Happy Holidays!

I want to wish all Case Managers a wonderful Holiday Season and a prosperous 2009!

Be on the lookout for changes to the blog and more promotion in 2009 to drive more activity to the site. We have enjoyed some good readership but now want to make this a more interactive and beneficial tool for all Case Managers.

Have ideas? Submit them to me at az.casemanagement.jobguy@gmail.com or sathornley@gmail.com

Be safe!

Steve

Article: Gap between public, private reimbursement raises coverage costs.

Health Insurers Protest $88.8 Billion ‘Hidden Tax’

Dec. 9 (Bloomberg) -- Employers and private health insurers pay a “hidden tax” of $88.8 billion each year because government programs fail to pay enough to doctors and hospitals, an industry-sponsored study found.
Inadequate reimbursements by programs such as Medicare and Medicaid increase the annual cost of covering a family of four by $1,788, according to the report, issued today by the actuarial consulting firm Milliman Inc. At hospitals, the payment gap between private and public insurance has more than doubled in 10 years, the Seattle-based firm said.

TO VIEW THE REST OF THIS ARTICLE-CLICK HERE:
http://www.bloomberg.com/apps/news?pid=20601203&sid=aeGBzglj2iyY&refer=insurance

Very applicable article for Arizona's Nurse Shortage and the Economy!

Economy may be tanking, but hospitals still hiring nurses

Amy C. Rippel Special to the Sentinel
November 22, 2008

When Mary Clark decided to relocate from Arkansas to Central Florida, she wasn't worried about the move. It was finding the perfect nursing job that was a concern.With about 13 years of experience as a registered nurse, Clark has had her share of good job-search experiences and bad ones. She applied at four hospitals in Lake County. But when the recruiters at Leesburg Regional Medical Center went all-out during the application process, Clark said she knew it was a perfect fit.During a time when companies are downsizing and cutting costs, some local hospitals are hiring nurses by the dozens.The Villages Regional Hospital and Leesburg Regional, together called Central Florida Health Alliance, recently hired 64 nurses during a two-month span. Florida Hospital Waterman in Tavares has hired about 130 nurses since January.

To read the rest of this article, click here:
http://www.orlandosentinel.com/news/local/lake/orl-lnursing2208nov22,0,280756.story

Happy Thanksgiving and Stories Wanted!

Hello Arizona Case Managers! I wanted to wish everyone a Happy Thanksgiving this week! 2008 has certainly flown by and soon we will be entering a brand new year!

Speaking of Thanksgiving and knowing we are all in the health care field in some fashion, I thought it would be interesting to share some of the interesting, heart warming stories that we would all like to hear around this time of year. Case Managers seem to have some good ones, whether recent or not, we would like to hear about them and share them on this blog. So whether it was a particular situation working with a patient or family member or even a fellow provider or practitioner, please share your stories. Feel free to email them to me at sathornley@gmail.com or just post them as a comment to this post and I will republish the best ones!

Thanks so much and I hope everyone has a safe and happy Holiday!

-Steve

Article: New U.S. Rule Pares Outpatient Medicaid Services

New U.S. Rule Pares Outpatient Medicaid Services

By ROBERT PEAR
Published: November 7, 2008

WASHINGTON — In the first of an expected avalanche of post-election regulations, the Bush administration on Friday narrowed the scope of services that can be provided to poor people under Medicaid’s outpatient hospital benefit.

TO VIEW THE REST OF THIS ARTICLE CLICK HERE:
http://www.nytimes.com/2008/11/08/washington/08regs.html?_r=1&ref=health&oref=slogin

Article: Health Insurers Prime for New Business With Democratic Rule

Health Insurers Prime for New Business With Democratic Rule

Health insurers are priming themselves to gain new business from policy changes likely to be approved with Democrats in control of Washington.

Democrats are expected to expand federal programs that cover low-income children and adults, groups that insurers are increasingly contracted to administer via private Medicaid plans. More funding for those programs could offset further cuts of government reimbursement made to private Medicare plans, for which the industry has been bracing. Other moves to reduce the number of uninsured also could boost the individual insurance market, which insurers also have been expanding into.

TO VIEW THE REST OF THIS ARTICLE, CLICK HERE:
http://online.wsj.com/article/SB122593755004203961.html?mod=dist_smartbrief

Harvard Study: US Hospitals lag in patient satisfaction.

U.S. Hospitals Lag in Patient Satisfaction10.28.08, 8:00 PM ET

WEDNESDAY, Oct. 29 (HealthDay News) -- Patients in many U.S. hospitals are not satisfied with their care, Harvard researchers report.

In the first national survey of patients' experiences, many hospitals were found wanting in key areas such as pain management and discharge instructions. In fact, almost one-third of patients gave low ratings to pain management, and one-fifth gave low ratings to communication at discharge.

"These data represent a sea change for the health-care system," said study author Dr. Ashish K. Jha, an assistant professor for health policy at the Harvard School of Public Health. "Until now, we have had no high-quality information about how patients perceive the care they receive."
"Even though we spend $2 trillion on health care, you would think that things like always managing patients' pain in the hospital is something we would have gotten right by now," Jha said.

TO VIEW THE REST OF THIS ARTICLE, CLICK HERE:
http://www.forbes.com/forbeslife/health/feeds/hscout/2008/10/29/hscout620778.html

Article: A nurse case manager who puts others first

A Nurse Case Manager who puts others first.
Helping cardiac patients plan how to live, or choose how to die

When Janice Tully began nursing school more than 30 years ago, it was almost by default. Her sister was a nurse, she excelled at science, and she didn't know what other professions to consider. Besides, it seemed like a good fit.

Today, it would be difficult to imagine Tully as anything but a nurse. She's made the rounds as staff nurse at a number of institutions, from Beth Israel to the Visiting Nurse Association, eventually settling into her current position at Massachusetts General Hospital (MGH), where she is a cardiac case manager, a highly qualified specialist.

TO VIEW THE REST OF THE ARTICLE, CLICK HERE:
http://www.boston.com/jobs/salute/2008/janice_tully/?s_campaign=8315

Article: Study: Seniors not quite embracing generic drugs

By MATTHEW PERRONE – 12 hours ago

WASHINGTON (AP) — Seniors who switch between low-cost generic drugs and the original products based on who's footing the bill are likely driving up the cost of the government's Medicare drug plan, according to a new study.
Figures released Thursday show seniors are more likely to ask their pharmacist for generic medications when they are paying, but choose the more expensive originals when the government is covering the costs.
The study was published by Medco Health Solutions Inc., a drug benefit manager that handles prescriptions for about 20 percent of Americans. Prescription benefit managers earn more money when patients choose cheaper medications.

To view the rest of this article click here: http://ap.google.com/article/ALeqM5gxR61zVknBOPh6vu62nvCwGh8e1QD93DH41O0

InPatient Case Manager Jobs on the rise! Experienced Nurses Needed Now!

Case Management jobs are on the rise in Phoenix. Many openings for experienced Case Managers in the Hospital Setting. Please see info on the right and click the link for more info!
Refer your friends!

Steve

What a great conference!

This years CMSA Conference at the Tempe Buttes Resort was outstanding! As usual, the leadership team of CMSA Arizona did a wonderful job putting together a wonderful conference and I was able to meet many of the great Case Managers here in Arizona. This chapter really sets the standard for others to live up to!

I am sure that next years conference will be even better! And next year we will have the national CMSA conference here as well!

Kudo's again to Laura and the entire CMSA AZ leadership team for a job well done!

For those that couldnt make it, make sure to put this on your to do list for 2009!

The Countdown is on! ONLY FOUR DAYS!

Four more days until the annual CMSA-AZ Fall Conference at the Buttes Resort in Tempe!

I hope to see you all there! Come visit me at the PrimeStaff booth!- For more information on the conference, go to:

cmsaaz.com

Winning at RACS: The Best Defense Is The Best Offense

Winning at RACS: The Best Defense Is The Best Offense

By Randi Ferrare
for the Arizona Case Management Blog
September 2, 2008

In order to ward off the 40-45% denial rates that the CMS RAC Audit showed in the demonstration project, it is imperative that hospitals make changes to better control the utilization of services and improve medical documentation while the patients are still hospitalized.

There are some basic strategies to better your chances of not having the hospital stay denied. Most denials were because of either inpatient hospital stay was not medically necessary or services could have been performed as an outpatient. Basically, these two denial reasons mean the same and therefore can be avoided utilizing the same concurrent strategies:

1. Lower Patient Caseloads for Case Manager and Social Workers
2. Review Medicare Patients for Inpatient Criteria Daily
3. Emergency Department Case Management
4. Implement a Clinical Documentation Program


Case Manager Caseloads

What is an appropriate caseload for a Case Manager? 20-25 patients per Case Manager WAS the answer until the RAC Audits. However, that is for a “traditional” CM model, where the Case Manager performs utilization review, resource utilization, some discharge planning and basically manages the case through admission to discharge. However, the above ratio was for a payor mix of Managed Care and Medicare. Medicare patients, in the past, did not need daily review and to be scrutinized for meeting inpatient criteria for each day in the hospital. There was no accountability or reporting of these cases. In today’s environment, 15- 20 patients per Case Manager would be ideal.

