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Is your hospital a member? Click here to find out. In this issue:
CMA ON-CALL Throughout this publication, you will find references to "CMA On-Call" documents. On-Call is an online library that contains over 4,500 pages of medical-legal, regulatory, and reimbursement information. On-Call documents are available free to individual CMA members at the members-only website. Nonmembers can purchase On-Call documents for $2 per page in the CMA bookstore. OMSS members can also contact Samantha Pellon at 916/551-2872 or spellon@cmanet.org to obtain a copy of these documents.
More Hospital-Based Physicians Eligible for Medicare and Medicaid EHR Incentives On April 15, President Obama signed HR 4851, the Continuing Extension Act of 2010. In addition to postponing the 21 percent Medicare sustainable growth rate cut and extending COBRA and unemployment benefits, this bill made an important clarification regarding the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The Stimulus Act excluded "hospital-based" physicians from receiving EHR incentives from either Medicare or Medicaid. The bill defined "hospital-based" as meaning that the physician provided most of their treatment in the hospital, regardless of any employment or billing arrangement. The thought behind this exclusion was that all of the physicians in a hospital would be on the system set up by the facility. In practice, however, many hospital systems only cover inpatient and emergency rooms. This left physicians in hospital-based clinics in a difficult position. They did not qualify for direct incentives, but the hospital system did not include their practice. In hospital settings, the incentive would flow to the institution, not the physician. HR 4851 changes the definition of "hospital-based" physician for purposes of the Medicare and Medicaid EHR incentive programs. Specifically, it limits the definition of "hospital-based" physician to those who practice in inpatient or emergency room settings. This small but important change will allow physicians in hospital-based clinics, to access direct incentive payments. It is likely that there will be further clarification on the definition of "hospital-based" in the final Meaningful Use definition to be released next month. This change in the legislative language will allow for that final rule to more accurately reflect the realities of physician practices. MORE INFORMATION: Visit the CMA HIT resource page.
CMA Policy on Low and No-Volume Physician Privileging Approved The CMA Board of Trustees recently approved an interim policy that establishes guidelines for granting medical staff membership and clinical privileges to low- and no-volume physicians. The policy was adopted in response to a 2009 CMA House of Delegates (HOD) resolution that directs CMA to "study the privileging process and report back with recommendations on establishing guidelines for privileging 'low- and no-volume' physicians." The policy recommends that medical staffs consider methodologies and standards that address safely credentialing and privileging "low- and no-volume" physicians and provide opportunities for these physicians to participate in medical staff governance. This policy will need to be approved by the CMA HOD meeting in October 2010. The policy was developed to address the growing concern that the number of physicians who have shifted their practice of medicine from hospitals toward their private office and outpatient facilities has been steadily increasing. Although some believe that the reason for the shift is primarily economic—physicians have consciously decided to increase patient volume and practice revenue by providing care in lower-cost health care settings such as their offices and outpatient clinics—the reality is much more complicated. Growth in the number of hospitalists, improved technology to provide more procedures on an outpatient basis, and increased specialization among physicians have all contributed to the shift away from hospital-based practice. The new policy recognizes the priorities for privileging low- and no-volume providers will vary significantly depending on hospital size, availability of specialists, physician demographics, and local culture and practices. Rather than dictating a specific policy that should be adopted by all medical staffs, the new policy provides guidelines that medical staffs should consider in developing their own privileging policies. TAKE ACTION: Medical staffs should review their existing policy on privileging low- and no-volume physicians to determine if it reflects the needs and priorities of the medical staff and the community. MORE INFORMATION: Read the interim CMA policy on privileging low- and no-volume physicians.
