Smaller providers worry they can’t meet CMS’ out­pa­tient re­vi­sions

Modern Healthcare - - News - Jen­nifer Lubell

Crit­i­cal-ac­cess hos­pi­tals at odds with su­per­vi­sion plan

As the CMS con­tin­ues to tinker with its pol­icy re­gard­ing physi­cian su­per­vi­sion of ser­vices be­ing pro­vided in hos­pi­tal out­pa­tient de­part­ments, smaller providers say they may not have the man­power to com­ply with the lat­est re­vi­sions.

Hos­pi­tal com­ments on the agency’s pro­posed 2011 hos­pi­tal out­pa­tient re­im­burse­ment rule, due early this week, homed in on the agency’s pol­icy on physi­cian su­per­vi­sion of hos­pi­tal out­pa­tient ther­a­peu­tic ser­vices. Hos­pi­tal in­dus­try rep­re­sen­ta­tives are wor­ried that the CMS wants to re­quire more su­per­vi­sion than what they be­lieve is prac­ti­cal. The com­ment pe­riod is sched­uled to end Aug. 31.

The “di­rect su­per­vi­sion re­quire­ment” was first in­tro­duced in the 2009 out­pa­tient rule, call­ing for physi­cians to be phys­i­cally present in the out­pa­tient depart­ment of a hos­pi­tal at all times when out­pa­tient ther­a­peu­tic ser­vices were pro­vided. Al­though the agency has since re­laxed these pro­vi­sions, al­low­ing prac­ti­tion­ers who aren’t physi­cians to take on these su­per­vi­sory roles, new lan­guage in the 2011 pro­posed rule has hos­pi­tal ex­ec­u­tives concerned.

No mat­ter how the CMS tweaks this, crit­i­calac­cess hos­pi­tals are go­ing to strug­gle with it, said Gale Walker, pres­i­dent and CEO of Avera St. Bene­dict Health Cen­ter, Park­ston, S.D. Based on what the agency is plan­ning, the hos­pi­tal will need to hire at least four more mi­dlevel prac­ti­tion­ers or physi­cians to com­ply with the ev­er­chang­ing re­quire­ment, which would cost the hos­pi­tal at least $400,000 an­nu­ally.

The re­al­ity is, “in ru­ral South Dakota we don’t have that kind of per­son­nel,” said Walker, who planned to visit CMS of­fi­cials this week in Washington to dis­cuss the pro­vi­sion. “We’re go­ing to lay out sce­nar­ios to them, telling them that this is not prac­ti­cal.”

Specif­i­cally, the CMS iden­ti­fied a set of 16 non­sur­gi­cal ex­tended du­ra­tion ther­a­peu­tic ser­vices—from ob­ser­va­tion ser­vices to IV hy­dra­tion—and pro­posed a “hy­brid” model of su­per­vi­sion, said Roslyne Schul­man, the Amer­i­can Hos­pi­tal As­so­ci­a­tion’s se­nior as­so­ci­ate di­rec­tor for pol­icy devel­op­ment. Un­der the 2010 rule, all out­pa­tient ther­a­peu­tic ser­vices re­quire di­rect su­per­vi­sion. But there are vary­ing de­grees of su­per­vi­sion in the out­pa­tient set­ting for di­ag­nos­tic ser­vices, in­clud­ing: di­rect su­per­vi­sion, which re­quires the physi­cian or non­physi­cian prac­ti­tioner to be on the premises and be im­me­di­ately avail­able when the pa­tient re­ceives treat­ment, and gen­eral su­per­vi­sion, which means the ser­vices pro­vided are still un­der the prac­ti­tioner’s over­all di­rec­tion and con­trol, but the prac­ti­tioner’s pres­ence is not re­quired.

