Tuesday, April 9, 2013
Our New Lift Has Arrived in Outpatient
Over last weekend, our overhead lift was installed in our outpatient clinic at Black Oak. It should allow more options to safely treat bariatric patients and patients at high fall risk. This enhances our ability to serve patients discharged from the Inpatient Rehabilitation Center.
Saturday, April 6, 2013
Epic Go-Live 4-6-2013
3 a.m. All ready to go!
Ready to say goodbye to charts. They already seem like antiques.
4:15, still waiting. We have company from the Operations Center.
4:35 Names appear on the census. A team arrives to verify that all of our patients are listed. But still waiting.
By now, the day has begun and we dig into the nuts and bolts of working in an electronic record.
Monday, March 11, 2013
Newsletter Translation
For those who read the March Director's Notes, there was this phrase:
Goad a'michty! Ma dampt hoovercraft's breemin' ower wi bluiddy eyls!
The (loose) translation is: "My hovercraft is full of eels!"
Hope that you all find this helpful.
Goad a'michty! Ma dampt hoovercraft's breemin' ower wi bluiddy eyls!
The (loose) translation is: "My hovercraft is full of eels!"
Hope that you all find this helpful.
Wednesday, October 24, 2012
Threats to Rehab?
As the country approaches our "fiscal cliff" our representatives in Congress are searching for ways to reduce the deficit. An easy target is the portion of Medicare that goes to funding rehabilitation services. Below is the letter I have written to Senators Merkley and Wyden and Congressman Walden of Oregon.
Re: Protecting Access to Medical Rehabilitation
On behalf of Rogue Regional Medical Center (RRMC) in Medford, Oregon, I am writing to request your help in protecting patient access to medical rehabilitation care. Our inpatient rehabilitation unit (IRU) provides medically necessary, inpatient rehabilitation and therapy to patients with conditions such as strokes, neurological impairments, spinal cord injuries, and traumatic injuries that require intensive rehabilitation. Our goal is to provide rehabilitation care that gives patients the opportunity for a quick recovery and enables them to resume an active, productive lifestyle in their home, work, and community. RRMC’s Inpatient Rehabilitation Center improves patient outcomes and reduces costs by maximizing patient health and functional skills and preventing subsequent medical complications and readmissions. Ultimately the result is that we reduce the burden of care on society and the caregivers for these patients, in addition to providing a much higher quality of life to the patients themselves.
In light of the importance of medical rehabilitation, I am concerned with proposals that would: (1) impose additional reimbursement cuts on Inpatient Rehabilitation Facilities (IRFs); (2) establish site neutral payments; and (3) reinstitute the 75% Rule. I urge you to reject these proposals in any future Medicare physician fee fix or deficit reduction legislation. IRFs are not part of the health care spending and growth problems. The rehabilitation field has appropriately responded to payment changes and has kept spending flat since 2004, and growth has been negative in three of the last five years.
In addition—in the arena of outpatient rehabilitation services—I ask that Congress extend the therapy caps exceptions process permanently or at least indefinitely until CMS can implement a new payment system. Medicare beneficiaries who are recovering from conditions that require intensive therapy will not be able to receive all of the necessary therapy with the therapy caps in place.
Reimbursement Cuts
We also ask that you reject efforts to impose additional targeted market basket cuts or freezes for IRFs. Medical rehabilitation represents only a tiny portion of Medicare spending, yet IRFs have been subject to numerous payment cuts in recent years. For example, most recently, Congress enacted the Middle Class Tax Relief and Job Creation Act of 2012, which reduces Medicare bad debt payments beginning in Fiscal Year 2013. Inpatient rehabilitation hospitals and units will also be subject to a sequestration cut of up to 2 percent beginning in 2013. Additionally, the Affordable Care Act subjects IRFs, inpatient hospitals, long-term care hospitals, psychiatric hospitals and outpatient hospitals to across the board cuts and productivity adjustments totaling $156.6 billion. These hospital and outpatient payment cuts will be incurred in addition to a $4 billion cut to IRFs enacted as part of the MMSEA.
Any additional cuts will disproportionately and unfairly affect IRFs when growth or spending problems simply do not exist in the hospital rehabilitation sector. Medicare spending on rehabilitation hospitals and units has been flat since 2004, while Medicare spending on other post acute care providers has soared. Since 2003, inpatient rehabilitation hospitals and units have had the lowest Medicare spending growth of any post-acute care provider and growth has been negative in three of the last five years.
