Mary Ellen Schneider

Medicare beneficiaries seeking coverage for sexual reassignment surgery will no longer be automatically denied, thanks to a ruling from a federal appeals board.

On May 30, the Department of Health and Human Services departmental appeal board overturned a Medicare national coverage determination issued in 1989 that stated that transsexual surgery for sex reassignment would not be covered by the government because it was "experimental" and had a high rate of serious complications.

The appeals board ruled that the national coverage determination was no longer valid because it was based primarily on outdated scientific information from 1981.

Officials at the Centers for Medicare & Medicaid Services have 30 days to implement the decision. Aaron Albright, director of media relations at the CMS, said Medicare administrative contractors will make coverage decisions on a case by case basis or under a local coverage determination based on clinical evidence.

The decision does not address other treatments, including hormone therapy.

The ACLU, Gay & Lesbian Advocates & Defenders, and National Center for Lesbian Rights filed an administrative challenge to the Medicare national coverage policy in 2013 on behalf of Denee Mallon, a transgender woman who has been seeking surgery for severe gender dysphoria.

The groups praised the decision for removing a "threshold barrier" to medical care for transgender people who are covered by Medicare.

"It is consistent with the consensus of the medical and scientific community that access to gender transition–related care is medically necessary for many people with gender dysphoria," the groups said in a statement. "The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition–related surgeries denied. They should either get coverage, or at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment."

[email protected]

On Twitter @maryellenny

Medicare beneficiaries seeking coverage for sexual reassignment surgery will no longer be automatically denied, thanks to a ruling from a federal appeals board.

On May 30, the Department of Health and Human Services departmental appeal board overturned a Medicare national coverage determination issued in 1989 that stated that transsexual surgery for sex reassignment would not be covered by the government because it was "experimental" and had a high rate of serious complications.

The appeals board ruled that the national coverage determination was no longer valid because it was based primarily on outdated scientific information from 1981.

Officials at the Centers for Medicare & Medicaid Services have 30 days to implement the decision. Aaron Albright, director of media relations at the CMS, said Medicare administrative contractors will make coverage decisions on a case by case basis or under a local coverage determination based on clinical evidence.

The decision does not address other treatments, including hormone therapy.

The ACLU, Gay & Lesbian Advocates & Defenders, and National Center for Lesbian Rights filed an administrative challenge to the Medicare national coverage policy in 2013 on behalf of Denee Mallon, a transgender woman who has been seeking surgery for severe gender dysphoria.

The groups praised the decision for removing a "threshold barrier" to medical care for transgender people who are covered by Medicare.

"It is consistent with the consensus of the medical and scientific community that access to gender transition–related care is medically necessary for many people with gender dysphoria," the groups said in a statement. "The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition–related surgeries denied. They should either get coverage, or at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment."

[email protected]

On Twitter @maryellenny

Medicare beneficiaries seeking coverage for sexual reassignment surgery will no longer be automatically denied, thanks to a ruling from a federal appeals board.

On May 30, the Department of Health and Human Services departmental appeal board overturned a Medicare national coverage determination issued in 1989 that stated that transsexual surgery for sex reassignment would not be covered by the government because it was "experimental" and had a high rate of serious complications.

The appeals board ruled that the national coverage determination was no longer valid because it was based primarily on outdated scientific information from 1981.

Officials at the Centers for Medicare & Medicaid Services have 30 days to implement the decision. Aaron Albright, director of media relations at the CMS, said Medicare administrative contractors will make coverage decisions on a case by case basis or under a local coverage determination based on clinical evidence.

The decision does not address other treatments, including hormone therapy.

The ACLU, Gay & Lesbian Advocates & Defenders, and National Center for Lesbian Rights filed an administrative challenge to the Medicare national coverage policy in 2013 on behalf of Denee Mallon, a transgender woman who has been seeking surgery for severe gender dysphoria.

The groups praised the decision for removing a "threshold barrier" to medical care for transgender people who are covered by Medicare.

"It is consistent with the consensus of the medical and scientific community that access to gender transition–related care is medically necessary for many people with gender dysphoria," the groups said in a statement. "The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition–related surgeries denied. They should either get coverage, or at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment."

[email protected]

On Twitter @maryellenny

On June 1, physicians and teaching hospitals began registering with the Centers for Medicare & Medicaid Services to review their data under the Open Payments program.

Under Open Payments – previously – CMS officials publish information on the financial relationship between physicians and drug and device manufacturers. In September, CMS plans to release information on payments and gifts made to individual physicians and teaching hospitals during the last five months of 2013. The payments may include compensations for meals and travel, consulting payments, or research grants.

The data release will be based on information collected and reported by the drug and device industry. However, physicians and teaching hospitals will have a chance to review and dispute their data before September.