Daily Medicare Utilization Review/Discharge Planning

As stated above, Medicare patients were not and still are not reviewed each day mainly because there was no reason or urgency to move them along the care continuum. Times have changed. Medicare patients should be treated no differently than a managed care patient. There is a real possibility that the RAC Audit will do a retrospective medical record review and deny the entire inpatient stay for not meeting inpatient medical necessity. Case Managers can no longer put the Medicare inpatient reviews to the bottom of their priority lists- they are just as important to review and case manage to the next appropriate level of care as quickly and as cost-effectively as the patients with managed care.


ED Case Management

If your hospital does not have an Emergency Department Case Manager, you need to get one fast! ER Case Management is your hospital’s weapon to keep inappropriate admissions (inpatients or Observation patients) out of the hospital if they don’t meet criteria. These specially trained Case Managers are part of the ER team and can assist the ER physicians by assessing the needs of the patient, applying admission criteria, utilizing their clinical judgment and utilize their discharge planning expertise to assist the ER Physician with the most appropriate disposition if admission to the hospital is not an option. Without this vital role, the influx of inappropriate admissions, whether full inpatient admissions or “Observation”, can only be addressed once they are on the patient floors in a bed. And by then it may be too late, you may already have admitted someone whom the hospital stay will be denied thusly costing your hospital thousands of dollars in lost revenues.

Clinical Documentation

Performed by either a specially trained Case Manager or a Clinical Documentation Specialist, clinical documentation involves reviewing the concurrent inpatient medical record for accurate and complete physician documentation that reflects the whole picture of the patient. The chart should show how sick the patient is; their co-morbidities, complications, resources, tests and treatments are being used to make the patient well. The significance of capturing this information, in the form of physician documentation is that when the medical record goes to coding for billing, the coders are only allowed to code what the physician actually documented. The ramifications and consequences of not having complete and accurate physician documentation in the medical record has taken clinical documentation from an unknown process to the latest healthcare strategy largely due to the resulting increased reimbursements, higher case mix indexes, and more accurate severity of illness.

Switch to ICD-10 should prove very costly!

Switch to ICD-10 should prove very costly

By anne
Created Aug 27 2008 - 4:11am

Providers are far from done in their struggles to implement the new National Provider Identifier number, which has proved to be every bit as troublesome as the industry predicted. But apparently, HHS was determined to raise the angst level further. With its recent announcement that it was pushing for an October 2011 deadline for the industry to switch from ICD-9-CM to ICD-10 codes, health organizations are bracing themselves for millions in additional IT and operational expenses.ICD-9-CM codes, which are used for electronic claims processing, remittance, advice, eligibility inquiries, referral authorizations and more, have been in place for 30 years, but most other developed nations around the world use ICD-10 codes. The new code set will allow clinical IT systems to record far more specific and rich diagnostic information than ICD-9 codes, as it contains more than 155,000 codes, while ICD-9 contains only 17,000.As the switch occurs, brace yourself for reimbursement nightmares. HHS admits that the switch--like the NPI cutover--could initially cause significant cash flow problems for providers because of the increased risk of payment hold-ups due to coding and systems problems. HHS is predicting that claims-error rates will rise between 6 and 10 percent, up from a normal 3 percent rate typically seen for annual updates of ICD-9. (If NPI experience is any indication, that's probably a pretty conservative error estimate--so expect significantly worse cash holdups than HHS is predicting.)Meanwhile, as readers know, such a switch will prove to be immensely complex, not to mention quite costly, on the IT front. While estimates vary from one consulting firm to another, HHS estimates the cost of the switch at $1.64 billion industry-wide, including $356 million in training costs, lost productivity costs of $572 million and system change costs of $713 million.

Great press about CASE MANAGERS!

Wall Street Journal

Aid From Unlikely Sources

By JILIAN MINCER
August 24, 2008

When a serious medical crisis occurs, your insurance company may provide more than hospital coverage.

A growing number of plans offer specially trained case managers to help patients during a major illness.

Different from disease-management programs, which focus on patients with a chronic condition such as asthma or diabetes, the case-management services are for patients with costly and complex medical conditions such as cancer or an organ transplant. These managers -- typically nurses -- help patients with everything from avoiding duplicated tests to finding the best-priced prescriptions and other services.

(CLICK BELOW FOR THE REST OF THIS ARTICLE): http://online.wsj.com/article/SB121954162768766735.html?mod=dist_smartbrief

AHCCCS Numbers Jump

Arizona's Medicaid population has grown by 56,500 people over the last 12 months.
The number of enrollees in the Arizona Health Care Cost Containment System, the state's Medicaid health care program, stands at 1.12 million, up 5 percent from August 2007. That comprises nearly 18 percent of the state's 6.3 million residents. Another 1 million Arizonans do not have health insurance, according to St. Luke's Health Initiatives.
Sixteen percent of Maricopa County's 3.8 million residents are enrolled in AHCCCS.

2nd Article in RACS Series!

RACS and Case Management: Medicare Patients Can’t Be Pushed to the Bottom of your Priority List Anymore

August 15, 2008
By Randi Ferrare
for the Arizona Case Management Blog

If your hospital is as typical as the majority of the hospitals across the country, your Case Management department may be engaged in the preparation for RACS because of your involvement in the appeal process. However, if this is the only role your organization thinks Case Management can play, that could cost your organization millions of dollars.

During the 3 year RAC demonstration project, CMS had an overwhelming 40-45% denial rate. 99% of those denials were categorized as either services that could have been rendered in an outpatient setting or the inpatient stay was not medically necessary. When it came down to it: the denials were for unnecessary hospitalizations.

Unlike the demonstration project in Florida, New York and California, the new yet-to-be released CMS RAC contract will have a provision that the RAC is only allowed to ask for medical records for patients that had an admit date of October 2007 or later. This creates an opportunity to do a stellar job concurrently while the patients are still in-house.

Case Management needs to treat Medicare as they do managed care. The days of reviewing Medicare charts every three days are gone. Chart review should occur every day, along with making sure that the patient’s care is progressing and moving toward discharge.

So considering that fact, you are probably saying, “Our caseloads are too high to manage that work”. You are probably correct; most Case Management departments across the country are grossly understaffed, sometime with caseloads as high as 40 -45 patients per Case Manager. Not only does that effect job satisfaction and departmental turnover, but it greatly impacts LOS, denials, and patient throughput. All of these key indicators are vitally important to the financial health of the hospital.

You don’t have to be a rocket scientist to realize that you need staff and internal processes that will be able to handle the additional duties and workload that a RAC audits brings.

So, now what? Well, the first step is to engage your immediate supervisor, CFO, CEO - basically anyone that can assist you in hiring enough Case Managers to get their caseloads to a more manageable level of 15-20 cases per manager.

How do you do that? Educate upper management and provide a cost benefit analysis to them that substantiates your need for more staff.

2nd Article in RACS Series coming soon!

Stay tuned for the next installment in the Article series on Medicare RACS. It will be posted to the blog soon!

Steve

Article: Medicare adds to do-not-pay list

By KEVIN FREKING
ASSOCIATED PRESS WRITER

WASHINGTON -- Medicare is adding to its do-not-pay list for hospitals two new categories of preventable conditions it won't cover, a much smaller number than it had been contemplating.
Last year, the Centers for Medicare and Medicaid Services set new ground by determining it no longer pay would extra costs for treating certain preventable conditions, referred to as "never events." An example of a never event is a transfusion with the wrong blood type.

Medicare officials announced Thursday that it no longer will pay the extra-care costs associated with treating dangerous blood clots in the leg following knee or hip-replacement. The program also will not pay extra for complications stemming from poor control of blood sugar levels.

To view the rest of this article click here:
http://seattlepi.nwsource.com/national/1152ap_medicare_hospital_payments.html

My Apologies!

Many of you found the blog even though I misguided you! Many of my emails communicated the wrong link so thanks for getting here through your own navigation!

Please pass the word along that this blog does not have the traditional "www" in front of it, which was my mistake. It is simply: http://azcasemanagement.blogspot.com

Thanks for letting your friends and collegues know!

-Steve

Article Series: RACS and Case Management- First Article!

RACS and Case Management

Here it Comes: Permanent CMS RAC Audits Expanding to a State Near You

By Randi Ferrare for the Arizona Case Management Blog
July 21, 2008

Unless you have been comatose in an intensive care unit, you’ve heard horror stories about the CMS RAC (Recovery Audit Contractor) demonstration project that, along with the real estate market, has been wreaking havoc for the last three years in Florida, California and New York.
This unbounded, wildly successful program has allowed CMS to recoup “overpayments” totaling close to $1 billion dollars, resulting in Congress passing a permanent CMS audit process to roll-out to all states by 2010.

The “RAC” will be called the “MAC” (Medicare Administrative Contractor).
During the demonstration project period, I made many Hospital Administrators and Board of Directors aware of the urgency and reality of the CMS RAC audit program during presentations.
Often to lighten the somber mood in the room, I pointed out that the RAC audit program does have a silver lining to its unprecedented 40%-45% denial rate of reviewed medical records. That silver lining is the CMS Trust Fund.

