficient and cost-effective structure for delivering patient care.”

• Medicare patients can save more than 50% on out of pocket costs when having a procedure at an ASC, and also save the Medicare program approximately 40% on an annual basis
• A patient may save as much as 61%, or more than $300, compared to their out-of-pocket coinsurance for the same procedure in the hospital
• ASCs perform more than 22 million surgeries a year, spread over a dozen different specialties
• ASCs perform 40 percent of all Medicare colonoscopies in the U.S. each year

This language was passed in a compromise bill with the Federal Reimbursement Allowance (FRA) tax extension for hospitals, which is an assessment that earned $1.5 billion in federal matching dollars in 2009.  Because this tax expires in September of 2011, it was the hospital industry’s top priority to extend the sunset this year.

Source of Data:  MedPAC Report to the Congress:  Medicare Payment Policy, March 2004 and Ambulatory Surgery Center Advocacy Committee

Pictured Above (Left to Right): Cindy Young, John Blanck, Michelle Lehew, Michelle Dickison, Harry Eggleston MD, Lori Meltner, Diana Carr-President, Denice Morrison, David Lewis, Nancy Sturgeon, Michael Ladevich, Kim Nitsche

Surgical Technologists Legislation Sits Still: Neither SB 178 or HB 526 moved further in the legislative process this week, as both have yet to have a hearing in the House or Senate chamber.  Identical in language, these bills would require all surgical technologists and hospitals and ASCs to be certified through the National Board of Surgical Technology and Surgical Assisting (NBSTSA).   It has come to our attention that this legislation is in fact being pushed by the NBSTSA.  This is an opportunity for ASCs to further educate Missouri’s legislators on the safety measures and training used for your staff.  Please provide feedback on any information available regarding the training program used for your surgical technologists.  Distribution of this information related to low infection rates will provide substantial evidence to the validity of your current process.

Advancement of Patient Medical Records Legislation:  HB 528 filed last week by Rep. Caleb Jones (R-California) to require health care providers to provide medical records within 15 business days was referred to the Health Insurance Committee on Thursday.  The Senate Health Committee also voted out SB 62 this week, which would allow health care providers to charge a retrieval fee for outsourced records.  Rep. Keith Frederick, M.D. (R-Rolla) has identical language filed under HB 580, which was referred to the Health Care Policy Committee on Thursday.

Prompt Credentialing Hearing on Wednesday: The House Professional Registration and Licensing Committee will hear HB 347 on Wednesday relating to the Prompt Credentialing of Physicians.   This will require health carriers to credential providers within 60 days or be subject to certain penalty provisions. Sen. Rob Schaaf M.D. (R-St. Joseph) has an identical version (SB 212) that is currently in the Senate Health, Mental Health, Seniors and Families Committee.  Please notify our team by next Monday if you are interested in testifying on behalf of this legislation.

CON Repeal Inches Forward: By a narrow vote of 4-3, the Senate Health, Mental Health, and Seniors Committee passed SB 86 to repeal Missouri’s Certificate of Need requirement for health care facilities.  In addition, Rep. Todd Richardson (R-Poplar Bluff) filed HB 685 in the House this week to repeal the CON requirement.  The only difference between the Senate version and the House is that HB 685 leaves nursing home facilities under CON regulation.  As always with the legislative session, that provision is open to change as the bill moves forward.

Tort Legislation Hits Rules Committee: The Missouri Association of Trial Attorneys appears to be alone in fighting legislation that would require a defendant to pay only the percentage at which he or she is found to be guilty.  HB 364, sponsored by Rep. Mark Parkinson (R-St. Charles), prevents a defendant from paying 100% of the damages solely because they are 51% or more at fault.  The bill was voted out of committee last week and reported to the Rules Committee on Tuesday.  Once voted out of the Rules Committee, HB 364 is eligible for debate on the House Floor.

ID Badge Bill Passes 18-0 with Consent Status: On Wednesday, the House Professional Registration and Licensing Committee passed HB 287 by a vote of 18-0 with consent status.  This legislation, sponsored by Rep. Ellen Brandom (R-Sikeston), will ensure providers are easily identified and highly transparent for patient satisfaction.  Under the House Committee Substitute version, all physicians licensed under RSMO 334 will have the title “PHYSICIAN” in bold letters on the bottom one half inch of their ID Badge and nurses will carry their title as defined in RSMO Chapter 334, such as “REGISTERED NURSE.”  Nothing in this bill shall prohibit a provider from putting additional credentials after their name on their badge, such as “M.D., D.O., or APRN.”  If passed, all other titles will be promulgated in the rules process by the Department of Health.  The Senate version, SB 137, was voted out of the Senate Health, Mental Health, Seniors and Families Committee last week by a vote of 6-2 and is sponsored by Sen. Dan Brown (R-Rolla).  Read more HERE in an article by the Missourinet.