Starting June 1, physicians and teaching hospitals were able to register on the CMS Enterprise Portal. In July, physicians and teaching hospitals must register again in the Open Payments system. Once registered in both systems, providers will be notified if data is submitted about them.

While there is no deadline for registration in either the Enterprise Portal or the Open Payment system, physicians and teaching hospitals will have only 45 days to review their data once it becomes available.

Data can be disputed during the 45-day period; however, if disputed data is not corrected by the drug or device manufacturer, it will be publicly listed as disputed.

Physicians aren’t required to review their data, but both CMS and the American Medical Association are encouraging them to do so.

The Open Payments program "will impact many physicians with a current medical license and it is important that they are properly registered to review and ensure the accuracy of the data reported by manufacturers and group purchasing organizations before the world sees it," Dr. Ardis Hoven, AMA president, said in a statement. "To avert one of the problems that came to light as a result of the Medicare claims data release earlier this year, we strongly urge physicians to make sure their information in the national provider identifier (NPI) database is current."

The AMA is asking CMS to give physicians more time to review and dispute their data.

The AMA has also released an online toolkit to help physicians stay on top of the Open Payments deadlines.

[email protected]

On Twitter @maryellenny

*Updated 6/2/2014

On June 1, physicians and teaching hospitals began registering with the Centers for Medicare & Medicaid Services to review their data under the Open Payments program.

Under Open Payments – previously – CMS officials publish information on the financial relationship between physicians and drug and device manufacturers. In September, CMS plans to release information on payments and gifts made to individual physicians and teaching hospitals during the last five months of 2013. The payments may include compensations for meals and travel, consulting payments, or research grants.

The data release will be based on information collected and reported by the drug and device industry. However, physicians and teaching hospitals will have a chance to review and dispute their data before September.

Starting June 1, physicians and teaching hospitals were able to register on the CMS Enterprise Portal. In July, physicians and teaching hospitals must register again in the Open Payments system. Once registered in both systems, providers will be notified if data is submitted about them.

While there is no deadline for registration in either the Enterprise Portal or the Open Payment system, physicians and teaching hospitals will have only 45 days to review their data once it becomes available.

Data can be disputed during the 45-day period; however, if disputed data is not corrected by the drug or device manufacturer, it will be publicly listed as disputed.

Physicians aren’t required to review their data, but both CMS and the American Medical Association are encouraging them to do so.

The Open Payments program "will impact many physicians with a current medical license and it is important that they are properly registered to review and ensure the accuracy of the data reported by manufacturers and group purchasing organizations before the world sees it," Dr. Ardis Hoven, AMA president, said in a statement. "To avert one of the problems that came to light as a result of the Medicare claims data release earlier this year, we strongly urge physicians to make sure their information in the national provider identifier (NPI) database is current."

The AMA is asking CMS to give physicians more time to review and dispute their data.

The AMA has also released an online toolkit to help physicians stay on top of the Open Payments deadlines.

[email protected]

On Twitter @maryellenny

*Updated 6/2/2014

On June 1, physicians and teaching hospitals began registering with the Centers for Medicare & Medicaid Services to review their data under the Open Payments program.

Under Open Payments – previously – CMS officials publish information on the financial relationship between physicians and drug and device manufacturers. In September, CMS plans to release information on payments and gifts made to individual physicians and teaching hospitals during the last five months of 2013. The payments may include compensations for meals and travel, consulting payments, or research grants.

The data release will be based on information collected and reported by the drug and device industry. However, physicians and teaching hospitals will have a chance to review and dispute their data before September.

Starting June 1, physicians and teaching hospitals were able to register on the CMS Enterprise Portal. In July, physicians and teaching hospitals must register again in the Open Payments system. Once registered in both systems, providers will be notified if data is submitted about them.

While there is no deadline for registration in either the Enterprise Portal or the Open Payment system, physicians and teaching hospitals will have only 45 days to review their data once it becomes available.

Data can be disputed during the 45-day period; however, if disputed data is not corrected by the drug or device manufacturer, it will be publicly listed as disputed.

Physicians aren’t required to review their data, but both CMS and the American Medical Association are encouraging them to do so.

The Open Payments program "will impact many physicians with a current medical license and it is important that they are properly registered to review and ensure the accuracy of the data reported by manufacturers and group purchasing organizations before the world sees it," Dr. Ardis Hoven, AMA president, said in a statement. "To avert one of the problems that came to light as a result of the Medicare claims data release earlier this year, we strongly urge physicians to make sure their information in the national provider identifier (NPI) database is current."

The AMA is asking CMS to give physicians more time to review and dispute their data.

The AMA has also released an online toolkit to help physicians stay on top of the Open Payments deadlines.

[email protected]

On Twitter @maryellenny

*Updated 6/2/2014

The Food and Drug Administration is requiring all tanning beds to carry a "black box" warning that the devices should not be used by children under age 18 years.