The CMS Trust Fund ensures that monies spent by the generations following baby boomers into retirement, will be replenished with money that has been recouped from “unnecessary hospitalizations”. Hopefully to ensure that our subsequent generations will be able to collect Social Security benefits, as our parents and grandparents have.

Much to the dismay of hospital CFOs everywhere, the RAC program is expanding and can’t be avoided. As stretched as it is today with the ever growing debt of charity care and costly medical advancements in technology coupled with the physician demands for this latest technology, the healthcare dollar will only go so far. For the lucky few who have been able to have even the slightest positive bottom line, this program is a real threat and can’t be taken lightly.

For the hospitals on the front line during the RAC Audit program in the demonstration states, they are weary yet enlightened. Weary with all the added work, expense, staffing challenges and multiple process changes to deal with the audit. Enlightened because they are ahead of the curve.

For the hospitals that are yet to be part of the program, the task of preparing can be downright frightening.

To help get brought up to speed, there is a 62-page document titled, “ The Medicare Recovery Audit Contractor (RAC)- An Evaluation of the 3 Year Demonstration” available from CMS. You’ll find this document on the CMS website (located at http://www.cms.hhs.gov
). It contains a wealth of information, both good and bad. It is quite an impressive document, examining what worked, what didn’t, and what changes are in store for the permanent “MAC” program.

At the very least, take a quick look and thumb through it. To help your Hospital join the “enlightened” forward on the Executive Summary to your “powers that be”.

Click here to access a copy of The Medicare Recovery Audit Contractor (RAC)- An Evaluation of the 3 Year Demonstration:
http://ohcci.com/docs/RAC_Demonstration_Evaluation_Report.pdf

Article: Disease Prevention Called a Better Bet

Disease Prevention Called a Better Bet
Wellness Programs Yield Greater Returns, Report Finds


By Megan Greenwell
Washington Post Staff Writer Friday, July 18, 2008; Page B03

An ounce of prevention in community health programs could save states hundreds of millions in health-care costs, a new study has found.

The report from the Trust for America's Health, a nonprofit health advocacy group, found that programs encouraging physical activity, healthy eating and no smoking were a better investment than those concentrating primarily on treatment.

TO VIEW THE REST OF THIS ARTICLE, CLICK HERE:
http://www.washingtonpost.com/wp-dyn/content/article/2008/07/17/AR2008071700990.html?hpid=moreheadlines

Article Series on Medicare RACS to begin!

Hello Case Managers! I hope you had a great weekend!

As promised, the series of articles on Medicare RACS will begin soon! Please check back to the blog as our guest author, Randi Ferrare, will present a very thorough review on this topic!

Thanks, Steve

Article: United Healthcare Cuts Jobs, Phoenix affected.

UnitedHealth Ends Options Suits, Cuts 4,000 Jobs (Update2)

By Avram Goldstein
July 2 (Bloomberg) -- UnitedHealth Group Inc. agreed to the biggest settlement of lawsuits involving backdated stock options and said the company would trim 4,000 jobs after its membership fell and expenses for providing medical coverage rose.
UnitedHealth, the largest U.S. health insurer, said today it would pay $912 million to end two class-action cases over grants of stock options to executives. The Minnetonka, Minnesota, company last year restated earnings dating to 1994 because of a backdating probe that cost former Chief Executive Officer William McGuire his job in 2006.
The company today cut its annual earnings forecast for the second time. Health insurers have reported higher expenses and lower profits, driving down the six-member Standard & Poor's 500 Managed Health Care Index by 47 percent this year. The worst may now be over, analysts said after UnitedHealth's announcement.

TO VIEW THE REST OF THIS ARTICLE CLICK HERE:
http://www.bloomberg.com/apps/news?pid=20601087&sid=aIr_f.FU0g1w&refer=home

NEWS Article: Bush delays Medicare fee cut for doctors

Bush administration delaying Medicare fee cut.


By JIM ABRAMS, Associated Press Writer Mon Jun 30, 7:56 PM ET

WASHINGTON - The Bush administration said Monday it will delay paying doctors for treating Medicare patients in early July to give Congress more time to block a scheduled 10.6 percent fee cut.

To read the rest of this article, click this link:
http://news.yahoo.com/s/ap/20080630/ap_on_go_co/congress_medicare;_ylt=AoUb94R2Okp3dA3hapMWZ7rVJRIF

Introducing a new blog guest Author! New article series to begin soon!

It is with great pleasure that I announce the association of Randi Ferrare as a new guest author on our blog! (Please see her bio on the right panel). We are fortunate to have someone as knowledgeable as Randi in the Case Management field writing on the blog. She will begin a series of articles on Medicare RACS and other topics starting in the month of July!

We look forward to having you Randi!

Thanks, Steve

Responses!

Thanks so far to responses received for the post below. Keep them coming and I appreciate the participation! - Please remember to keep comments as P.C. and respectful. -even if they are anonymous :)

Steve

Local Case Manager Needs your advice! Please Help!

A Local Case Manager emailed me to post this question for some input and advice from the local Case Management Community. You can respond under the comment section and your response can remain anonymous. Thanks in advance for your input! (please note that comments will not show immediately)

I'm a hospital case manager and we have a patient whose residence is in another state. He came here to stay with family and look for a job, with the intention of moving if work was found. He is not sure if he wants to stay here or go back to his home state. Meanwhile, he became ill, was hospitalized and now is in need of dialysis. He is ambulatory and could probably be discharged from hospital except that he has no insurance and cannot be hooked up with OP HD. He will not qualify for AHCCCS as he is not a resident of AZ. Our hospital doesn't provide OP HD. We have applied for Medicaid in his home state but that could take a considerable length of time to come through, if he qualifies. One of my co-workers says we can't steer him to county. I'm not sure why we can't. Isn't Maricopa Hospital there to serve the indigent? Do you know of any options?

Article: Health insurers’ report cards show need for improvement

Report from the AMA.....To read this article, follow this link: http://www.ama-assn.org/ama1/pub/upload/mm/368/nhirc-flier.pdf

Thanks, but we still need more!

Thanks for the response about my invitation for guest blog authors! We still need more! I need to hear from Case Managers throughout the state that can share with us their experience...the topics are open!

Please email me at sathornley@gmail.com for more info! Thanks, Steve

June Job Opportunities Updated

Please check out the job opportunties bar on the right hand side of the blog for updated postings! Refer your friends and associates! Thanks so much, Steve

News Article: Blues Plans Are Helping Hospitals Reduce Hospital-Acquired Infections With Electronic Tools and Incentive Programs

Reprinted from The AIS Report on Blue Cross and Blue Shield Plans, a hard-hitting independent monthly newsletter on business strategies, products and markets, mergers and alliances, and financing of BC/BS plans.
By Jill Brown, Managing Editor, (jbrown@aispub.com)

Hospital-acquired infections (HAIs) are among a growing list of "never events" for which CMS and some health insurers — including Blue Cross and Blue Shield plans such as WellPoint, Inc. — say they will no longer reimburse hospitals' treatment costs. Alongside that penalty approach, Blues plans such as Horizon Blue Cross Blue Shield of New Jersey, Blue Shield of California and Excellus Blue Cross and Blue Shield of New York are working collaboratively with hospitals to help reduce the incidence of HAIs, using tools such as electronic infection-monitoring systems.

To view the rest of this article, click here: http://www.aishealth.com/Bnow/hbd060508.html

News Article: Recovery audit contractors "RAC" up another challenge for providers

Frank Fedor
A new Medicare demonstration project is under way in three states in which recovery audit contractors are reviewing old Medicare claims to discover overpayments and demand their repayment from providers. The RACs, which will review claims over the next three years, will be paid on the basis of a percentage of the overpayments they recover. If they recover a fraction of what Medicare estimates it overpays each year, the impact upon providers will be large and the program will likely be extended nationwide.

A $19 Billion Annual Overpayment Problem

The purpose of the RAC project is to recover the large amounts of overpayments annually estimated for the Medicare program. From 1996 through 2002, the Office of Inspector General published annual Medicare fee-for-service error rates. These showed net projected overpayments (overpayments minus underpayments) of $23.2 billion in 1996 and a general trend down to $13.3 billion in 2002.

In 2003, Michael O. Leavitt, secretary of the Department of Health and Human Services, established two programs to more comprehensively monitor the accuracy of Medicare fee-for-service payments: the Comprehensive Error Rate Testing program and the Hospital Payment Monitoring program. Leavitt claims these programs use a larger sample size and are much more precise than the methods earlier used by the OIG. Under these new methodologies, Medicare net overpayments were $19.6 billion for 2003 and $19.8 billion for 2004. Note that the use of the new methodology resulted in a $6 billion-plus increase in estimated net overpayments from 2002 to 2003 and 2004.

Obviously, if RACs were operating nationwide and could identify Medicare fee-for-service net overpayments of even half of $19 billion a year, the impact on providers would be huge.