New Physician Signage Regulations Take Effect 6/27 California physicians will soon be required to inform their patients that they are licensed by the Medical Board of California, and to provide patients with the board's contact information. Despite CMA objections, the Office of Administrative Law recently approved these regulations, which are intended to let consumers know where to go for information on or with complaints about California medical doctors. The new regulations, which take effect June 27, 2010, require physicians to provide this notice by one of three methods: Prominently posting a sign in an area of their offices that is conspicuous to patients, in at least 48-point type in Arial font. Including the notice in a written statement, signed and dated by the patient or patient's representative, and kept in that patient's file, stating the patient understands the physician is licensed and regulated by the board. Including the notice in a statement on letterhead, discharge instructions, or other document given to a patient or the patient's representative; the notice must be placed immediately above the patient's signature line in at least 14-point type. Regardless of which method you choose, the notice must read as follows: NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California, (800) 633-2322, www.mbc.ca.gov. According to the medical board, physicians, not facilities, are responsible for compliance with this regulation. This means physicians must make sure, regardless of practice setting, that they are in compliance. This regulation applies to every location where medicine is practiced by a physician in California, including hospitals, nursing homes, medical clinics, outpatient facilities, urgent care centers, etc. This regulation applies to all physicians, including those in hospital-based practices that do not see patients in their own offices (ex. radiology, anesthesiology, hospitalists, emergency medicine, etc.) If physicians practicing in a hospital choose to comply using the signage option, they will need to work with the hospital to determine where the sign should be posted. According to the medical board, in hospitals and multi-level clinics, posting in a conspicuous place on each floor where patients are likely to see it would suffice. If physicians practicing in a hospital choose one of the other options, they may need to work with the hospital administration to ensure that the required notice statement is added to discharge papers or other forms that are provided to patients. Medical staffs can assist these physicians by working with the hospital to ensure physician compliance with the regulations. TAKE ACTION: Although physicians, not facilities, are responsible for ensuring compliance with these regulations, the most effective way for hospital-based physicians to comply will be to work with the hospital to post the notice in public areas of the hospital or to have the notice printed on hospital discharge papers. Medical staffs can assist members in hospital-based practices by advocating that the notice be posted on each floor of the hospital or that the required notice is added to hospital discharge or other forms that are given to patients. MORE INFORMATION: Visit the Medical Board regulations website.
California Interpretation of Emergency Transfer Laws More Restrictive than Feds The California Department of Public Health (CDPH) is interpreting California's emergency transfer laws to prohibit on-call physicians from sending their representatives (such as physician assistants) to the emergency department unless the physician has examined the patient there first. This interpretation is contrary to that of the federal government (EMTALA), which expressly allows the activity. While CMA disagrees with the CDPH interpretation, unless this issue is clarified, CMA believes the safest approach is for physicians to refrain from sending in representatives in situations where the physician has not first examined the patient. TAKE ACTION: Medical staffs should review On-Call document #1216, "Emergency Transfer Laws: Medical Staff and On-Call Requirements" and educate physicians regarding their on-call responsibilities. MORE INFORMATION: Also relevant to this issue is On-Call document #1214, "Payment to Secure Availability of On-Call Services."
Joint Commission Approves New Medical Staff Standard On March 18, the Joint Commission announced that it approved revisions to medical staff standard MS.01.01.01 (formerly MS1.20) that are designed to improve patient safety. While CMA did raise some objections, we believe that the new standard is a vast improvement over the previous standard. The revised standard, which took effect March 31, strengthens medical staff self-governance through increased transparency, communications, and accountability. For example, the Introduction to the new standard recognizes the vital role of the medical executive committee plays, stating that it "serves as a voice for the medical staff to communicate to the governing body, and is, therefore, accountable to the organized medical staff, regardless of how" the committee is selected. This standard will be surveyed for compliance beginning April 1, 2011. As the new standard is fully consistent with CMA policy, CMA Model Medical Staff Bylaws (2010) already are complaint, though amendments will be considered for the 2011 edition that further strengthen the right to self-governance. TAKE ACTION: Physicians and medical staffs who wish to have input into any proposed future amendments are urged to e-mail medstaffhelp@cmanet.org. MORE INFORMATION: Visit the Joint Commission website on MS 01.01.01.
