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AHA again attacks HHS OIG compliance reviews


The American Hospital Association (AHA) has again complained to the Centers for Medicare & Medicaid Services about “serious problems’’ with the hospital-compliance reviews by the Office of the Inspector General (OIG) of the Department of Health & Human Services.

AHA complained last week that the audits routinely include “fundamental flaws and inaccuracies, both in the OIG’s understanding and application of Medicare payment rules and in the procedures the OIG uses to conduct the audits.” The hospital trade organization asserted that this causes very overstated repayment demands, undermines hospitals’ reputations and steals time and resources from patient care.

The association added that the audits can lead to uneven and unfair application of Medicare payment rules. It notes that some hospitals aren’t audited and the appeals process operates inconsistently

Healthcare Dive noted that: “This is not a new issue for hospitals. In a June 2014 letter to then-HHS Secretary Kathleen Sebelius, the AHA called for an immediate halt to the audits, saying the OIG’s findings and estimated payments were incorrect and ‘entirely redundant.’ A recent uptick in penalties for alleged reimbursement fraud and abuse has galvanized hospitals to again press for audit reforms.

“AHA says OIG’s tendency to extrapolate its findings to all claims in an audit period is aggravating the problem of overall flawed reports.’’

The news service speculated: “The AHA may be hoping HHS scales back the review process altogether, which would not be particularly surprising with the pressure in President Donald Trump’s administration to roll back regulatory burden. Recently, the CMS said it will take a more targeted approach in some areas to finding and investigating Medicare fraud and improper payments. It will focus on providers whose claim error rates or unusual billing practices stand out compared to similar providers.’’

“But while hospitals call for reforms in the OIG compliance reviews, a recent Wall Street Journal report raised serious concerns about hospital safety. Reviewing hundreds of Joint Commission inspection reports, the Journal found about 350 hospitals that maintained accreditation in 2014 despite Medicare violations. More than a third of those had additional deviations in 2015 and 2016.’’

To read more, please hit this link.



No consensus on defining a high-performing health system


Perhaps surprisingly, a study published by the Joint Commission found no consensus on what constitutes a high-performing health system.

To read the Joint Commission’s report, please hit this link.

Researchers funded by the Agency for Healthcare Research and Quality reviewed 57 articles and other studies published between 2005 and 2015 in search of a widely accepted definition  for high-performance. Instead, they found no consistent results.

But some  of the more common criteria were:

About 75 percent of the studies in the review used more than one factor to rate performance, but just five used five or more factors in defining/describing high performance.

The authors wrote: “The absence of a consistent definition of what constitutes high performance and how to measure it hinders our ability to compare and reward healthcare delivery systems on performance, underscoring the need to develop a consistent definition of high performance.”

To read the Joint Commission’s report, please hit this link.

Joint Commission officers criticize federal outcomes-measures system


A study in the Annals of Internal Medicine says that few medical-outcome measures being used or considered for federal accountability programs are adequate. Of 10 measures analyzed using four key criteria, only three fulfilled all criteria, and half of the measures met   one or no criteria.

David W, Baker, M.D., the Joint Commission’s executive vice president, and Mark R. Chassin, M.D., president and CEO of the Joint Commssion, wrote: “During the past few years, federal public reporting and payment programs have focused less on measuring processes and more on measuring outcomes, such as readmission, health care-associated infections, and mortality. [O]utcome measures must be chosen carefully to ensure that the outcomes can be influenced by providers and that differences in outcomes are attributable to disparities in the care provided rather than the result of variations in the populations of patients seen.”

As part of their conclusion, they write:

“The [National Quality Forum’s] seminal work in this area is driving the field forward to a better understanding of how best to structure patient-reported outcome measures, capture meaningful information for patients as well as providers, and lay a solid foundation for the use of these measures for accountability. Given the critical importance of these measures, we need to rapidly explore and adapt to novel methods to capture the patient voice, including the use of computer-adapted technology.”


“We believe that the gold standard for assessing a risk-adjustment methodology is to compare the risk factors in the model with the true prognostic factors for the outcome that have been identified in detailed clinical epidemiology studies.”

To read the Annals piece, please hit this link.


‘Lean methodologies overrated’?


Front entrance of Virginia Mason’s main building.

A Seattle hospital system has  long been taking a “systems approach” in improving healthcare quality and cutting costs, looking to emulate some of Toyota’s practices.

Virginia Mason Health System has been lauded as being an exemplar of “Lean” methodology, based on eliminating waste and focusing on always adding more value.

But a blogger for Med Page Today who (rather timidly) uses the nom de plume of “Skeptical Scalpel” says Lean may be grossly overrated. He/she writes:

“Attempts to incorporate Lean into healthcare have met with varying degrees of success. I blogged about this 6 years ago and pointed out that a literature review done back then found ‘significant gaps in the [Lean and Six Sigma] healthcare quality improvement literature and very weak evidence that [Lean and Six Sigma] improve healthcare quality.’

Randomized prospective trials of Lean in medicine are lacking. A recent “paper from the Journal of the American College of Radiology found only seven studies on the use of Lean in radiology and they showed ‘high rates of systematic bias and imprecision.’ The authors concluded there was ‘a pressing need to conduct high-quality studies in order to realize the true potential of these quality improvement methodologies [Lean and Six Sigma] in healthcare and radiology.’

“In 2010, Toyota had recalled more than 9 million vehicles for various defects. Nothing has improved. So far this year, Toyota has recalled over 11,654,000 vehicles….”