The labeling doesn’t carry any penalties for allowing teens to use tanning beds, but FDA officials said it sends a signal about their safety to the public.

"It reflects a very strong statement by FDA that we do not believe [tanning beds] should be used in individuals under the age of 18 because of the evidence that cumulative exposure to UV radiation is harmful to individuals and increases the likelihood of skin cancers, including melanoma," said Nancy Stade, deputy director for policy at the FDA’s Center for Devices and Radiological Health.

©Vidmantas Goldbergas/iStockphoto.com

Agency officials did not rule out taking further actions to restrict tanning bed use in the future.

In a final order released on May 29, the FDA reclassified sunlamp products and ultraviolet (UV) lamps intended for use in sunlamp products from class I (low-risk) to class II (moderate-risk) devices. The regulatory change allows the agency to require tanning bed manufacturers to submit a premarket notification, also called a 510(k) submission, prior to marketing the devices. The premarket notification process requires manufacturers to show that their products meet certain performance testing requirements.

The new classification also allows FDA to require more stringent labeling of tanning beds.

The FDA is ordering all tanning beds to prominently display a black box warning on the device that states "Attention: This sunlamp product should not be used on persons under the age of 18 years."

Marketing materials including websites, brochures, and user instructions must carry four additional warning statements under the new FDA order. The warning statements include:

• Contraindication: This product is contraindicated for use on persons under the age of 18 years.

• Contraindication: This product must not be used if skin lesions or open wounds are present.

• Warning: This product should not be used on individuals who have had skin cancer or have a family history of skin cancer.

• Warning: Persons repeatedly exposed to UV radiation should be regularly evaluated for skin cancer.

In strengthening the warning label for tanning beds, the FDA cited statistics from the American Academy of Dermatology that individuals who have been exposed to UV radiation from indoor tanning experience a 59% increase in their risk of melanoma. The risk increases each time an individual uses a sunlamp product, according to the AAD.

The new rules take effect 90 days after their official publication on June 2. For new tanning devices, manufacturers must begin submitting 510(k) notifications after the effective date of the regulation. For devices that are already on the market, manufacturers have 450 days to submit their 510(k) notification and comply with the new labeling requirements.

Physician groups, including the AAD, praised the increased regulation of tanning beds.

"Restricting teens’ access to indoor tanning is critical to preventing skin cancer," Dr. Brett M. Coldiron, president of the AAD, said in a statement. "As medical doctors who diagnose and treat skin cancer, dermatologists are committed to reducing its incidence and saving lives. Therefore, we will continue to communicate to the FDA the need for stricter regulations on the use and sale of indoor tanning devices for minors under the age of 18."

[email protected]

On Twitter @maryellenny

The Food and Drug Administration is requiring all tanning beds to carry a "black box" warning that the devices should not be used by children under age 18 years.

The labeling doesn’t carry any penalties for allowing teens to use tanning beds, but FDA officials said it sends a signal about their safety to the public.

"It reflects a very strong statement by FDA that we do not believe [tanning beds] should be used in individuals under the age of 18 because of the evidence that cumulative exposure to UV radiation is harmful to individuals and increases the likelihood of skin cancers, including melanoma," said Nancy Stade, deputy director for policy at the FDA’s Center for Devices and Radiological Health.

©Vidmantas Goldbergas/iStockphoto.com

Agency officials did not rule out taking further actions to restrict tanning bed use in the future.

In a final order released on May 29, the FDA reclassified sunlamp products and ultraviolet (UV) lamps intended for use in sunlamp products from class I (low-risk) to class II (moderate-risk) devices. The regulatory change allows the agency to require tanning bed manufacturers to submit a premarket notification, also called a 510(k) submission, prior to marketing the devices. The premarket notification process requires manufacturers to show that their products meet certain performance testing requirements.

The new classification also allows FDA to require more stringent labeling of tanning beds.

The FDA is ordering all tanning beds to prominently display a black box warning on the device that states "Attention: This sunlamp product should not be used on persons under the age of 18 years."

Marketing materials including websites, brochures, and user instructions must carry four additional warning statements under the new FDA order. The warning statements include:

• Contraindication: This product is contraindicated for use on persons under the age of 18 years.

• Contraindication: This product must not be used if skin lesions or open wounds are present.

• Warning: This product should not be used on individuals who have had skin cancer or have a family history of skin cancer.

• Warning: Persons repeatedly exposed to UV radiation should be regularly evaluated for skin cancer.

In strengthening the warning label for tanning beds, the FDA cited statistics from the American Academy of Dermatology that individuals who have been exposed to UV radiation from indoor tanning experience a 59% increase in their risk of melanoma. The risk increases each time an individual uses a sunlamp product, according to the AAD.