Federal Health Reform Impacts Medical Staffs On March 21, the House of Representatives voted to approve the Senate health care reform bill, the Patient Protection and Affordable Care Act (HR 3590) by a vote of 219-212. President Obama signed the bill on Tuesday, March 23, and it became Public Law 111-148. The Senate and House then passed the Health Care and Education Affordability Reconciliation Act (HR 4872), a negotiated set of changes to HR 3590 (P.L. 111-148,) by a vote of 56- 43 and 220-211 respectively. The Reconciliation Act passed both houses on March 25 and was signed by President Obama on March 30. This law marks the largest overhaul of the American health care system since the passage of Medicare in 1965. The legislation begins to address significant concerns resulting from a growing population of uninsured and underinsured Americans, increasing health care costs, insurance industry abuses, and other barriers to access health care. In addition to its much-touted impact on the uninsured, HR 3590 also addresses a wide range of other health care issues including a number of provisions that will significantly impact hospitals, medical staffs and the overall delivery of patient care within hospitals. NEW PAYMENT MODELS With respect to the delivery of hospital services, this law establishes several demonstration and pilot projects designed to provide incentives for hospitals and physicians to work collaboratively to provide high quality care and efficient service delivery. Participating hospitals will be expected to agree to various bundled payment models and meet certain criteria for managing patient care. Linking Payment to Quality Outcomes in Medicare A value-based purchasing program for hospitals will launch in FY2013. This program will link Medicare payments to quality performance on common, high-cost conditions such as cardiac, surgical, and pneumonia care. The Physician Quality Reporting Initiative (PQRI) is extended through 2014, with incentives for physicians to report Medicare quality data. Participating physicians will receive feedback reports beginning in 2012. Long-term care hospitals, inpatient rehabilitation facilities, and hospice providers will participate in value-based purchasing with quality measure reporting starting in FY2014, with penalties for non-participating providers. (Section 3001) Hospital Value-Based Purchasing Program Provides a Medicare value-based purchasing incentive payment to any hospital that meets specific performance standards (tied to measurements) established by the Secretary of Health and Human Services. Under this program, a percentage of a hospital's Medicare payment would be tied to hospital performance on quality measures related to common and high-cost conditions. A hospital could be ineligible for incentive payments if that hospital in a particular fiscal year receives a payment reduction (due, for example, to hospital acquired conditions or excess readmissions); is found to have quality deficiencies; does not have enough relevant performance measures; or does not meet the necessary caseload threshold. For the first year, value-based incentive payments would rely on five measures tied to acute myocardial infarction, heart failure, pneumonia, surgeries, and health care-associated infections. The program may start on or after October 1, 2012. Demonstration Project to Evaluate Integrated Care Around a Hospitalization Establishes a federal Health and Human Services demonstration project for up to eight states to evaluate the use of bundled payments for the provision of integrated care for a Medicare beneficiary with respect to an episode of care that includes a hospitalization and for concurrent physician services provided during that hospitalization. The demonstration begins January 1, 2012, and ends December 31, 2016. (Section 2703) Medicare Shared Savings Program Creates a shared savings program by January 1, 2012, to promote accountability for a patient population, coordinate items and services under Parts A and B, and encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery. Under this program, groups of providers and suppliers meeting certain criteria may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through Accountable Care Organizations (ACOs.) ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings. (Section 3022) Pediatric Accountable Care Organization Demonstration Project Creates a four year demonstration project that begins in 2012 and ends in 2016. Specified pediatric medical care providers could be recognized as ACOs and become eligible to receive incentive payments equal to a portion of the amount of excess savings. (Section 2706) National Pilot Program on Payment Bundling Establishes a pilot program to encourage hospitals, physicians, and other providers to improve the coordination, quality, and efficiency of health care services – and save money – through bundled payment models. Acute care inpatient services, physician services (in and outside an acute care hospital), outpatient services (including emergency care), post-acute care services (including home health, skilled nursing facility, inpatient rehabilitation, and inpatient hospital services provided by a long-term care hospital) will be included in the pilot program, which will begin January 1, 2013, and run five years. It will focus on up to 10 conditions selected by the