“Having adopted Lean methodology in 2002, Virginia Mason is not really a new story. How is it doing?

“About as well as Toyota.

“In May of this year, the Joint Commission paid a surprise visit to Virginia Mason Medical Center and found 29 instances where the hospital was out of compliance with standards. The Seattle Times wrote that among the problems were not having an adequate infection prevention and control plan, failure to store medication safely, and failure to provide a ‘care, treatment, services and an environment that pose[d] no risk of an immediate threat to health or safety.”‘


“{I}f Lean works so well in healthcare, can anyone tell me: how does a hospital that has been practicing Lean methodology for 14 years achieve 29 Joint Commission citations?”

To read the whole blog entry, please hit this link.


Virginia Mason gets back accreditation



Virginia Mason Medical Center.

The Joint Commission has given full accreditation back to Seattle’s Virginia Mason Medical Center four months after it failed to comply with standards set for U.S. hospitals.

On Sept. 17, the  commission upgraded the hospital’s status Sept. 17 from contingent to full accreditation after a site visit Sept. 16.

Unannounced Joint Commission visits  found that Virginia Mason was out of compliance in 29 areas, ranging from conducting fire drills and reducing risk of infection from medical equipment to providing an environment with no risk of  ‘immediate threat to life.”’ The last, of course, sounded quite ominous.

To read the whole story from The Seattle Times, please hit this link.

Anthem plans to offer incentives for integrated-care certification


Anthem Blue Cross and Blue Shield plans in Ohio and 13 other states have become the nation’s first health-insurance plans to offer providers incentives for obtaining integrated-care certification (ICC) from the Joint Commission, Healthcare Dive reports.

“The certification will help Anthem meet its care coordination measure under its Quality-In-Sights hospital incentive program, its performance-based reimbursement program for hospitals,” the news service reported.

So far only one Florida hospital, Parrish Medical Center, has attained integrated-care certification from the Joint Commission. “Anthem hopes its recognition of the standard will prompt hospitals to do so,” Healthcare Dive said.

The decision is part of a broader effort by CMS to reimburse based on quality, not quantity of procedures. Among CMS’s initiatives is a proposed bundled- payment model for heart attacks and bypass surgeries, with a demonstration project to be launched at 98 sites next year.

“The Joint Commission launched the ICC a year ago to recognize providers that excel at communication, information sharing and other behaviors aimed at creating a seamless experience for the patient across multiple healthcare settings,” Healthcare Dive reported.

To read the whole article, please hit this link.



What to do after a ‘Never Event’


According to a new report by Leapfrog, one in five hospitals don’t have a good system for dealing with hospital events that should never happen, such as wrong-site surgeries, objects left inside patients after surgery, deaths from medication errors or death or serious injuries from falls.

Leapfrog says that the response to such “Never Events” should include:

  • “Apologizing to the patient and/or family.”
  • Reporting the event to an outside agency “within 10 days of becoming aware that the event has occurred.”
  • “Performing a root-cause analysis. To identify the cause of the error and prevent future occurrences, hospitals must formally investigate the circumstances contributing to a Never Event. This requirement is in line with other national policies such as the one specified by The Joint Commission’s hospital accreditation program.”
  • Waiving “costs directly related to the Never Event. Hospitals must review these cases to determine which costs are attributable to the Never Event, and waive those costs so that neither the patient nor payer is billed.’’
  • “Making a copy of the policy available to patients, patients’ family members, and payers upon request.”


To read the full report, please hit this link.



Problems in Kaiser Permanente home-care programs

An independent audit  has found more than two dozen problems in Kaiser Permanente’s home-care programs in Oregon, including issues tracking patient medication, reports The (Portland) Oregonian.

The paper reported that “The programs serve 750 patients who need hospice or other care at home. Three-quarters of them are on Medicare, a program that Kaiser touts as the best in the Northwest.

{T}he Joint Commission, which did the audit and which is the main healthcare accrediting organization, told Kaiser to follow up with an intensive series of additional audits. “The commission will watch providers care for patients again this month or next.”

For more details, please hit this link.

Physicians group urges review of pain-management standards


A group of physicians urge the Joint Commission and the CMS to end policies that the group says can lead to opioid overprescribing and addiction.  The action came as the nation tries to deal with the opioid epidemic.
Signatories asked the Joint Commission to re-examine its Pain Management Standards — which once helped push the idea of pain as the “fifth vital sign” — and asked the  CMS to get rid of patient-satisfaction questions about pain from its reimbursement procedures.

The letters were sent by Physicians for Responsible Opioid Prescribing (PROP), other medical and consumer groups and by senior health officials from Pennsylvania, Vermont, Alaska and Rhode Island.


Hospitals may face new disaster-preparation mandate


A proposed new federal regulation may substantially affect how hospitals must prepare for emergencies.

Among its provisions:

*Many healthcare providers would be compelled to make preparations for major emergencies (such as weather disasters or epidemics)  as a condition for getting Medicare and Medicaid reimbursement. Current federal rules don’t require even minimal preparations for such disasters.

*Providers  covered by the proposed rule would have to conduct regular disaster drills, plan for maintaining services during power failures and create systems to track and care for displaced patients.

Ashley Thompson, a senior vice president at the American Hospital Association, told The New York Times  that the AHA generally agrees with the proposal, but wants Medicare to align its requirements with crisis-preparedness standards developed by such other bodies as the Joint Commission.


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