Statutory Basis

RACs were created at the direction of Congress under section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Section 306 directs the HHS secretary to conduct a demonstration project to show the use of recovery audit contractors in identifying payment errors under the Medicare program.
The project, announced by the Centers for Medicare and Medicaid Services on March 31, is to last for no longer than three years and is to cover at least two states that are among those with the highest per capita utilization rates of Medicare services. The contractors may not be current fiscal intermediaries or carriers. Preference must be given to contractors who have demonstrated proficiency for cost control or recovery audits with private insurers, health plans, or providers. The HHS secretary must submit a report to Congress within six months after the program ends.

Two other aspects of section 306 are most relevant to providers. First, under section 306(e), the recovery of an overpayment to a provider by an RAC does not necessarily prohibit the secretary or attorney general from investigating and prosecuting allegations of fraud or abuse arising from such overpayment. Second, under section 306(a)(1), RACs may be paid on a contingency basis. As implemented by CMS, RACs are required to identify both overpayments and underpayments, but they are paid only a percentage of the overpayments they recover. In information sessions, CMS says the amount of underpayments to providers identified does not reduce the amount of overpayments upon which the RAC is paid, but the obvious incentive is to focus resources on identifying overpayments.

How the Demonstration Project Will Work RACs are categorized into those that will pursue Medicare secondary payer overpayments and those that will pursue non-MSP overpayments. In November 2004, CMS posted two "statements of work" that give some detail about how RACs are to operate.

During the three-year demonstration, RACs will pursue only overpayments occurring in California, Florida, and New York. Nevertheless, a provider not located in one of these three states may have some of its claims subject to RAC review because the nonMSP RACs are permitted to attempt to identify overpayments made on claims submitted to carriers and intermediaries in any of these states or to durable medical equipment regional carriers for services provided to beneficiaries with a primary residence in one of these three states.

Impact on providers. Providers are likely to see little impact from the MSP RACs. The MSP RACs will audit only group health plan claims--not liability, no-fault, or workers' compensation claims. Demands for payment will be made only to employers, not to providers.

On the other hand, providers will be affected by the non-MSP RACs, which will seek to identify overpayments and underpayments to providers. The parameters of what these RACs may and may not pursue are somewhat complex. In general, non-MSP RACs may attempt to identify over- and underpayments that result from incorrect payment amounts and noncovered, not reasonably necessary, incorrectly coded, or duplicate services. Non-MSP RACs may not pursue overpayments on services under a non-Medicare fee-for-service program (such as a Medicare managed care, Medicare drug card, or drug benefit program), resulting from the cost report settlement process, or resulting from the miscoding of evaluation and management services (except services resulting from E&M services that are not reasonable and necessary or violations of Medicare's global surgery payment rules that involve E&M services).

Non-MSP RACs will have access to CMS's national claims history data initially for FY02 through FY04, and then updated monthly. CMS will maintain a claims database to prevent overlap in the pursuit of the same overpayments between RACs and CMS, CMS's contractors, the Department of Justice, and the OIG.

* Types of reviews. Non-MSP RACs will conduct both automated and complex reviews. An automated review will involve the application of an RAC's proprietary software to the national claims history data furnished By CMS and may be used only when there is certainty that the service was not covered or was incorrectly coded, a duplicate payment, or otherwise an overpayment. A complex review requires the review of copies of medical records. Providers should note that if an RAC does not receive copies of medical records within 45 days of its request, the RAC is authorized to find that the claim was overpaid.

Section 935 of the MMA prohibits the use of random claim selection for any purpose other than to establish an error rate. For this reason, CMS prohibits a non-MSP RAC from randomly selecting cases for which it requests copies of medical records. Instead, the RAC is to use data analysis to identify claims most likely to contain overpayments in a process CMS calls "targeted review." An RAC may not target solely high-dollar claims, But must identify other information that leads the RAC to Believe the claim is likely to contain an overpayment.

* Communication of results. Non-MSP RACs must communicate to the provider only the overpayments that result from automated reviews and all results of complex reviews whether they result in an overpayment or not. Non-MSP RACs must follow all Medicare statutes, regulations, policies (including local coverage determinations), and local coverage/ coding articles. The RAC must also communicate to the provider which coverage/coding/payment policy or article was violated to result in the overpayment, and notify the provider of its appeal rights.

The notification of overpayments will take the form of a demand letter. If repayment is not made, the matter may be referred to CMS for offset, or after 180 days to the Department of the Treasury for collection.

RACs have no authority to compromise claimed overpayments. They do have limited authority to agree to a payment plan.

* Appeals. Providers have full appeal rights as they would if CMS or one of its contractors had identified the overpayment. Once the provider appeals, the RAC must stop pursuing the claim. Interest continues to accrue throughout the appeal process.

Practical Impact of RACs

Providers in California, Florida, and New York need to consider several steps in addressing RAC audits.

First, they should identify who within the organization will receive RAC communications and prepare them to deal with RAC requests or communications of payment errors. The individuals currently receiving information from Medicare will, by default, also receive information from the RAC. Contact information with the RAC can be customized so communications come to staff trained to deal with RACs and their special deadlines.

Second, the potential larger scale of overpayments both in number of claims and total value of dollars that will result from RAC audits make it prudent for providers to review their practices in addressing government audits and claims of overpayment. A provider may want to take a more aggressive approach in auditing some of the same claims the RAC audits to ensure that all underpayments are also found and to confirm the accuracy of the RAC's findings of overpayments. Providers should also carefully review their process for deciding whether to appeal notices of overpayment they currently receive from Medicare. There may be current cost-benefit calculations that do not apply to the larger volume and value of overpayment notices that an RAC may send, and the current staff may not be prepared to make a large volume of appeal decisions within the short deadlines allowed. Because of the larger amounts at stake, more resources may be needed in the early stages of the appeal process to develop the factual record that sets the foundation for the issues that can be appealed to federal court.

Third, the provider must carefully consider the compliance implications of the RAC's findings of overpayments. For example, if the RAC finds overpayments of a certain systematic type for 2003, the provider should examine whether the same type of systematic overpayment occurred in 2004 and beyond. The provider may have excellent defenses to claims of fraud or violations of the False Claims Act in not discovering that these overpayments had occurred in 2003, but these defenses may weaken in defending the same overpayments made in 2004 and beyond if the provider did nothing to investigate and correct the situation after receiving the RAC notification of these overpayments.

On the other hand, if the provider disputes the RAC's findings of overpayments, then it is that much more important to timely appeal the overpayments. The exercise of appeal rights may show the existence of a legal dispute and the absence of the statutory element of "knowledge" of falsity needed to prove a violation of the False Claims Act. A failure to timely appeal notifications of overpayments can arguably have the opposite effect.

Many of these same issues should be considered by providers that do business in multiple states that include one of the RAC states or with CMS carriers and intermediaries located in an RAC state. An overpayment in a facility in an RAC state may suggest a review of whether it is a companywide issue or otherwise occurring in facilities in non-RAC states. For the same reason, although providers outside of California, Florida, and New York will not feel an immediate impact from RACs, these providers should nevertheless monitor how the RACs operate and what the RACs find to see whether they should consider investigating a similar type of overpayment or adjust some aspect of their practices.

Very interesting times are just around the corner.

MEDICARE FEE FOR SERVICE FAST FACTS (FY03 AND FY04)
Total payments issued FY03: $199.1 billion FY04: $213.5 billion
Gross error rate FY03: 10.8 percent FY04: 10.1 percent
Net error rate FY03: 9.8 percent FY04: 9.3 percent

AT A GLANCE
Old Medicare claims in California, Florida, and New York are now subject to review by recovery audit contractors. To deal with these audits, providers should:
* Identify who within their organization will receive RAC communications
* Reviewtheir practices in addressing government audits and claims of overpayment
* Consider the compliance implications of the RAC's findings of overpayments

Frank Fedor, JD, is a partner, Murphy Austin Adams Schoenfeld, LLP, Sacramento, Calif., and a member of HFMA's Northern California Chapter. Questions or comments about this article may be sent to him at ffedor@murphyaustin.com.

News Article:Employers get more creative to help workers stop smoking.

DETROIT — Can't stop smoking? Your employer wants to help.

For the first time, a growing number of companies is offering free or reduced-cost smoking cessation strategies.

What's in it for you, besides your health?

Your company's health plan may lower your monthly insurance premium, provide a coach to help you stop or help pay for prescription smoking cessation medicines.

Many businesses have become more aggressive and creative in helping workers quit.

TO VIEW THE REST OF THIS ARTICLE, CLICK HERE:
http://www.honoluluadvertiser.com/apps/pbcs.dll/article?AID=/200806020100/BUSINESS/806020324

Seeking Guest Authors for this Blog

Hello Case Managers,

I am seeking guest bloggers/authors for this blog to write on a variety of topics relating to medical case management. We need your knowledge and input!

If you would like to submit a written article, please email me at sathornley@gmail.com

Thanks for your continued support of this blog!

Steve

News Article: Medicare could fail, Leavitt says

Medicare could fail, Leavitt says
By James ThalmanDeseret News
Published: May 29, 2008

The federal government is on the verge of breaking one of its oldest promises to its citizens — health care for the elderly — U.S. Secretary of Health and Human Services Secretary Michael Leavitt told a conference of seniors during a Wednesday visit to Salt Lake.