Secretary of Health and Human Services. The Secretary will submit a plan to Congress by January 1, 2016, to expand the pilot program, if doing so will improve patient care and reduce spending. The Secretary may at any point after January 1, 2016, expand the duration and scope of the pilot program if it is determined that the expansion is expected to reduce spending without reducing the quality of care, if it is certified by the Centers for Medicare and Medicaid Services (CMS) Chief Actuary that such an expansion would reduce program spending, and if the expansion does not deny or limit the coverage or provision of benefits. The pilot program will separately test the continuing care hospital model using certain criteria. (Sections 3023 as amended by Section 10308) Medicaid Global Payment System Demonstration Project Establishes a demonstration project from FY 2010-2012, in coordination with a new Centers for Medicare and Medicare Innovation, that will allow up to five states to adjust their current payment structure for safety net hospitals (or networks) from a fee-for-service model to a global capitated payment structure. (Section 2705) Extension of Gainsharing Demonstration The gainsharing demonstration project established by the Deficit Reduction Act of 2005 is extended until September 30, 2011. The gainsharing demonstration provides for up to six demonstration projects to test and evaluate methodologies and arrangements between hospitals and physicians designed to govern the utilization of inpatient hospital resources and physician work to improve the quality and efficiency of care provided to beneficiaries and to develop improved operational and financial hospital performance with sharing of gains as specified in the project. A final report is due to Congress by September 30, 2012. (Section 3027) PAYMENT REDUCTIONS AND PENALTIES In addition to testing new payment models, the law imposes a series of payment reductions and penalties related to a projected decrease in the number of uninsured patients seeking care in hospitals and penalties for excess hospital-acquired conditions and readmissions. Disproportionate Share Hospital Payments Disproportionate share hospital (DSH) payments provide financial assistance to hospitals that serve a large number of low-income patients, such as people with Medicaid coverage and the uninsured. Medicaid DSH payments are the largest source of federal funding for uncompensated hospital care. Starting in FY 2014, a hospital's Medicare DSH payment will be reduced to reflect expected lower uncompensated care costs relative to increases in the number of insured. States' DSH allotments will be reduced by 50 percent once a state's uninsurance rate decreases by 45 percent (low DSH states would receive a 25 percent reduction). As the rate continues to decline, states' DSH allotments would be reduced by a corresponding amount. At no time could a state's allotment be reduced by more than 65 percent compared to its FY2012 allotment. The new law also requires the Secretary of Health and Human Services to adjust Medicare DSH payments to reflect a hospital's uncompensated care costs. The Secretary will pay 25 percent of an empirically justified amount, as established by the Medical Payment Advisory Commission (MedPAC). The other piece of the Medicare DSH payment reflects the product of three factors: 1) aggregate payments made to hospitals before/after passage of legislation, 2) percentage change in percent of uninsured individuals under 65, and 3) the percent of uncompensated care for a hospital as compared to all hospitals. Hospital-Acquired Conditions Includes new penalties for hospitals related to hospital-acquired conditions (HACs) and excess readmissions. Beginning in FY2015, a 1 percent penalty will be added to hospitals in the top quartile of HAC rates, resulting in overall hospital payment reductions of $1.5 billion over 10 years. Excess Readmissions Reduces Medicare inpatient hospital payments – starting in FY 2012 – on the dollar value of each hospital's percentage of potentially preventable Medicare readmissions measures identified by the National Quality Forum: heart attack, heart failure, and pneumonia. Beginning in FY 2015, the program will be expanded to include four additional measures recommended by the Medical Payment Advisory Commission (MedPAC): acute myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and other vascular issues, as well as others recommended by the Secretary of Health and Human Services. The Secretary would be required to define the time period for how hospital readmissions (post discharge) are defined. TAKE ACTION: Medical staffs should be aware that with these reform efforts, they will face new challenges. As discussed, many of the payment reforms relate to quality of care and it is essential that the medical staff be involved in the preparation of clinical protocals and approves any and all clinical protocols that are implemented to assure that patients are adequately protected. Further, many of these reforms will likely increase further interest in physician-hospital alignments and, consistent with CMA Model Medical Staff bylaws, it is critical that the medical staff be actively involved in the review and approval of any contracts to ensure the provision of quality of care in the hospital. MORE INFORMATION: Visit CMA's Federal Health Reform page.
