Rule re­vamp: Hos­pi­tals get gov­ern­ing choice

Modern Healthcare - - THE WEEK IN HEALTHCARE - Jes­sica Zig­mond

Bring­ing hos­pi­tals from the Madonna era into the Lady Gaga era is how some staff at the Amer­i­can Hospi­tal As­so­ci­a­tion re­fer to the first ma­jor up­date of Medi­care’s con­di­tions of par­tic­i­pa­tion for hos­pi­tals since 1986.

In a final rule is­sued this month, the CMS made changes to more than a dozen con­di­tions that Medi­care-en­rolled hos­pi­tals must fol­low start­ing July 16. The agency is­sued the reg­u­la­tion along with the Medi­care Reg­u­la­tory Re­form rule in re­sponse to a broad ini­tia­tive Pres­i­dent Barack Obama an­nounced last year to stream­line or elim­i­nate fed­eral reg­u­la­tions.

To­gether, the reg­u­la­tions are ex­pected to save about $1 bil­lion across the na­tion’s health­care sys­tem in the first year and more than $5 bil­lion over five years.

“Gen­er­ally, CMS does is­sue lit­tle piece­meal re­vi­sions,” said San­dra Di­varco, a part­ner at Mcder­mott Will & Emery in Chicago, re­fer­ring to the Medi­care con­di­tions of par­tic­i­pa­tion rule. “The scope of these re­vi­sions was very broad and the gov­ern­ing body changes go to the heart of the con­di­tions of par­tic­i­pa­tion be­cause the re­sult is a fun­da­men­tal re-work­ing of the gov­er­nance and over­sight mod­els CMS per­mits.”

A key change to the gov­ern­ing body con­di­tion of par­tic­i­pa­tion gives hos­pi­tals the choice to have one gov­ern­ing body over­see a mul­ti­hos­pi­tal sys­tem.

Pre­vi­ously, each hospi­tal had its own gov­ern­ing body to man­age func­tions such as cre­den­tial­ing.

The new rule pro­vides a spec­trum from which hos­pi­tals can choose sep­a­rate gov­ern­ing bod­ies, one body for the en­tire sys­tem, or some­thing in the mid­dle of those two op­tions.

Di­varco said many hos­pi­tals will likely choose the mid­dle ap­proach in which “sub­boards” at the mem­ber hos­pi­tals would over­see cer­tain el­e­ments, such as qual­ity ef­forts, but would make rec­om­men­da­tions on other mat­ters to the larger sys­tem gov­ern­ing board.

“It poses an op­por­tu­nity for mul­ti­hos­pi­tal sys­tems to eval­u­ate how they want their gov­er­nance to be struc­tured,” she said.

A rep­re­sen­ta­tive for the Joint Com­mis­sion was not avail­able for an in­ter­view, but the Oak­brook, Ill.-based ac­cred­it­ing or­ga­ni­za­tion re­sponded to the rule with a state­ment that said the changes “mir­ror the Joint Com­mis­sion’s pol­icy of al­low­ing one gov­ern­ing body to over­see mul­ti­ple hos­pi­tals in a sin­gle health sys­tem, pro­vid­ing or­ga­ni­za­tions the flex­i­bil­ity to de­ter­mine the most ef­fec­tive gov­er­nance struc­ture to suit its or­ga­ni­za­tional and busi­ness needs.”

The AHA is also pleased with the re­vi­sion, said Nancy Foster, the as­so­ci­a­tion’s vice pres­i­dent for qual­ity and pa­tient safety. But Foster said the new rule fell short in ap­ply­ing a sim­i­lar stan­dard to med­i­cal staff struc­tures.

“A num­ber of health sys­tems have very de­lib­er­ately moved to unify their med­i­cal staff, be­liev­ing they are able to bet­ter work with those staffs to en­sure high qual­ity, con­sis­tent care across the sys­tem,” Foster said, adding that an in­te­grated med­i­cal staff al­lows a mul­ti­hos­pi­tal sys­tem to cre­ate ef­fi­cien­cies in ad­min­is­tra­tive tasks such as cre­den­tial­ing and li­cen­sure. “And it en­ables them to draw on the ex­per­tise on a wider va­ri­ety of physi­cians when they’re look­ing to con­duct peer re­views, or con­sider, for in­stance, what decision sup­port they will em­bed in the elec­tronic health records.”

Last Oc­to­ber, the CMS sought com­ment on this is­sue in its pro­posed rule and noted that some stake­hold­ers re­ported that mul­ti­hos­pi­tal sys­tems have in­te­grated their gov­ern­ing body and med­i­cal staff func­tions to pro­vide care more ef­fi­ciently.

“We do not be­lieve that the cur­rent med­i­cal staff COP lan­guage im­plies that we re­quire a sin­gle and sep­a­rate med­i­cal staff for each hospi­tal within a mul­ti­hos­pi­tal sys­tem,” the pro­posed rule said. “There­fore, we have re­tained the cur­rent re­quire­ment with­out re­vi­sion.”

This has led to con­fu­sion and frus­tra­tion among hospi­tal rep­re­sen­ta­tives such as the AHA.

“In the pro­posed rule, they said they looked at this is­sue of a uni­fied med­i­cal staff along with a uni­fied gov­ern­ing board, and it was their con­clu­sion that it per­mit­ted a uni­fied med­i­cal staff,” Foster said. “In the final rule, they did not change an iota of the lan­guage, but they came back say­ing their lan­guage does not per­mit a uni­fied med­i­cal staff.”

At dead­line, a CMS of­fi­cial was not avail­able for an in­ter­view. Foster said the AHA will con­tinue to talk with CMS of­fi­cials about “the wis­dom of al­low­ing hos­pi­tals to have a uni­fied med­i­cal staff.”

The Amer­i­can Med­i­cal As­so­ci­a­tion sup­ported the agency’s decision on that point.

“We are pleased that CMS adopted nu­mer­ous AMA rec­om­men­da­tions in the final Medi­care con­di­tions of par­tic­i­pa­tion rule, in­clud­ing a re­quire­ment that there be a sin­gle med­i­cal staff for each in­di­vid­ual hospi­tal,” AMA Pres­i­dent Dr. Peter Carmel said in a state­ment. “The AMA strongly sup­ported this change from the pre­vi­ous pro­posal, which would have al­lowed a med­i­cal staff to be used over a mul­ti­hos­pi­tal sys­tem. A self-gov­erned and au­ton­o­mous med­i­cal staff at each hospi­tal is im­per­a­tive to en­sure the health and safety of pa­tients.”

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