Site Neutral Payments
The President and the nursing home industry have proposed equalizing Medicare reimbursement for certain conditions regardless of whether the patient is served in a skilled nursing facility (SNF) or an IRF. This proposal ignores fundamental differences between the care provided and the outcomes achieved in IRFs as compared to SNFs.
Medicare requirements for IRFs are stringent and different from other post acute care providers. To be classified as an IRF, the hospital must have medical directors and nurses who specialize in physical medicine and rehabilitation, have 60% of admissions come from 13 specific diagnoses, and only admit patients who can sustain 3 hours of therapy a day and have the potential to meet predetermined goals. Other post-acute care providers do not share these requirements.
The proposal also fails to compare the total costs per episode of care in an IRF versus a SNF, the quality of care, and the patients’ health status at discharge. The Medicare Payment Advisory Committee (MedPAC) reports that IRF patients have an average length of stay of 13.1 days compared to SNF patients with an average length of stay of 34 days in 2009. Our unit at RRMC averages closer to 12.5 days average length of stay. According to CMS, 81.1% of IRF patients are able to be discharged home after rehabilitation compared to 45.5% of SNF patients. MedPAC reports that patients in IRFs demonstrated significantly higher Functional Independence Measure (FIM) motor scores than those in nursing homes. In short, IRFs provide superior, cost-effective care. Furthermore, SNF patients are re-admitted to acute care hospitals within 30 days at over twice the rate for IRF patients.
75% Rule
Some have proposed reinstating the 75% Rule compliance threshold for IRFs. Congress should oppose this outdated, rejected, and arbitrary policy that fails to recognize the current state of the rehabilitation field.
In 2004, CMS began phasing in regulations that would require 75% of IRF patients to have one of 13 specified conditions before the hospital or unit could qualify as an IRF for payment purposes. Congress recognized that the 75% Rule was adversely affecting access to medically necessary rehabilitation services for patients and that IRFs were forced to decline admission of patients based on their condition category rather than their clinical needs. Accordingly, Congress enacted statutory language to permanently reduce the compliance threshold to 60% in the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007. Rehabilitation hospitals and units paid for this statutory relief by agreeing to a zero percent market basket update for eighteen months.
Since that time, there has been virtually no Medicare spending growth in the rehabilitation sector, and the number of IRFs has declined. In addition, CMS adopted new, more restrictive medical necessity coverage criteria in January 2010, which has further constrained the growth of admissions to IRFs. Reinstating the 75% Rule would drastically reduce the ability of IRFs to admit clinically appropriate patients and does not take into account the challenges facing the field. Congress should not relitigate the outdated 75% Rule proposal, which was rejected overwhelmingly on a bipartisan basis by previous Congresses.
Therapy Caps Exceptions Process
Therapy caps discriminate against the oldest and sickest Medicare beneficiaries should there be no exception for patients suffering from acute conditions, such as a stroke or hip fracture, or patients with multiple rehabilitation episodes in one year. Congress has recognized the need to extend the exceptions process by including an extension most recently in the Middle Class Tax Relief and Job Creation Act of 2012, which extends the exceptions process for outpatient therapy caps through December 31, 2012. Congress should include an extension of the therapy caps exceptions process in any end of year legislation.
I will add that the current methodology of applying for and administering exceptions to the caps is cumbersome, costly, and burdensome for providers, and it is counter-productive and intimidating for Medicare beneficiaries. This system needs revision.
Conclusion
Again, thank you for considering these issues. Additional cuts to IRFs could seriously jeopardize access to care for Medicare beneficiaries and individuals with disabilities. These vulnerable populations should not be expected to shoulder unfairly the burden of offsetting the costs of the Medicare physician fee fix or deficit reduction legislation. Further, extension of the therapy caps exceptions process is critical to maintaining access to medically necessary inpatient rehabilitation care for the oldest and sickest Medicare beneficiaries.
Please feel free to contact me at if you have any questions or concerns. And please consider this an invitation to visit our unit and see for yourself the kind of services we provide for your constituents.
Sincerely,
Bob Perlson
Director, Rehabilitation Services
Rogue Regional Medical Center
Re: Protecting Access to Medical Rehabilitation
On behalf of Rogue Regional Medical Center (RRMC) in Medford, Oregon, I am writing to request your help in protecting patient access to medical rehabilitation care. Our inpatient rehabilitation unit (IRU) provides medically necessary, inpatient rehabilitation and therapy to patients with conditions such as strokes, neurological impairments, spinal cord injuries, and traumatic injuries that require intensive rehabilitation. Our goal is to provide rehabilitation care that gives patients the opportunity for a quick recovery and enables them to resume an active, productive lifestyle in their home, work, and community. RRMC’s Inpatient Rehabilitation Center improves patient outcomes and reduces costs by maximizing patient health and functional skills and preventing subsequent medical complications and readmissions. Ultimately the result is that we reduce the burden of care on society and the caregivers for these patients, in addition to providing a much higher quality of life to the patients themselves.