CMA Revises Bylaws to Strengthen Medical Staff Self Governance Mechanisms Physicians throughout California have been extremely concerned about the potential lack of self-governance of their medical staffs and have asked for specific guidance as to how they can regain that right in order to protect patient care. While CMA had already done much in the way of promoting self-governance, CMA's 2009 House of Delegates, by adopting numerous amendments to the CMA Model Medical Staff Bylaws, has provided medical staffs with additional mechanisms to achieve it. Significant amendments are summarized below. A. Meaningful Elections for Officers of the Medical Staff (Section 9.1-3) To meet its professional obligation to govern itself, medical staffs must have the ability to truly select and remove their own leadership. Because questions have arisen as to whether the slate of officers presented to the medical staffs are truly representative, or whether the slate consists of persons who are more aligned with the hospital itself, new bylaws have been added making the nominations process more transparent. B. Bylaws Committee (Sections 11.11-1 and 11.11-2) Medical staff bylaws go to the heart of self-governance. They define the rights and responsibilities of the medical staff vis-à-vis the hospital board and the administration, and they are an enforceable agreement between those parties that is vital to the ability of the medical staff to protect patient care. Given the importance of the bylaws committee, the CMA Model Medical Staff Bylaws now recommend that at least some of the members be elected by the medical staff itself and that their duties be enhanced to include appropriate oversight over the medical staff's ability to be self-governing. C. Chairship of the Joint Conference Committee. (Section 11.5-1) To ensure consistency and the utility of this committee, the model bylaws now provide that the chair alternate every other meeting so that both parties in the Joint Conference Committee have equal control. Further, it is also recommended that the chair representing the medical staff not have a financial relationship with the hospital to ensure objectivity. D. Medical Staff Representation to the Board. (Section 9.4) The model bylaws have been expanded to include the entire hospital system and to ensure that hospitals not be the entity that appoints medical staff members to serve on the Board. E. Increased Transparency. (Sections 11.3-3, 12.1-1, 12.1-2, 12.1-3, 12.2-1, 12.4-1, 12.4-2, and 12.5) CMA has received a number of complaints from medical staff members that they are unable to access important medical staff information concerning, for example, how MEC members voted on non-confidential matters of interest to the medical staff, proposals to amend the bylaws, rules or regulations, budgetary information, etc. Others have complained that they have not received this information in a timely fashion. While CMA believes that peer review and other protected information should remain confidential, the CMA House of Delegates adopted a number of mechanisms to make medical staff operations more transparent and accountable and therefore representative. Areas that are addressed include: Ensuring agendas and supporting materials are distributed sufficiently in advance of the meeting; Ensuring that medical staff members have sufficient notification; Ensuring that medical staff members have an opportunity to request that items are placed on the agenda; Ensuring that medical staff members have an opportunity to review documents prior to voting upon/considering them; Ensuring transparency concerning proposals; Allowing for electronic voting, as provided by the Bylaws; Providing for the ability of members to participate at a meeting by electronic or telephonic means; Requiring that minutes include the names of those with potential conflicts of interest, and that all minutes be available to any medical staff member upon request (with the exception of matters discussed in executive session); Requiring that the records of MEC meetings note whether and how each member of the MEC voted on matters that do not raise peer review or other sensitive issues. F. Medical Staff Dues-Oversight. (Sections 9.2-4 and 14.2-1) One of the tenets of SB 1325, California's medical staff self-governance law, is that the right of self-governance includes assessing medical staff dues and utilizing them as appropriate for the purposes of the medical staff. Physicians have questioned whether medical staff funds are being appropriately utilized for medical staff purposes and how much funding the medical staff actually has for the purposes of securing independent legal counsel. To ensure transparency and accountability over medical staff funds, the model bylaws require that there be a required medical staff budget and accounting concerning medical staff funds, which is prepared on a quarterly basis. This accounting should be available to any medical staff member upon request. G. Rules and Regulations (and Hospital Policies). (Sections 14.1 and 15.5) Concerns have been expressed that rules and regulations that infringe upon core self-governance issues are being adopted without the full vote of the medical staff. To ensure that medical staffs themselves are able to vote upon and understand the rules concerning their rights to self-governance, rules and regulations should be limited to procedural details only implementing the bylaws. Further, it should be clear that any hospital policy that infringes on medical staff self-governance shall not apply. H. Increased Oversight. 