Un­der the lat­est pro­posed re­vi­sion, the 16 “non­sur­gi­cal ex­tended du­ra­tion ther­a­peu­tic ser­vices” would re­quire di­rect su­per­vi­sion for the ini­ti­a­tion por­tion of the ser­vice fol­lowed by gen­eral su­per­vi­sion once the pa­tient has been sta­bi­lized. But “you still have to have a physi­cian or non­physi­cian prac­ti­tioner present for the ini­tial ob­ser­va­tion” of a pa­tient for these 16 spe­cific ser­vices, Schul­man ex­plained.

The CMS in the rule-mak­ing ex­plained that it was propos­ing this amend­ment to of­fer more flex­i­bil­ity to hos­pi­tals in meet­ing the di­rect su­per­vi­sion re­quire­ment with­out com­pro­mis­ing pa­tient safety and qual­ity. Ru­ral or crit­i­cal-ac­cess hos­pi­tals in com­mu­ni­ties with a short­age of health pro­fes­sion­als, how­ever, may find this a tall or­der to com­ply with, Schul­man said.

Crit­i­cal-ac­cess hos­pi­tals had got­ten a re­prieve from the di­rect su­per­vi­sion re­quire­ment only for 2010, but en­force­ment will start up again in 2011 un­less the re­prieve is ex­tended.

From a re­im­burse­ment stand­point, “this means the ser­vice won’t be cov­ered (un­der Medi­care) un­less a doc­tor is right there at the be­gin­ning,” Schul­man said. Many physi­cians, es­pe­cially those with pri­vate prac­tices out­side of a hos­pi­tal cam­pus, not to men­tion nurse prac­ti­tion­ers and physi­cian’s as­sis­tants, aren’t go­ing to be able or will­ing to ded­i­cate their en­tire day at the hos­pi­tal’s out­pa­tient depart­ment di­rectly su­per­vis­ing pa­tients, Schul­man added.

Crit­i­cal-ac­cess hos­pi­tals and other small and ru­ral fa­cil­i­ties will be able to fur­nish a su­per­vi­sory fig­ure in 30 min­utes, “but not 24-7,” she con­tin­ued.

Com­pli­ance will be much eas­ier for ur­ban hos­pi­tals that have the full-time staff, in­clud­ing ra­di­ol­o­gists, hos­pi­tal­ists, res­i­dents and other peo­ple to step in to these su­per­vi­sory roles, said Terry Mills, who heads the fam­ily medicine depart­ment at the Wi­chita Clinic, in Newton, Kan. Even if the CMS is say­ing the pa­tient doesn’t have to be su­per­vised for the en­tire round of treat­ment, just at the out­set, “all of that is split­ting hairs for no con­se­quences. If there are not enough peo­ple there or in­volved in other crit­i­cal roles, the hos­pi­tal still won’t meet that re­quire­ment,” he said.

En­forc­ing such a pro­vi­sion may be la­bor­in­ten­sive, but that’s the kind of thing that the CMS’ new Re­cov­ery Au­dit Contractors, which get paid a con­tin­gency fee for re­cov­er­ing im­proper pay­ments, will be look­ing at, Schul­man said.

Even with the threat of an au­dit hang­ing over­head, some hos­pi­tals are strug­gling just to com­ply with the cur­rent re­quire­ments on physi­cian su­per­vi­sion. “I can tell you there are not many hos­pi­tals that are ap­ply­ing the rule right now,” said Felix Aguirre, vice pres­i­dent of med­i­cal af­fairs at IPC: The Hos­pi­tal­ist Co., head­quar­tered in Hollywood, Calif. In the AHA’s view, the CMS should take a step back, look at all out­pa­tient ther­a­peu­tic ser­vices on a broader scale, with com­ment from physi­cians who prac­tice in ur­ban and ru­ral hos­pi­tal out­pa­tient de­part­ments, and fig­ure out which ones need di­rect or gen­eral su­per­vi­sion.

Some hos­pi­tals say they don’t have enough per­son­nel to com­ply with the pro­posed rule.

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