Shoring up Medicare is the single most important and possibly the ugliest political issue the country will face, but it must face it now, the former Utah governor told the home state crowd gathered at the Little America Hotel for the 21st Annual Utah Conference for Seniors hosted by Sen. Orrin Hatch and his wife, Elaine.

If something isn't done to seriously address how things are today and recognize that the premise of Medicare no longer holds true, the Medicare trust fund could well become insolvent by 2019. Four or five years later, he said, Medicare could come apart from the inertia of economic and demographic forces the plan's designers couldn't have imagined.

It's a combination of things, from the global economy to the mounting obligations to seniors, he said. Generations of younger workers who were counted on to underwrite Medicare are dramatically declining, just as the largest group of Americans in history reach the age when they're likely to use more medical care than they did in the previous 64 years combined.

Another factor is the burgeoning cost of health care, which is estimated by Leavitt's advisers to account for 41 percent of the typical family budget by 2030. In 25 years, the 13 percent of the federal budget now earmarked for health-care services will be more like 23 percent, he said.

"What we see coming is whitewater and treacherous whirlpools," Leavitt said, likening the course of Medicare in the near future to a river with rapids tough enough to challenge the most expert river runners.

He was quick to note the problems can be solved if the various stakeholders — including Congress, the current and next administration, public and private sector employers, and the seniors themselves — get a sense of what's ahead "and get in and start paddling around danger spots."

Leavitt was short on specific measures that could be used to reorient Medicare. The fist step, however, is coming to grips with the fact that the plan will have twice the cost and half the people underwriting, he said.

It will take more positive approaches, similar to the significant cost savings and improved quality achieved through the recently implemented Part D Medicare plan.

"When seniors began to shop, they selected options that created competition and have driven down costs by 40 percent," he said.

Young families struggling to make ends meet today will no doubt argue that the Medicare deal wasn't struck by their generation, he said. Seniors will argue that they paid into the system and expect to have the promise kept.

"I can't stress enough that virtually nothing is how it used to be," Leavitt said, adding that imported goods to the United States will top $2 trillion this year, "a figure inconceivable just 10 years ago."

Like it or not, change is coming.

"We can fight it and fail, we can accept it and survive or we can lead it and prosper," he said.

News Article: Doctors' house calls on the rise. Visits let physicians learn of patients' lives.

Doctors' house calls on the rise
Visits let physicians learn of patients' lives

By CHERIE BLACKP-I REPORTER
John Devine is 82 years old and has no interest in leaving home to socialize with others.

He'll pass on the so-called "senior activities" and get-togethers. He would rather read in the library of his assisted-living facility in Burien.

Wanting to stay home makes doctor visits and routine checkups a bit difficult, though. But Devine, a small, spry man with a Scottish brogue and a mischievous smile, has that taken care of. He has a doctor make a house call to him about once a month for a checkup and to help coordinate any other medical care he needs.

Once considered on the verge of extinction, house calls are making a comeback.

TO VIEW THE REST OF THIS ARTICLE, CLICK HERE:
http://seattlepi.nwsource.com/local/364946_housecalls29.html

Hope everyone had a great Memorial Weekend!

Hope you enjoyed the mild temperatures and had a good holiday!- Steve

News Article: U.S. ads push patients to shop for hospitals

The Bush administration today launches a $1.9 million advertising campaign touting its effort to rate hospitals and urging patients to check a government website before choosing one.
The ad campaign in 58 regional newspapers lists hospitals and their scores on two of more than 30 measures available on the website: the percentage of patients getting antibiotics before surgery to prevent infection and whether patients "always" got help when they asked for it.
The government's campaign promoting the website by the Centers for Medicare & Medicaid Services (CMS) comes amid a flurry of efforts by states and the private sector to rate medical providers. The movement is fueled by demands from employers and consumer groups, including AARP and the Consumers Union, for more information about cost and quality.

To read the rest of this article, click here: http://www.usatoday.com/news/health/2008-05-20-Hospitalads_N.htm

Seeking some amazing Inpatient Case Managers for East Valley!

I am consulting with some East Valley acute facilities that are seeking RN Case Managers with acute care experience (2 years+). These are amazing opportunties with excellent pay/benefits. Please call me for details or if you know someone you can refer, I pay a $1,000 referral bonus/finders fee!

Call me for details, 480.305.6118

Steve

Health Choice Arizona, Inc. Awarded New Contract

FRANKLIN, Tenn.--(BUSINESS WIRE)--IASIS Healthcare® LLC (“IASIS”) announced today that Health Choice Arizona, Inc. (“Health Choice”), IASIS’ prepaid Medicaid and Medicare managed health plan in Phoenix, Arizona, has been awarded a new contract from the Arizona Health Care Cost Containment System (“AHCCCS”), the state agency that administers Arizona’s Medicaid program. Health Choice’s existing contract with AHCCCS expires September 30, 2008. The new contract continues to give Health Choice a state wide presence and provides for a three-year term commencing October 1, 2008, with AHCCCS having the option to renew for two additional one-year periods. The new contract covers Medicaid members in the following Arizona counties: Apache, Coconino, Maricopa, Mohave, Navajo and Pima counties, which are counties covered by Health Choice’s existing contract, as well as Yuma, LaPaz and Santa Cruz counties, which are new counties awarded to Health Choice in the recent bid process.
IASIS, located in Franklin, Tennessee, is a leading owner and operator of medium-sized acute care hospitals in high-growth urban and suburban markets. The Company operates its hospitals with a strong community focus by offering and developing healthcare services targeted to the needs of the markets it serves, promoting strong relationships with physicians and working with local managed care plans. IASIS owns or leases 16 acute care hospital facilities and one behavioral health hospital facility with a total of 2,770 beds in service and has total annual net revenue of approximately $1.9 billion. These hospital facilities are located in six regions: Salt Lake City, Utah; Phoenix, Arizona; Tampa-St. Petersburg, Florida; three cities in Texas, including San Antonio; Las Vegas, Nevada; and West Monroe, Louisiana. IASIS also owns and operates a Medicaid and Medicare managed health plan in Phoenix that serves over 129,000 members.

AHCCCS Contract Awards will bring a host of changes

Reports from various sources are showing significant changes in the acute care contract awards. Most significantly impacted looks like APIPA/United which will loose all but a a few counties and drop around 100,000 lives off the books.

Phoenix Health Plan has picked up six new counties including Pima County. Healthchoice maintains their current counties and may have picked up some additional counties. Mercy Care Plan will fall back to Maricopa, Cochise, Greenlee, and Graham counties.

As a result of the changes, their will assuredly be changes to affect both Case Management and Utilization/Concurrent review nurses and their respective positions within the health plans.

Stay tuned as we track the developments and possible lingering job opportunities that will arrise in the local Medicaid market!

Thanks, Steve

News Article: Chronic ailments have 51% of insured on pills

For the first time, it appears that more than half of all insured Americans are taking prescription medicines regularly for chronic health problems, a study shows.

To view the rest of this article, click here: http://www.freep.com/apps/pbcs.dll/article?AID=/20080514/NEWS07/805140429/1009

Posting Comments

Some have asked how to post comments to more actively participate in this Blog.

At the bottom of each post or news article, there is a section that looks like this:

Posted by Steve Thornley, CSP at 12:54 PM 0 comments - Simply click on the link where it states "0 comments " and it will allow you to post your comment anonymously.

Thanks and let's see some more posts on the blog. We enjoy your comments!

-ST

News Article: Cigna, hospital group agree to deal

Cigna Healthcare of Arizona and Catholic Healthcare West have struck a new 14-month pact that will give Cigna customers access to the health provider's area hospitals and surgical facilities, ending a two-week impasse that disrupted health-care options for many Arizonans.

to see the rest of this article, click here: http://www.azcentral.com/community/mesa/articles/2008/05/10/20080510biz-cigna0510-ON.html

Another great certification! Case Manager touts other certification options!

I recieved an email regarding other certification options for Case Managers. Definitely worth checking out and so I am passing along some good advice.....see below for details. I HAVE ALSO POSTED A LINK ON THE SIDE BAR TO THE American Nurses Credentialing Center. (ANCC)

**************************************************************************

I would like you to check out the website for ANCC= American Nurses Credentialing Center which is the credentialing arm of ANA. Although CMSA has long been aligned with the CCM certification, there are other certification options for nurse CM's. I believe CMSA has always "supported" the CCM certification because other professionals such as SW have been an integral part of CMSA. At this point It seems to me the vast majority of CMSA members are nurses, & I'd love to see information regarding the ANCC NCM certification displayed on your site. ANCC certifies nurses in many nursing specialty areas & is indeed the Gold Standard for certification of nursing specialties. This organization offers Magnet certification which is a really big deal for hospitals, & ANCC certification for CM's working in those hospital settings is generally supported as well. So- bottom line- I'd like you to consider placing information re: ANCC certification on your blog in as prominent a format as the CCM info currently posted.

Guess I'm asking for equal time for ANCC NCM certification Steve! Thank you, & again- great job with this new venture!

Approaching another milestone!