1. Self-Governance Ombudsman. (Section 9.5) Under most medical staff bylaws, there is no formal structure to ensure that the medical staff is truly self-governing. To remedy this, the model bylaws provides that the bylaws committee be given additional duties with respect to evaluating self-governance issues. Further, vesting within the OMSS representative on the medical staff, "ombudsman" type responsibilities could be beneficial to both the medical staff and to the OMSS in general. 2. Increased Oversight over the Attorney (Section 14.11) The model bylaws now require that the medical staff attorney provide written assurances to the medical staff that he/she is in fact independent and with no divided loyalty. I. Medical Staff Contracts Committee. (Deletion of Sections 14.9 and 14.9-1 and addition of Sections 11.18 – 11.18-3) CMA policy already recognizes the medical staff role with respect to hospital contracts with physicians, both on an exclusive and non-exclusive basis. The model bylaws now provide that there should be a subcommittee or committee of the medical staff that is formally organized to review such contracts. Further, the two bylaw provisions regarding the medical staff's role were consolidated. J. Resource Allocation Committee. (Addition of Sections 11.19 – 11.19-7) Medical staffs should also have involvement in the strategic planning within the hospital in areas that will impact the functioning of the self-governing medical staff. K. Increase Capital/Participation. (Section 14.2) A medical staff whose members actively participate will be more likely to be self-governing. To increase participation, it is recommended that medical staffs use sliding scale dues assessment, depending on the level of member participation. L. Potential Conflicts of Interest. (Sections 2.2, 2.3, 7.3-5, 9.1-2, 9.1-4, 10.6-1, 10.6-2, 10.7-1, 10.7-2, 11.1, 11.2-4, 14.6, 14.6-1, 14.6-2, 14.6-3, 14.6-4 and 14.6-5) An important component of protecting medical staff self-governance is ensuring that there are appropriate conflict of interest rules and disclosures to ensure elections are fair and other decision-making is in the best interest of the medical staff. Because physicians involved in leadership committees and roles are chosen for their expertise and leadership abilities, they often have personal, financial, or other outside interests that can affect or be affected by decisions concerning the medical staff. These interests must not undermine their primary allegiance to the medical staff and quality of care. Accordingly, it is essential that medical staffs adopt appropriate conflict of interest and disclosure rules as provided in the model bylaws. M. Disruptive Behavior Code of Conduct (Article 2.7) While the Joint Commission requirements obligate hospitals to establish a "code of conduct" for all persons working in the hospital, consistent with California law requiring that medical staffs be self-governing, this issue must be addressed by the medical staffs, and should be in the bylaws themselves so that they are adopted by the medical staff itself and enforceable. CMA's code of conduct ensures that medical staffs are in the position to undertake action against medical staff members whose conduct jeopardizes patient safety. N. Ongoing Professional Practice Evaluation (Sections 2.5, 6.1, 6.2, 6.2-1, 6.2-3, and 6.2-4) CMA's Model Medical Staff Bylaws have been revised to more fully incorporate the Joint Commission standard and provide other clarifications concerning peer review. TAKE ACTION: Medical staffs should review the revisions in the Model Medical Staff Bylaws to determine if additional amendments need to be made to their own bylaws. MORE INFORMATION: CMA's Annotated Model Medical Staff Bylaws are available in electronic or hard copy format. CMA's Annotated Model Medical Staff Bylaws are available to the public and nonmembers in hardcopy format for $1000. OMSS-member medical staffs receive a free copy of the bylaws in electronic format, sent directly to the OMSS physician representative. Hardcopies for the OMSS-member medical staff's Bylaws Committee and/or the MEC are available on request. Applicable county tax and shipping is added to all orders. To order, call CMA at (800) 786-4282 or visit our online bookstore.
OMSS Medical Staff Operations Survey At the request of OMSS member medical staffs, CMA has developed a survey to gather information about the current structure and practices of medical staffs. It is designed to primarily cover issues related to medical staff financial and legal practices. This information will be disseminated to OMSS members to provide a snapshot of current medical staff administrative and governance practices. We will also use this information to identify areas in which CMA can provide additional resources to medical staffs. We would appreciate participation from all OMSS member medical staffs. Thank you for taking time to provide information for this baseline report of medical staff structures and practices. TAKE ACTION: Take the 2010 CMA-OMSS Medical Staff Survey. |
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