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

Register here.

The two physicians in the General Assembly, Sen. Rob Schaaf (R-St. Joseph) and Rep. Keith Frederick (R-Rolla), are teaming up on an effort to ensure providers can be fairly reimbursed for the cost and labor used to retrieve medical records.  The House Health Care Policy Committee heard HB 580 this week, which allows providers to charge a fee for medical records that are stored at an off-site location.  Amendments are being drafted to cap the fee at $30 and increase other fees for copying and postage to adjust for inflation.  Under current law, providers can charge up to $17.67 for copying and costs of labor or supplies.  Sen. Schaaf has identical legislation in the Senate under SB 62, which was voted out of committee on February 22^nd.

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.

Senator Rob Schaaf (R-St. Joseph) has filed Senate Bill 153 to increase transparency in health care costs through the utilization of web-based systems.  This bill would require health carriers to establish web-based estimation systems so consumers can have better access to certain procedures.  Specifically, under RSMo Chapter 376.475, Section 1, the language states “The estimates shall include related estimates of typically needed and expected ancillary costs such as those for radiology, pathology, or anesthesiology services, and shall indicate when no contracted providers of such services are available under the individual’s benefit plan at a selected health care facility or provider.”

Rep. Jeanne Kirkton (D-St. Louis) filed the Prompt Credentialing Act on Thursday, which requires health carriers a 60 calendar window to credential physicians.  This year’s bill is HB 347, and includes bi-partisan support with House Speaker Steven Tilley (R-Perryville) as the primary co-sponsor.  The next step is committee referral, which could happen as early as next week.  See the full bill text HERE.

New Requirements for Surgical Technologists in ASCs:

By:  David M Jackson

Senator Dan Brown (R-Rolla) introduced Senate Bill 178 this week, which amends RSMo Chapter 334 and adds a new section relating to requirements in surgical technology in a health care facility.  Under this proposed legislation, no personnel shall practice as a surgical technologist without completing an accredited educational program for surgical technologists and holds and maintains the Certified Surgical Technologist credential administered by the National Board of Surgical Technology and Surgical Assisting.  Surgical technologists are waved from that requirement if they were trained in the armed forces or can provide evidence that they were employed to practice prior to August 28^th, 2011.  Please read HERE for the full legislation and more requirements related to surgical technologists.  Please contact our team with any concerns you may have about this legislation and the impact it could have on your Ambulatory Surgery Center.

www.pelopidas.com

FROM URL:  http://www.npr.org/2011/01/18/132937232/accountable-care-organizations-explained

Accountable Care Organizations, Explained

by JENNY GOLD

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January 18, 2011

As the House begins debate today on an effort to repeal the health care law, we took a closer look at one of the provisions of the law that health care providers are talking about the most — accountable care organizations.

ACOs take up only seven pages of the massive new health law but the idea has providers buzzing. ACOs are a new model for delivering health services that offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs. A cottage industry of consultants has sprung up to help even ordinary hospitals become the first ACOs on the block.

Yet the concept is still short on details. ACOs have been compared to the  unicorn: Everyone seems to know what it looks like, but nobody’s actually seen one. Exactly how ACOs would work in practice remains to be seen, though that hasn’t stopped the health care industry from embarking on a frenzied quest to create them as quickly as possible. The Centers for Medicare & Medicaid Services is expected to release detailed rules on ACOs within a few weeks.

Here is a brief guide to what we know about ACOs so far.

What is an accountable care organization?

An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. Under the new law, ACOs would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.

Think of it as buying a television, says Harold Miller, president and CEO of the Network for Regional Healthcare Improvement and executive director of the Center for Healthcare Quality & Payment Reform in Pittsburgh. A TV manufacturer like Sony may contract with many suppliers to build sets. Like Sony does for TVs, Miller says, an ACO would bring together the different component parts of care for the patient – primary care, specialists, hospitals, home health care, etc. – and ensure that all of the “parts work well together.”

The problem today, Miller says, is that patients are getting each part of their health care separately. “People want to buy individual circuit boards, not a whole TV,” he says. “If we can show them that the TV works better, maybe they’ll buy it,” rather than assembling a patchwork of services themselves. “But ACOs will need to prove that the overall health care product they’re creating does work better and costs less in order to encourage patients and payers to buy it.”

When will ACOs begin operating?

The ACO initiative is scheduled to launch in January 2012, but the race to form ACOs has already begun. Hospitals, physician practices and insurers across the country, from New Hampshire to Arizona, are announcing their plans to form ACOs, not only for Medicare beneficiaries but for patients with private insurance as well. Some groups have already created what they call ACOs.