We are approaching 500 visitors to the blog! Not bad for being live for just over three weeks. Please keep the blog lively by commenting. If it is easier to email me, I am happy to post your comments and do it annonymously if you prefer.

Thanks! Steve

Is working from home all it's cracked up to be?

As more and more companies move to a work from home program for Case Managers, I seem to have heard mixed results on this type of work situation lately. Sure gas is $3.50 a gallon and traffic is horrible and you can do work in your pj’s…but what about the social interaction that one generally gets from being around co-workers? Is the motivation spurred by teamwork synergy you generally feel working in the office lost as a result of the work from home situation? GIVE ME SOME FEEDBACK! I would love to have some comments on this topic from you all! Please email them or post by hitting on the “Comments” link below this post.

Thanks, Steve

Article: For many, nursing is a mid-career choice.

By Taryn Plumb, Boston Globe Correspondent May 4, 2008

We've all heard the old nursery rhyme about the butcher, the baker, and the candlestick maker.

Well, before becoming a nurse, Melissa Mattola-Kiatos was a third of the way through that lineup - as well as a few others.

In addition to her post as a junior butcher at Elm Street Market in her hometown of Everett, she once supervised a four-star restaurant at Faneuil Hall; performed hand rubs as a salesgirl at Donna Karan; and managed mutual funds for two investment companies.

Finally, four years ago, the Saugus 33-year-old decided to give nursing a go.

"I'm hoping this career sticks," she quipped as she sat in a narrow break room lined with lockers and stacked with medical textbooks at Melrose-Wakefield Hospital, where she has worked for two years.

But really, she said, "To date, becoming a nurse is the best decision I ever made."

She will celebrate that pride - alongside millions of colorful scrub-wearing comrades across the country - during National Nurses Week, May 6 through 12.

Mattola-Kiatos - a self-described overachiever who graduated from the Lawrence Memorial/Regis College Collaborative Associate of Science in Nursing Program and plans to pursue an advanced degree in nursing - is never short on praise for her job. "It's so personally rewarding," she said.

"I chose to do this. It wasn't something I fell into out of high school."

And she's hardly alone in her mid-career choice.

According to a 2002 survey by the Massachusetts Colleagues in Caring Collaborative, the mean age of graduating nursing students was 31.6.

David Schildmeier, spokesman for the Massachusetts Nurses Association, noted a few reasons for that trend: job security, better pay, and career satisfaction. "Many people come to nursing because they see meaning," he said.

That has been the case for Mattola-Kiatos. She said she gets the feeling at the end of every day that she's accomplished something. And despite the widely held belief that nurses do all the grunt work - emptying bed pans and changing bandages - she said there's a great deal of variety in her job.

For starters, she deals with a broad spectrum of patients, from those requiring hip or knee surgery to others who have pneumonia or appendicitis. "It's always something different," said Mattola-Kiatos, who often shows off pictures of her 85-pound Labrador, Wrigley, and is an avid Red Sox fan who wears her BoSox scrubs whenever knuckleballer Tim Wakefield pitches.
The challenge is in assessing the patient's needs, she said, from elders facing fears of dying to young moms fretting about day care.

"You spend time with patients and do everything in your power to meet their medical needs, but also their emotional needs," she said.

Generally, she works with four to five patients a day on Melrose-Wakefield's Med 4, a U-shaped complex with orange doors that smells of antiseptic, and the constant, soft beeping of various machines blending into the background. On a recent sun-soaked afternoon, she performed her rounds while mentoring new grads. Dressed in pink and green scrubs, a stethoscope slung around her neck, she mixed a batch of medicine at a counter, then entered a shaded room.

"Hi, my friend," she said with a smile to Albert D'Arco of Everett, an 80-year-old hunched on the bed in a hospital gown, his wrists wrapped in green, orange, and white hospital bands.

Calling him "Mr. D'Arco," Mattola-Kiatos inserted an IV into his right arm, pressed a button on a machine that beeped to life, and keyed in a series of numbers. "Are you 20?" she asked playfully before leaving the room. He laughed as he lay back in the bed, "Multiply that by 4."

Afterward, his son, Manny D'Arco of Winchester, described Mattola-Kiatos as "very professional, but very caring, too - which is lacking in a lot of healthcare professionals these days." He shrugged. "I feel better when she's up here."

Miguel Rivera, director of Med 4, agreed that Mattola-Kiatos has a certain way with patients. She's an "above and beyond type of employee," he said. She's "charismatic, with personality."

Yet Mattola-Kiatos will tell you that it's the patients who "stick in my head." With some, "I could tell you what room they stayed in, their full name, everything about them."

Still, she described the frustrations of the job, as well. For instance, there are always puzzles in diagnosing patients' injuries and sicknesses, she said. And, not surprisingly, the hardest days on the floor are when people die. She remembers the first time that happened. Although she didn't know the patient and had never seen him before, she "just started to cry."

On the other hand, day-to-day business brings regular rewards - the patients with stomach pains who come in hunched over and leave with smiles and hugs, for instance; or others who require hip replacements and go home with the ability to walk (or even dance) again.
In those cases, she said, "I did my job."

News Article: Walmart Widens Drug Discount Program

To see this article, click this link: http://online.wsj.com/article/SB121002048022568563.html?mod=dist_smartbrief

Poll Results.....

POLL OF THE WEEK: How do you rate your employers own health insurance benefits?

Wow, out of 18 people that responded- 50% said the health insurance they are offered by their employers was poor/below average!- I guess we have a long way to go with the insurance aspect of what employers offer for benefits.

Interesting!

Thanks, ST

News Article: Briefer hospitalizations are not always best, Pennsylvania study finds

For some patients, shorter hospital stays aren't better.
A study of 15,531 Pennsylvania patients diagnosed with a pulmonary embolism - a life-threatening condition in which a blood clot blocks a vessel in the lungs - found that those discharged more quickly were at greater risk of death.
The researchers, from Pittsburgh and Switzerland, examined hospital billing data from the Pennsylvania Health Care Cost Containment Council. They found that the patients who were discharged after four or fewer days were significantly more likely to die than those who remained in the hospital for five, six or more days.
The study sought to determine whether new guidelines that recommend patients identified as being at low-risk for complications be discharged more quickly were working as intended.

TO VIEW THE REST OF THIS ARTICLE CLICK HERE: http://www.philly.com/inquirer/breaking/news_breaking/20080415_Briefer_hospitalizations_are_not_always_best__Pennsylvania_study_finds.html?adString=inq.news/news_breaking;!category=news_breaking;&randomOrd=042508101503

News Article: Exodus of specialists from ERs raises concerns

To read this article, follow this link:

http://www.latimes.com/news/local/la-me-er25apr25,0,4475836.story

Ouch!

100 degrees by Monday in Phoenix??? Help!

News Article: Healthcare Coalition Approves Tools to Improve Patient Safety

Little Rock, Ark. (April 24, 2008) — The National Transitions of Care Coalition (NTOCC) Advisory Task Force has authorized the release of recently developed tools for helping healthcare professionals and organizations address problems inherent in transitioning patients from one level of care to another. The tools represent the culmination of several months of collaboration between 29 industry stakeholders who joined together in 2006 to address challenges associated with transitions of care. In addition, NTOCC is also releasing accompanying information on how to implement and measure the tools, as well as material designed to raise industry, policy maker, media, and the general public's awareness of transitions of care. The material will be made available on NTOCC's website (www.ntocc.org/) at the end of April. NTOCC is chaired and coordinated by the Case Management Society of America (CMSA) in partnership with sanofi-aventis U.S. LLC.

"The amount of work this group has accomplished in just 18 months is impressive," Cheri Lattimer, NTOCC Project Director and CMSA Executive Director said. "For a group this large, representing such various points of view within healthcare to come together and not only agree that transitions of care is a serious problem but also design, develop and launch tools to impact this issue a fantastic accomplishment."

Included with the launch of the tools is a "Case Study Implementation and Evaluation Plan" on how healthcare providers can implement them within their clinical environments, as well as a process for evaluating and measuring their effectiveness. "Providers can use the tools and process to start making changes in how transitions occur within their facilities," H. Edward Davidson, PharmD, MPH, and the representative of the American Society of Consultant Pharmacists (ASCP) said. "The goal is that providers are empowered to take the first step at measuring their own performances in transitions of care and identify areas for improvement. These areas include such things as improving how medication changes are reconciled when patients move from a nursing home to a hospital, through the hospital, and through the discharge process." The materials include an educational component about transitions of care, an implementation case study and evaluation methodology.

The released tools address several important areas that impact effective and safe transitions, including:

Personal Patient "My Medicine List" Essential Data Elements: This is a list of medications to be carried at all times by every patient. The data elements indicate the prescriptions that patients have been prescribed and are currently taking along with information about their over-the counter medications, vitamins, and nutritional supplements. The goal of the personal medicine list is to help patients improve their understanding of their current medicine regimens and assist healthcare providers in ensuring safe transference of medication information.

Medication Reconciliation Essential Data Specifications: These consensus elements will help healthcare professionals collect, transmit and receive critical medication information needed when patients move from one practice setting or level of care to another. The use of these elements in the reconciliation process required by the Joint Commission could help reduce medication errors.