Any Willing Provider and Hospital Privileges on Deck for Senate Health Committee: The Senate Health Committee will hear SB 111 sponsored by Sen. Rob Schaaf, M.D. (R-St. Joseph) on Tuesday, March 1, which contains any willing provider language and internet access to a health carrier’s standard fee schedule.  The Committee also plans to hear SB 136, which prohibits hospitals from making patient referrals a condition of receiving medical staff privileges.  SB 136 also prevents a hospital from denying privileges to a provider who has ownership interest in another health care facility, such as an Ambulatory Surgical Center.

By Joyce (Deno) Thomas, Senior VP Operations, Regent Surgical Health | November 08, 2010

Quality care is a hotspot topic throughout our country. CMS, the American Hospital Association, the American Medical Association, the Ambulatory Surgery Center Association, healthcare payors, and legislators, just to name a few, have jumped into the fray of quality care. Rhetoric is strong concerning how to control the rising cost of healthcare. While U.S. healthcare has come under fire, it is interesting to note that foreign countries approach U.S. firms to assist them in improving their hospitals and send their citizens to our country for the latest care.

During recent years, there has existed a turf battle between hospitals and ambulatory surgery centers. Who is the better provider of patient care services?

Hospitals provide high acuity care in a sophisticated high tech environment. Hospitals can provide centrally located services for cardiac, trauma, obstetrics, neurology, neonatal and other inpatient services. We need hospitals that are excelling in quality care, and must support their existence!

The ASC is an upshot of our healthcare having evolved to the benefit of our citizenry. With the advances in technology and technique much of what had to be done in a hospital setting 30 years ago can now be done safely in the outpatient environment. The data supports this move with evidence of higher patient satisfaction, lower infection rates, lower complication rates, and fewer errors.

The answer to quality care is extraordinarily simple. All providers must stay focused on the task at hand while providing individual patient care. Nothing should take precedent over the individual care of the moment. How does a provider accomplish this feat when we are challenged with ‘doing more with less’, decreasing reimbursements creating urgency to be more efficient, or distractions of institutional layers of bureaucracy, whether at the hospital or government level? The only way to improve patient care is to focus on the details of the moment. The ambulatory surgery center setting has provided the answer to staying focused.

In a well-managed, accredited ASC, the focus of the entire organizational structure is on the delivery of outpatient surgery patient care. Without the distractions from other areas of urgent/emergent patient care situations, the physicians and staff drill down to the details of providing the best experience for this patient’s episode of healthcare. The processes are tight in the ‘how to’ from the moment of scheduling and registration through the discharge of the patient. The oversight of the processes is minute in detail. Daily onsite management with the intimate involvement of the administrator, director of nursing and business office manager leads to immediate resolution of patient individual needs. Staff is involved in the quality operations and oversight of the facility from patient satisfaction through facility safety. The Board and Medical Executive Committee review the previous month’s reports and hammer out methods to improve processes.

This ownership of the process leads to an in depth understanding of and commitment to a quality patient care outcome. The engagement of ALL providers of care in a collaborative focus-driven environment leads to an excellent result for the most important person – the patient.

Learn more about Regent Surgical Health.

By Travis H. Brown

When two Anesthesiologists opened the first Ambulatory Surgery Center in Phoenix, AZ in 1970, they probably had little idea they were on the verge of introducing a facility what would become a key player in the health care industry.  On Thursday, August 12, 2010, over 5,000 Ambulatory Surgery Centers (ASC) in all fifty states had the opportunity to participate in National ASC Open House Day.  This was a chance for ASC’s to open their doors to the community, policy makers, and business leaders, and show them what is becoming a cornerstone of cost effective, convenient health care.

Poplar Bluff Medical Partners, a surgery center in Southeast Missouri composed of thirty five physicians, took advantage of ASC Open House Day to show the community why their facility can provide quality care at an affordable cost.  In addition to staff conducted tours of their endoscopy suites, operating rooms, and expansive technological capabilities, they kept everyone entertained with a bounce house for kids, snow cone stand from area cheerleaders, and BBQ for all the participants.  As a Missouri contract lobbyist for the Missouri Ambulatory Surgery Center Association (MASCA), our team was excited to see elected officials take interest in the event to better understand the surgery center operations and procedures.  In attendance were U.S. Congresswoman JoAnn Emerson (R-MO), Missouri State Senator Rob Mayer (R-Dexter), and two candidates for the Missouri House of Representatives, Steve Cookson and Todd Richardson.