In light of the importance of medical rehabilitation, I am concerned with proposals that would: (1) impose additional reimbursement cuts on Inpatient Rehabilitation Facilities (IRFs); (2) establish site neutral payments; and (3) reinstitute the 75% Rule. I urge you to reject these proposals in any future Medicare physician fee fix or deficit reduction legislation. IRFs are not part of the health care spending and growth problems. The rehabilitation field has appropriately responded to payment changes and has kept spending flat since 2004, and growth has been negative in three of the last five years.
In addition—in the arena of outpatient rehabilitation services—I ask that Congress extend the therapy caps exceptions process permanently or at least indefinitely until CMS can implement a new payment system. Medicare beneficiaries who are recovering from conditions that require intensive therapy will not be able to receive all of the necessary therapy with the therapy caps in place.
Reimbursement Cuts
We also ask that you reject efforts to impose additional targeted market basket cuts or freezes for IRFs. Medical rehabilitation represents only a tiny portion of Medicare spending, yet IRFs have been subject to numerous payment cuts in recent years. For example, most recently, Congress enacted the Middle Class Tax Relief and Job Creation Act of 2012, which reduces Medicare bad debt payments beginning in Fiscal Year 2013. Inpatient rehabilitation hospitals and units will also be subject to a sequestration cut of up to 2 percent beginning in 2013. Additionally, the Affordable Care Act subjects IRFs, inpatient hospitals, long-term care hospitals, psychiatric hospitals and outpatient hospitals to across the board cuts and productivity adjustments totaling $156.6 billion. These hospital and outpatient payment cuts will be incurred in addition to a $4 billion cut to IRFs enacted as part of the MMSEA.
Any additional cuts will disproportionately and unfairly affect IRFs when growth or spending problems simply do not exist in the hospital rehabilitation sector. Medicare spending on rehabilitation hospitals and units has been flat since 2004, while Medicare spending on other post acute care providers has soared. Since 2003, inpatient rehabilitation hospitals and units have had the lowest Medicare spending growth of any post-acute care provider and growth has been negative in three of the last five years.
Site Neutral Payments
The President and the nursing home industry have proposed equalizing Medicare reimbursement for certain conditions regardless of whether the patient is served in a skilled nursing facility (SNF) or an IRF. This proposal ignores fundamental differences between the care provided and the outcomes achieved in IRFs as compared to SNFs.
Medicare requirements for IRFs are stringent and different from other post acute care providers. To be classified as an IRF, the hospital must have medical directors and nurses who specialize in physical medicine and rehabilitation, have 60% of admissions come from 13 specific diagnoses, and only admit patients who can sustain 3 hours of therapy a day and have the potential to meet predetermined goals. Other post-acute care providers do not share these requirements.
The proposal also fails to compare the total costs per episode of care in an IRF versus a SNF, the quality of care, and the patients’ health status at discharge. The Medicare Payment Advisory Committee (MedPAC) reports that IRF patients have an average length of stay of 13.1 days compared to SNF patients with an average length of stay of 34 days in 2009. Our unit at RRMC averages closer to 12.5 days average length of stay. According to CMS, 81.1% of IRF patients are able to be discharged home after rehabilitation compared to 45.5% of SNF patients. MedPAC reports that patients in IRFs demonstrated significantly higher Functional Independence Measure (FIM) motor scores than those in nursing homes. In short, IRFs provide superior, cost-effective care. Furthermore, SNF patients are re-admitted to acute care hospitals within 30 days at over twice the rate for IRF patients.
75% Rule
Some have proposed reinstating the 75% Rule compliance threshold for IRFs. Congress should oppose this outdated, rejected, and arbitrary policy that fails to recognize the current state of the rehabilitation field.
In 2004, CMS began phasing in regulations that would require 75% of IRF patients to have one of 13 specified conditions before the hospital or unit could qualify as an IRF for payment purposes. Congress recognized that the 75% Rule was adversely affecting access to medically necessary rehabilitation services for patients and that IRFs were forced to decline admission of patients based on their condition category rather than their clinical needs. Accordingly, Congress enacted statutory language to permanently reduce the compliance threshold to 60% in the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007. Rehabilitation hospitals and units paid for this statutory relief by agreeing to a zero percent market basket update for eighteen months.