Elements of Excellence Transitions of Care Checklist: This list provides a detailed description of effective patient transfer between practice settings. This process can help to ensure that patients and their critical medical information are transferred safely, timely, and efficiently.
In addition, NTOCC authorized the release of materials that will help the industry, consumers, government officials, and regulators better understand the problems inherent in transitions of care and recommendations on how to create better transitions. This material includes an awareness slide deck, as well as a detailed concept paper outlining steps to be considered by the healthcare industry and policy makers to improve transition performance.

Transitions of care include situations in which a patient moves from primary care to specialty physicians or moves within the hospital including moves from the emergency department to other various departments, such as surgery or intensive care; or when a patient is discharged from the hospital and goes home or to an assisted living, skilled nursing facility, or hospice. Patients, especially older persons, face significant challenges when moving from one level of care or practice setting to another in the healthcare system. During these transitions, lack of communication can result in redundant or conflicting information that often creates serious issues for patients, their caregivers and their families.

The NTOCC Advisory Board includes the Academy of Managed Care Pharmacy (AMCP), American Association of Homes and Services for the Aging (AAHSA), American Geriatrics Society (AGS), American Medical Directors Association (AMDA), American Medical Group Association (AMGA), American Society of Health-System Pharmacists (ASHP), American Society on Aging (ASA), American Society of Consultant Pharmacists (ASCP), AXA Assistance USA Inc., Case Management Society of America (CMSA), Consumers Advancing Patient Safety (CAPS), Health Services Advisory Group (HSAG), Institute for Healthcare Improvement (IHI), Joint Commission International Center for Patient Safety (ICPS), Lipitz Center for Integrated Health Care, Mid-America Coalition on Health Care (MACHC), National Association of Directors of Nursing Administration - Long Term Care (NADONA / LTC), National Association of Social Workers (NASW), National Business Coalition on Health (NBCH), National Case Management Network of Canada (NCMN), National Quality Forum (NQF), Predictive Health, LLC, sanofi-aventis U.S., LLC, Society of Hospital Medicine (SHM), The Joint Commission Disease - Specific Care Certification, United Health Group (UHG), URAC, and the United States Department of Defense.

WOW! Over 250 visitors in 48 hours!

I have had some overwhelming response since I went live with the blog! Within 48 hours of our official launch we have had over 250 hits! - I am glad to see that the Arizona Case Management community has been so responsive and I hope you will all come back and visit regularly. I am posting new things everyday!

Thanks for a wonderful start! -Steve

Is there any GOOD news out there anymore?

Several months ago, I took the T.V. out of my bedroom. It was a fitting decision mostly based on the fact that the number of books on my night stand kept piling up and my excuse to not read them was getting rather lame. Usually my excuse was based on procrastination but more specifically wanting to numb myself each night with watching the news and seeing what was new in the world. But where has all that feel good news gone? Has it really dwindled in to one or two news stories a week? - How does this apply to case management you ask? We'll for months, it seems that all I hear about health care is the same; insurance costs skyrocketing, re-use of needles at clinics in Nevada, etc.etc. It gets old people! But I know there are good things happening...and maybe I am just singing the blues after a rough week!

So who else to turn to for good news but Case Managers. They see the "feel good stuff" happen everyday! Please share with me your stories! I will post them! - Names will be kept anonymous, but I really want to hear what is going on out there! I know you all aspire to be eloquent writers so lets here your stuff!

I look forward to the hearing some feel good stories and I promise to send a special prize for the one I like the best! - Funny or heartwarming, I am open to all!

Please email them to me at sathornley@gmail.com

JOB Opportunities Section.......

I received an inquiry about posting jobs to this blog by an employer. I think this is a good forum to have access to these resources as well as many other great things to share. The fact is, that Phoenix is a very robust market for literally dozens of non-clinical nursing and Case Management opportunities at all levels.

To that end, I have created a section of Job Opportunities to the right of the screen and will update them regularly with links to specific information.

Thanks for the inquiry about this and I hope this will be a good resource for all!

Please comment and send me suggestions on how I can improve the blog and any particular topics that we can discuss!

Thanks! Steve

Article: Part D improved prescription compliance

To read this article, click on this link: http://news.yahoo.com/s/nm/20080422/hl_nm/medicare_usa_dc;_ylt=AoP84QzKSsVP3gWTFLMjQokQ.3QA

Too funny to pass up! - You will all enjoy this!

I read this and thought it was perfect for this blog. Enjoy!

Two Doctors & HMO Manager

Two doctors and an HMO manager died and lined up at the pearly gates for admission to heaven. St. Peter asked them to identify themselves.One doctor stepped forward and said: "I was a pediatric spine surgeon and helped kids overcome their deformities."St. Peter said, "You can enter."The second doctor said "I was a psychiatrist. I helped people rehabilitate themselves."St. Peter also invited him in.The third applicant stepped forward and said, "I was an HMO manager. I helped people get cost-effective health care."St. Peter said, "You can come in too." But as the HMO manager walked by, St. Peter added, "You can stay three days. After that, you will be released."

Question Regarding the CCM Examination

Thank you for the recent question about the CCM Examinations. They are conducting the last "paper and pencil" test this month and in the fall the tests will be all computer based.

For more information on taking the CCM exam and becoming certified, visit:

http://www.ccmcertification.org/index.html

Thanks again!

Steve

Case Managers Study Guide for CCM Exam

I came across a company that produces a study guide that may be helpful for this preparing for the CCM exam! Visit: http://www.jbpub.com/ for more info!

Steve

WELCOME New Visitors!

Thanks for stopping by! I hope to hear from many of you and what sort of challenges you are facing in the Case Management world! - I am preparing for my honeymoon of sorts to beautiful Costa Rica, but will keep up with things on the blog so please send me your topics to moderate!

Happy Tuesday!- Steve

Article: Employers seek alcohol abuse options from health plans.

To view this article go to: http://www.aishealth.com/Bnow/hbd041808.html

Please come back here to comment!

How do we look so far Arizona?

I personally wanted to thank all those who have stopped by the blog so far! I hope that you have found the information interesting and informative! Please come back and visit often and please make comments!

Your contributions are greatly appreciated. Also, note that I have added a WEEKLY POLL at the right of this section. I hope you will all vote and I’ll do my part to keep them applicable and interesting!

Have a great Thursday Night!- We are almost to the weekend!

Steve Thornley – sathornley@gmail.com

Article: Patient-Controlled Health Records Could Change Future of Research

WEDNESDAY, April 16 (HealthDay News) -- Increasing patient control of health records could dramatically change how medical research is conducted, say Children's Hospital Boston researchers.
In a Sounding Board article in the April 17 issue of the New England Journal of Medicine, the researchers noted that the shift to personally controlled health records (PCHRs) will give patients and doctors easier access to records during clinical care and will also have a major impact on the conduct of biomedical research.
With PCHRs, patients have Web-based access to almost all the information -- such as lab tests, diagnoses, medications and clinical notes -- in their medical records. They can decide who gets to see that information.
"Giving patients access and control over their medical records will unlock a whole new world where researchers will suddenly be able to recruit hundreds, thousands, possibly millions of patients from all over the world, and have access to new data sets and populations. Imagine the possibilities this will bring and the impact it will have on bringing research to the bedside," article co-author Dr. Isaac Kohane, of the hospital's informatics program, said in a prepared statement.
More than a decade ago, Kohane, colleague Dr. Kenneth Mandl and others on the informatics team at Boston Children's developed the first PCHR.
While PCHRs offer many benefits, there are some potential pitfalls.
"While this is exciting indeed, without forethought and regulation, the tremendous benefit of PCHRs -- for research and clinically -- could easily be overshadowed by problems that could arise from the unethical and uncontrolled use of a patient's valuable medical information," article co-author Dr. Kenneth Mandl said in a prepared statement.
"Who will have access to the data, for what purposes, and under what sort of regulation? Can patients sell their information? How will we establish and protect their identity? These are the kinds of questions -- among many others -- that we need to ask now and clarify before PCHRs become mainstream," Mandl said.
"While PCHRs may seem futuristic, they are here now and will be widely adopted in the not-so-distant future. Fortune 100 companies are already signing on to develop their own PCHRs for their employees. We cannot afford to be asleep at the wheel. Before they hit prime-time, we need to think about what is at stake and what has to happen -- including regulations and standards -- if PCHRs are to be used to the full extent of their potential," Kohane said.

Article: Making the Grade: Doctors say insurance company rankings of doctors are based on cost, not quality. ....

To view this article, please visit:

http://www.newsweek.com/id/132496

And please come back and comment!

Article: Mesa General Closure......

Mesa General staff looking elsewhere as hospital closes
Art Thomason
Apr. 15, 2008 09:39 AM
The Arizona Republic

With the healthcare job market still fit, the name of a familiar Mesa institution is on a surge of new résumés under review by medical service providers in the Southeast Valley.

Employees of Mesa General Hospital wasted no time applying for jobs at other medical centers after the announcement March 25 that it will close June 1.

But Audrianne Schneider, a Mesa General spokeswoman, said Friday the hospital's Tennessee-based owner, Iasis Healthcare, assures that the hospital is sufficiently staffed to serve its patients until the doors are locked.