With our nation’s health care climate changing rapidly, it is essential that surgery centers like Poplar Bluff Medical Partners demonstrate their capabilities and choices in providing safe, effective outpatient operations.  As health care reform under Obamacare increases the number of medically insured Americans, it will become even more important for patients to utilize surgery centers that can offer cost effective alternatives with quicker turnaround time.  A 2007 study shows that Medicare and its beneficiaries pay an average of 54% more for a procedure performed in a hospital outpatient setting.  According to the US Department of Health and Human Services, ASCs saved Medicare and its beneficiaries approximately $1.7 billion dollars.   In terms of efficiency and accuracy, nearly a third of ASC’s report that 90% of their procedures start within seven minutes of when their scheduled to begin.  All surgery centers are regulated to meet specific requirements by the Center for Medicaid and Medicare Services (CMS), and all facilities in Missouri are licensed with the Missouri Department of Health and Senior Services.

In ASC Review, physician and surgery center owner Ken Pettine, MD, says “Every time I hear Obama talk on reform, it’s about quality care at lower costs.  ASCs do that the best.  They are the right entity at the right time.”  With an influx in Medicaid expansions, there will be an expected push towards cost saving opportunities.  Moreover, as hospitals continue to lose billions of dollars in reimbursements, the idea of shifting operations to an outpatient hospital setting becomes more viable and advantageous.  Ambulatory Surgery Centers are becoming the new face of patient safety in health care, and it will be important for individuals and families across the country to tour a facility and analyze the direct savings and benefits ASCs can provide.

“Advancing Surgical Care” is the name of the campaign that kicked off earlier today, says the Ambulatory Surgery Center Advocacy Committee (ASCAC), which includes the national and state ASC associations as well as representatives of all types of ASC operators and physicians.

“At a time when healthcare costs are skyrocketing and access to quality patient care is a national priority, ASCs continue to offer high-quality, patient-centered care to communities throughout the country and create a cost savings for both the individual and the health care system as a whole,” says Andrew Hayek, chair of the Ambulatory Surgery Center Advocacy Committee and president and CEO of Surgical Care Affiliates. “As an industry, we are committed to providing patients the highest quality care in the safest environment possible and are working with physicians, hospitals and other stakeholders throughout the healthcare system to ensure that we continue to advance surgical care.”

“Patients report a 92% satisfaction rate in the healthcare services they receive at ASCs throughout the country,” says Kathy Bryant, president of the ASC Association. “We are proud to come together as an industry to lead this much-needed dialogue around the care, value and superior patient outcomes associated with ASCs.”

Outpatient Surgery Magazine Staff

FROM: http://www.outpatientsurgery.net/news/2010/03/11

State Reps. Sara Gagliardi and Debbie Benefield plan to introduce legislation that would require surgical techs to register with the state’s Department of Health and Department of Regulatory Agencies (DORA). Another measure would require healthcare facilities to report by name techs that are fired or disciplined for irresponsible behavior and check the state’s database of names to make sure potential hires haven’t been flagged because of past disciplinary actions or legal troubles.

FROM: http://www.outpatientsurgery.net/news/2010/03/6

The lawmakers were motivated to act after Kristen Diane Parker, a surgical tech who stole syringes of fentanyl while working at Rose Medical Center in Denver and Audubon Surgery Center in Colorado Springs, was sentenced on Feb. 24 to 30 years in federal prison. Ms. Parker claimed to be unaware that she was infected with hepatitis C butadmitted to replacing stolen needles with used ones she had used to get high. Her actions forced about 6,000 patients to undergo testing for the incurable disease. To date, at least 18 infections have been linked to the 27-year-old former tech.

Surgical techs are the only position on the surgical team not required by Colorado law or regulations to be competent, qualified or credentialed, says Catherine Sparkman, JD, director of government affairs for the American Association of Surgical Techs. Techs are currently required to be registered in Washington state and have title protection in Illinois, she says. In Indiana, Texas, South Carolina and Tennessee, STs must be graduates of accredited surgical technology programs and certified by a nationally accredited credentialing organization.

Tech credentialing legislation has been filed in 9 states and will be initiated in several more in 2011, according to Ms. Sparkman, who supports legislation that ensures hospitals and other healthcare facilities employ only appropriately educated and certified surgical techs.

DORA, however, released a report in January that “found no evidence of widespread competency-related harm caused by surgical technologists… the current model, where employers determine the qualifications and competencies of the surgical technologists they employ, is sufficient to protect the public health, safety and welfare.”

Rep. Gagliardi says she hopes to work with DORA and representatives from Family Voices of Colorado — the grassroots organization that requested the DORA review — to help them understand that the registry is the right thing to do. A registered nurse, she expresses outrage over Ms. Parker’s violation of the trust patients put in their caregivers and says her recklessness went against everything healthcare professionals are trained to believe in: protecting patients. “The registry,” she says, “is another safety measure to let techs know we’re watching and that stealing medication is not easy to get away with.”

Daniel Cook