Since that time, there has been virtually no Medicare spending growth in the rehabilitation sector, and the number of IRFs has declined. In addition, CMS adopted new, more restrictive medical necessity coverage criteria in January 2010, which has further constrained the growth of admissions to IRFs. Reinstating the 75% Rule would drastically reduce the ability of IRFs to admit clinically appropriate patients and does not take into account the challenges facing the field. Congress should not relitigate the outdated 75% Rule proposal, which was rejected overwhelmingly on a bipartisan basis by previous Congresses.
Therapy Caps Exceptions Process
Therapy caps discriminate against the oldest and sickest Medicare beneficiaries should there be no exception for patients suffering from acute conditions, such as a stroke or hip fracture, or patients with multiple rehabilitation episodes in one year. Congress has recognized the need to extend the exceptions process by including an extension most recently in the Middle Class Tax Relief and Job Creation Act of 2012, which extends the exceptions process for outpatient therapy caps through December 31, 2012. Congress should include an extension of the therapy caps exceptions process in any end of year legislation.
I will add that the current methodology of applying for and administering exceptions to the caps is cumbersome, costly, and burdensome for providers, and it is counter-productive and intimidating for Medicare beneficiaries. This system needs revision.
Conclusion
Again, thank you for considering these issues. Additional cuts to IRFs could seriously jeopardize access to care for Medicare beneficiaries and individuals with disabilities. These vulnerable populations should not be expected to shoulder unfairly the burden of offsetting the costs of the Medicare physician fee fix or deficit reduction legislation. Further, extension of the therapy caps exceptions process is critical to maintaining access to medically necessary inpatient rehabilitation care for the oldest and sickest Medicare beneficiaries.
Please feel free to contact me at if you have any questions or concerns. And please consider this an invitation to visit our unit and see for yourself the kind of services we provide for your constituents.
Sincerely,
Bob Perlson
Director, Rehabilitation Services
Rogue Regional Medical Center
Wednesday, August 1, 2012
RRMC Celebrates HealthGrades Award
Today we celebrated with speeches and cake the fact that Healthgrades (an independent source of healthcare quality assessment) has rated Rogue Regional Medical Center the #1 orthopedic hospital in Oregon, and one of the top 100 such hospitals in the country. Not only is this honor a reflection on the outstanding commitment and teamwork of everyone who has a role in the program, but it also translates into a much safer patient experience with far fewer complications than lower-graded hospitals experience.
Congratulations for our staff for this amazing accomplishment, which spans for up to 6 years for some of the award categories.
- Posted using BlogPress from my iPhone
Congratulations for our staff for this amazing accomplishment, which spans for up to 6 years for some of the award categories.
- Posted using BlogPress from my iPhone
Wednesday, July 25, 2012
Fair Warning
I consider myself very computer literate, and very cautious about computer security. But today I had a 15 second brain freeze: I got an email from "the help desk" asking me to confirm my user name because they were updating. I clicked on the link, and entered my user name, hit "enter" and the web screen closed with a thank-you.
I swallowed my pride and immediately called our help desk, who confirmed I'd been duped. In all likelihood my computer was infected with some sort of code to steal passwords or other information. I was told to turn off the computer immediately, and that I'd be hearing back from someone soon. "Soon" was about 20 minutes later when two of our fine computer techs showed up at my office. One of whom pretty much made it known that, well, I hadn't used my head. The next thing that I know, my CPU and hard drive are being escorted out the door to be jailed, examined, cleansed and otherwise invaded for a few days.
My mistake should be your learning moment: Do not open links from unknown sources. Do not provide passwords or similar information to anybody (the help desk does not need that stuff!), and if you do make a mistake, call the help desk immediately; if there might be a delay in calling, shut off the computer until you get in touch with them.
I swallowed my pride and immediately called our help desk, who confirmed I'd been duped. In all likelihood my computer was infected with some sort of code to steal passwords or other information. I was told to turn off the computer immediately, and that I'd be hearing back from someone soon. "Soon" was about 20 minutes later when two of our fine computer techs showed up at my office. One of whom pretty much made it known that, well, I hadn't used my head. The next thing that I know, my CPU and hard drive are being escorted out the door to be jailed, examined, cleansed and otherwise invaded for a few days.
