Hello Case Managers!

I know it has been a while since I have posted. The new year has brought new challenges (and excitement) and a lot of work to do. I am personally excited to have the National CMSA conference being brought to Phoenix!

In my travels, I have found a great forum for Case Managers on the Web and with all the happenings going on right now, I may not be posting as much so wanted to point my readers to that great blog.

Please go to: http://allnurses.com/case-management-nursing/

Let's continue to cause of great Healthcare for all! This is not goodbye, just time out for a while.

Thanks so much, Steve

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.