"We're committed to the same level of care that our patients have come to expect and deserve until June 1," she said. "From the very beginning we said would do our best to retrain as many members of our (hospital) family as we could. We have had several internal job fairs, our employees have shown a great interest in transferring to another Iasis facility and every effort is being made to keep as many employees as possible."

"People are not bailing out," she added. "There are staff that will be transferring to another facility who will stay with us through May 31."

Applications from Mesa General employees are piling up on desks at Banner Health, the state's largest healthcare provider.

"We received between 15 and 20 applications since the announcement that Mesa General was closing," said Rosanna Bailey, recruitment program manager for the Banner east Mesa campus that includes Banner Baywood Medical Center and Banner Heart Hospital. "We've always gotten applicants from them, but not that many in a short amount of time."

Banner Baywood spokeswoman Coiya Lynn said job offers were extended to several applicants but she didn't know when they would start work.

Chandler Regional Medical Center has hired some of the 20 Mesa General nurses who applied for jobs, said the center's marketing and public relations manager, Julie Graham.

Mesa leaders continue to express disappointment that the hospital is closing and residents in neighborhoods near Mesa and University drives say they are concerned that the hospital will become another vacant building in west Mesa.

"I still am wondering why they are closing it," said Jessica Egnew, who lives about a block north of the hospital. "We are worried about what they are going to do with it and we sure don't want it abandoned. And we don't want whatever they put in there to bring down the neighborhood."

Mesa General's closing comes as new medical centers open in the Southeast Valley, including the 178-bed Mountain View Medical Center owned by Iasis Healthcare.

The 43-year-old hospital's landlord, Sierra Land Group Inc., has not announced any plans for the property.

"We want to make sure the land is put to good use," said Patricia Martineau, who lives in a neighborhood east of the hospital. "Every time something is closed down there is always concern about the downturn of the area."

Mesa developer and real estate investor Michael Pollack said continuing to use the hospital for medical services would be the most prudent choice at this time. Its worst use, he said, is office space.

"The highest and best use of that property is medical," he said. "We already have a huge supply of office space in this area and that last thing we need is a whole lot of additional space added to the market."

News Article: Feds Try to Cut Costs of Hospital Errors

Follow this link to read this story:
http://www.forbes.com/feeds/ap/2008/04/14/ap4888243.html

Seeking information on local Emergency Depts. with 24 Hour Case Managers…..

Good Afternoon Case Managers! I am seeking/surveying to find out which Phoenix area Hospitals utilize 24 hour Case Managers specfically assigned to the Emergency Department. Your help will be greatly appreciated! You can reply by making a comment to this post!

Thanks, Steve

A little off topic…but not really! - Top Worst Foods to Eat!

I had this emailed to me recently….we all love to eat out and some of this really surprised me (and then some didn’t) Enjoy!

The Top 20 Worst, Most Unhealthful Foods in America

20: Worst Fast-Food Chicken Meal - Chicken Selects Premium Breast Strips from McDonald’s (5 pieces) with cream ranch sauce. 830 Calories, 55 grams fat (4.5 trans fat), 48 carbs. Add a large fries and regular soda and this seemingly innocuous chicken meal tops out at 1,710 calories.

19: Worst drink - Jamba Juice Chocolate Moo’d Power Smoothie (30 fl oz). 900 calories, 10 g fat, 183 carbs, 166 g sugar. Jamba Juice calls it a smoothie, MSNBC calls it a milk shake. The beverage contains as much sugar as 8 pints of Ben & Jerry’s butter pecan ice cream.

18: Worst supermarket meal - Pepperidge Farm Roasted Chicken Pot Pie (whole pie). 1,020 calories, 64 g fat, 86 g carbs. Label may say this pie serves two, but, who ever divided a small pot pie in half? Once you crack the crust, there will be no stopping.

17: Worst ‘healthy’ burger - Ruby Tuesday Bella Turkey Burger. 1,145 calories, 71 g fat, 56 g carbs.

16: Worst Mexican entree - Chipotle Mexican Grill Chicken Burrito. 1,179 calories, 47 g fat, 125 g carbs, 2,656 mg sodium.

15: Worst kids’ meal - Macaroni Grill Double Macaroni ‘n’ Cheese. 1,210 calories, 62 g fat, 3,450 mg sodium. It’s like feeding your kid 1-1/2 boxes of Kraft mac ‘n’ cheese.

14: Worst sandwich - Quiznos Classic Italian (large). 1,528 calories, 92 g fat, 4,604 mg sodium, 110 g carbs. A large homemade sandwich would more likely provided about 500 calories.

13: Worst salad - On the Border Grande Taco Salad with Taco Beef. 1,450 calories, 102 g fat, 78 g carbs, 2,410 mg sodium. This isn’t an anomaly: Five different On the Border salads on the menu contain more than 1, 100 calories each.

12: Worst burger - Carl’s Jr. (Hardee’s on East Coast) Double Six Dollar Burger. 1,520 calories! , 111g fat. Carl’s Jr. brags it’s home to this enormous sandwich, but the restaurant chain also provides convenient nutrition info on its Web site — so ignorance is no excuse for eating it.

11 : Worst steak - Lonestar 20 oz T-bone. 1,540 calories, 124g fat. Add a baked potato and Lonestar’s Signature Lettuce Wedge, and this is a 2,700 calorie blowout.

10: Worst breakfast - Bob Evans Caramel Banana Pecan Cream Stacked and Stuffed hotcakes. 1,540 calories, 77 g fat (9 g trans fat), 198 g carbs, 109 g sugar. Five Egg McMuffins yield the same caloric cost as this stack of sugar-stuffed flapjacks, which is truly a heavy breakfast, weighing in at a hefty pound and a half.

9: Worst dessert - Chili’s Chocolate Chip Paradise Pie with Vanilla Ice Cream. 1,600 calories, 78 g fat, 215 g carbs. Would you eat a Big Mac for dessert? How about three? That’s the calorie equivalent of this decadent dish. Clearly, Chili’s customers get their money’s worth.

8: Worst Chinese entree - P.F. Chang’s Pork Lo Mein. 1,820 calories, 127 g fat,! 95 g carbs. The fat content in this dish alone provides more than 1,100 calories. And you’d have to eat almost five servings of pasta to match the number of carbs it contains. Now, do you really need five servings of pasta?

7: Worst chicken entree - Chili’s Honey Chipotle Crispers with Chipotle Sauce. 2,040 calories, 99 g fat, 240 g carbs. ‘Crispers’ refers to an extra thick layer of break crumbs that soak up oil and adds unnecessary calories and carbs to these glorified chicken strips.

6: Worst fish entree - On the Border Dos XX Fish Tacos with Rice and Beans. 2,100 calories, 130 g fat, 169 g carbs, 4,700 mg sodium. Perhaps the most misleadingly named dish in America : A dozen crunchy tacos from Taco Bell will saddle you with fewer calories.

5: Worst pizza - Uno Chicago Grill Chicago Classic Deep Dish Pizza. 2,310 calories, 162 g fat, 123 g carbs, 4,470 mg sodium. Downing this ‘personal’ pizza is equivalent to eating 18 slices of Domino’s Crunchy Thin Crust cheese pizza.

4: Worst pasta - Macaroni Grill Spaghetti and Meatballs with Meat Sauce. 2,430 calories, 128 g fat, 207 g carbs, 5,290 mg sodium. This meal satisfied your calorie requirements for an entire day.

3: Worst nachos - On the Border Stacked Border Nachos. 2,740 calories, 166 g fat, 191 g carbs, 5,280 sodium.

2: Worst starter - Chili’s Awesome Blossom. 2,710 calories, 203 g fat, 194 g carbs, 6,360 mg sodium.

1: The worst food in America - Outback Steakhouse Aussie Cheese Fries with Ranch Dressing. 2,900 calories, 182g fat, 240g carbs. Even if you split these ’starters’ with three friends, you’ll have downed a dinner’s worth of calories before you entree arrives.

WOW!

Article: Researchers Find Gene Mutation That Increases Asthma Risk

Great article! Link to it at:
http://health.usnews.com/usnews/health/healthday/080409/researchers-find-gene-mutation-that-increases-asthma-risk.htm

Article: “…patient centered case management results in 38% decrease in hospital admissions….”

I found this article dated Feb 15, 2007..It may be a little old, but good information on the impact Case Management has on healthcare!
Visit this link for the article: http://www.cmu.edu/news/archive/2007/February/feb15_blueshield.shtml
-ST

Salary.com report of Arizona Case Management Salaries

Salary.com reports that Arizona Nurse Case Managers Average between $52,791/year (25th percentile) and $68,255/year (90th percentile). Usefull information when assessing your employment situation and new opportunities.

Greetings Arizona Case Managers!

Welcome to the Arizona Nurse Case Management Blog! It is hoped that this will be an excellent forum for the exchange of information beneficial to the Case Management community! Please join me as I moderate posts and comments of useful and helpful information that will benefit our niche in the Healthcare field!

-Steve Thornley

More to come.....

Just starting this new blog! More to come!