Thursday, July 19, 2012
Hospital Updates
It’s budget time again here at Asante
When I prepare the budget I ask myself: Will the changes result in more, or less, quality? And: Will the changes add or subtract value from our communities?
When I used to participate in interviews of Speech Pathologist candidates, one of our staff had a very interesting question that he’d ask them: “If you are asked to choose between high productivity and high quality, which would you choose?” It’s really a trick question because the two choices are not mutually exclusive. In fact, from the customer’s viewpoint—those who pay our bills—higher productivity is likely to be seen as higher quality. If a customer sees waste and then gets a bill and makes the connecton between the charges and the waste, they would not feel that we deliver quality.
What are the indicators of quality? I look for the following key indicators: (1) Safety: We do not harm anybody. (2) Patient satisfaction. (3) High performance of our outcomes compared to benchmarks.
What is an indication of value? Value is really a sum of quality (safety, satisfaction and outcomes) compared to cost. If cost goes up without an increase in quality, then value goes down.
I’ll give you a value story: Last winter I stayed for an extended stay in a particular motel. In making up my mind which motel I’d would be staying in, my deciding factors for choosing this particular facility was that it was the newest motel in the area and it offered free meals at both breakfast and dinner. It also had a spa. All of this, with a competitive price, made it seem like a higher value than the other nearby motels. However, I noticed as I stayed there that the dinner meals tended towards the red-meat, or fried, or bacon-laced varieties. In other words, not what I considered healthy or even something I would eat. So it turned out that the free dinner had little value for me. And I also noticed that the motel made no efforts to be “green.” There was no in-room recycling bin, and the spa pump seemed to run continuously. A wasteful facility! Plus I noticed my first night there that the grab bar in the bathtub was loose and posed a risk. I informed the front desk, and they asked me, “do you want us to fix it?” Hello? The final straw on the safety issue was that the sidewalks in the morning were poorly lit and there were tree branches hanging over the walks that I had to dodge, and there was black ice that was not de-iced. Clearly a hazard. It is interesting that what I turned out valuing was a little different that what I thought I would value. Things that I took for granted (safety, healthy food, environmental consciousness) were not part of this facility’s quality consciousness.
I could go on about how this wonderful new facility let me down in the value category, but at the end of the day I will not go back, I will not recommend it to friends, and I posted a review on TripAdvisor that’s been read over 500 times. Who knows how much business they’ve lost. (I have to admit that bacon-lovers might actually gravitate to the place after reading my review.)
As a hospital, we’re under the same sort of scrutiny. Not only does the government rate our performance against quality benchmarks, but our patients click away on their computers to share their experiences. Our industry expects that—in terms of reimbursement—these are the good ol’ days; it will get tougher to achieve a bottom line that allows us to invest our “profits” in new technology, buildings, and so forth. How do we continue to deliver better value and better quality on tighter budgets? The answer is that we don’t yet know, but we know that we must. And we also know that the answers will come from all levels of the organization, not just the “top.”
---
Speaking of adding value: The Inpatient Rehabilitation Center (IRC) is about to complete its fifth year of operation. Have we added value by adding this service line? I’ll provide some data points below, and you can decide.
ü Outcomes are generally better than our comparison group of regional rehab facilities.
o Discharges to community are 2.15% higher than benchmark
o Patients are admitted to the IRC 4.15 days earlier from date of onset than benchmark
o Average length of stay is .59 days shorter
o FIM change per day (rate of functional improvement) is 25% greater than benchmark
o Total functional improvement of our patients is 9.2% higher than benchmark.
o The rate of discharge back to an acute facility is 35% of the benchmark rate.
ü Our market share of inpatient rehab discharges in this county now stands at 63% and is slowly growing.
ü A significant number of our patients are employees or family members of employees of Asante
ü Acute patients are generally admitted much more quickly than they would have been prior to establishment of the facility. We are also able to admit and treat patients with problematic payment sources, outright charity, or whose discharge plans who might otherwise have made them difficult placements at other facilities.
ü We’ve also treated some high profile cases that have brought positive publicity to Asante
ü Financially, the unit continues to be a contributor to the RVMC bottom line so that we can offer a full range of services at Asante
By those measures, I believe we are delivering great quality and value to the community. I see cards, letters, and Values In Action submissions that tell me we show outstanding compassion to our patients and families. This unit is part of Asante ’s Mission
Thanks and congratulations to all who work on the unit, those who help cover when workload or staffing fluctuate, those who work in the background to assure the unit is supplied, cleaned and that the billing processes work. Truly, this is a team effort and there is not enough praise to touch on what a jewel this is!
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