Why did Congress include ACOs in the law?

As lawmakers search for ways to reduce the national deficit, Medicare is a prime target. With baby boomers entering retirement age, the costs of the program for elderly and disabled Americans are expected to soar.

ACOs would make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work they’d have to seamlessly share information. Those that save money while also meeting quality targets would keep a portion of the savings.

The Congressional Budget Office estimates that ACOs could save Medicare at least $4.9 billion through 2019. That’d be far less than one percent of Medicare spending during that period, but if the program is successful it can be expanded by the Secretary of Health and Human Services.

How would ACOs be paid?

In Medicare’s traditional fee-for-service payment system, doctors and hospitals generally are paid more when they give patients more tests and do more procedures. That drives up costs, experts say. ACOs wouldn’t do away with fee for service but would create savings incentives by offering bonuses when providers keep costs down and meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers would get paid more for keeping their patients healthy and out of the hospital.

If an ACO is not able to save money, it would be stuck with the costs of investments made to improve care, such as adding new nurse care managers, but would still get to keep the standard Medicare fees. The law also gives regulators the ability to devise other payment methods, which would likely ask ACOs to bear more risk. For example, an ACO could be paid a flat fee for each patient it cares for.

How will an ACO be different for patients?

Patients may not even know that they are part of an ACO. Although doctors will want to refer patients to hospitals and specialists within the ACO network, patients will still be free to see doctors of their choice outside the network.ACOs also will be under pressure to provide high quality care because if they don’t meet standards, they won’t receive savings bonuses – and could lose their contracts.

Who’s in charge — hospitals, doctors or insurers?

Hospitals, doctors and insurers are all vying to run ACOs. Kelly Devers, a senior fellow at the nonprofit Urban Institute, explains that the question was left purposely vague in order to be flexible. “We know there are a range of provider organizations” that could manage an ACO, “but we don’t know which one is superior.”

Some regions of the country, including parts of California, already have large multi-specialty physician groups that may become an ACO on their own, likely by networking with neighboring hospitals. “A lot of health care organizations are going to dust off the existing structures they had in place” in the past, Devers says.

In other regions, large hospital systems are scrambling to buy up physician practices with the goal of becoming ACOs that directly employ the majority of their providers. Because hospitals usually have access to capital, they may have an easier time than doctors in financing the initial investment required by an ACO.

Some of the largest health insurers in the country, including Humana, United Healthcare and Cigna, already have announced plans to form their own ACOs. Insurers say they can play an important role in ACOs because they track and collect data on patients, which is critical for coordinating care and reporting on the results.

If I don’t like HMOs, why should I consider an ACO?

ACOs may sound a lot like health maintenance organizations. “Some people say ACOs are HMOs in drag,” says Devers. But there are some critical differences – notably, an ACO patient is not required to stay in the network.

Steve Lieberman, a visiting scholar at the Engelberg Center for Health Care Reform at the Brookings Institution and the president of Lieberman Consulting Inc., explains that ACOs aim to replicate “the performance of an HMO” in holding down the cost of care while avoiding “the structural features that give the HMO control over [patient] referral patterns,” which limited patient options and created a consumer backlash in the 1990s.

What can go wrong?

Lieberman cautions that ACOs are not a panacea. “ACO has become the three-letter health acronym of the year, if not the decade,” he says. The health industry tends to operate with “kind of a herd behavior,” rushing to implement an idea “without working through the detailed business questions of how they’ll work.”

Many health care economists fear that the race to form ACOs could have a significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs.

But Lieberman says while ACOs could accelerate consolidations, it’s already “such a powerful and pervasive trend that it’s a little like worrying about the calories I get when I eat the maraschino cherry on top of my hot fudge sundae. It’s a serious public policy issue with or without ACOs.”

Are there any possible legal concerns?

Doctors, hospitals and others in the health care industry have raised concerns that ACOs could run afoul of antitrust and anti-fraud laws, which try to limit market power that drives up prices and stifles competition. One concern is that ACOs, particularly those in rural markets, could grow so large that they would employ the majority of providers in a region.

To help providers avoid legal problems, the Federal Trade Commission says it is trying to clarify antitrust guidelines for ACOs, and the U.S. Justice Department’s antitrust division has offered to provide an expedited antitrust review process for ACOs.

This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn’t affiliated with Kaiser Permanente.