The new rules take effect 90 days after their official publication on June 2. For new tanning devices, manufacturers must begin submitting 510(k) notifications after the effective date of the regulation. For devices that are already on the market, manufacturers have 450 days to submit their 510(k) notification and comply with the new labeling requirements.

Physician groups, including the AAD, praised the increased regulation of tanning beds.

"Restricting teens’ access to indoor tanning is critical to preventing skin cancer," Dr. Brett M. Coldiron, president of the AAD, said in a statement. "As medical doctors who diagnose and treat skin cancer, dermatologists are committed to reducing its incidence and saving lives. Therefore, we will continue to communicate to the FDA the need for stricter regulations on the use and sale of indoor tanning devices for minors under the age of 18."

[email protected]

On Twitter @maryellenny

The Food and Drug Administration is requiring all tanning beds to carry a "black box" warning that the devices should not be used by children under age 18 years.

The labeling doesn’t carry any penalties for allowing teens to use tanning beds, but FDA officials said it sends a signal about their safety to the public.

"It reflects a very strong statement by FDA that we do not believe [tanning beds] should be used in individuals under the age of 18 because of the evidence that cumulative exposure to UV radiation is harmful to individuals and increases the likelihood of skin cancers, including melanoma," said Nancy Stade, deputy director for policy at the FDA’s Center for Devices and Radiological Health.

©Vidmantas Goldbergas/iStockphoto.com

Agency officials did not rule out taking further actions to restrict tanning bed use in the future.

In a final order released on May 29, the FDA reclassified sunlamp products and ultraviolet (UV) lamps intended for use in sunlamp products from class I (low-risk) to class II (moderate-risk) devices. The regulatory change allows the agency to require tanning bed manufacturers to submit a premarket notification, also called a 510(k) submission, prior to marketing the devices. The premarket notification process requires manufacturers to show that their products meet certain performance testing requirements.

The new classification also allows FDA to require more stringent labeling of tanning beds.

The FDA is ordering all tanning beds to prominently display a black box warning on the device that states "Attention: This sunlamp product should not be used on persons under the age of 18 years."

Marketing materials including websites, brochures, and user instructions must carry four additional warning statements under the new FDA order. The warning statements include:

• Contraindication: This product is contraindicated for use on persons under the age of 18 years.

• Contraindication: This product must not be used if skin lesions or open wounds are present.

• Warning: This product should not be used on individuals who have had skin cancer or have a family history of skin cancer.

• Warning: Persons repeatedly exposed to UV radiation should be regularly evaluated for skin cancer.

In strengthening the warning label for tanning beds, the FDA cited statistics from the American Academy of Dermatology that individuals who have been exposed to UV radiation from indoor tanning experience a 59% increase in their risk of melanoma. The risk increases each time an individual uses a sunlamp product, according to the AAD.

The new rules take effect 90 days after their official publication on June 2. For new tanning devices, manufacturers must begin submitting 510(k) notifications after the effective date of the regulation. For devices that are already on the market, manufacturers have 450 days to submit their 510(k) notification and comply with the new labeling requirements.

Physician groups, including the AAD, praised the increased regulation of tanning beds.

"Restricting teens’ access to indoor tanning is critical to preventing skin cancer," Dr. Brett M. Coldiron, president of the AAD, said in a statement. "As medical doctors who diagnose and treat skin cancer, dermatologists are committed to reducing its incidence and saving lives. Therefore, we will continue to communicate to the FDA the need for stricter regulations on the use and sale of indoor tanning devices for minors under the age of 18."

[email protected]

On Twitter @maryellenny

The boarding of patients in the emergency department continues to plague hospitals. But could a registry of psychiatric bed availability help ease the problem?

More than 12% of emergency department (ED) visits were for mental health, substance abuse conditions, or both in 2007, according to government data, and those patients were two-and-a-half times more likely to be admitted to the hospital than ED patients with other conditions. But there are fewer and fewer beds available for these patients.

Nationally, there are about 26.1 inpatient psychiatric beds per 100,000 patients, down from 29.9 in 2009, according to a report from the American College of Emergency Physicians. And experts say that around 50 beds/100,000 are actually needed to meet the current demand.

The result is that patients experiencing a mental health crisis are often boarded in the ED with limited or no psychiatric treatment for hours or days.

Some states are looking at psychiatric bed registries as a way to quickly identify needed beds and ease the ED backlog.

Virginia is the latest place to begin using an online system to track the availability of inpatient psychiatric beds. In March, the Virginia Acute Psychiatric and CSB Bed Registry went live, providing data on open beds at public mental health hospitals, private hospitals, and crisis stabilization units throughout the state. The website, which is run in partnership with the state hospital association, is updated daily.

The site is designed to aid clinicians who are trying to place individuals in mental health crisis who are under an emergency custody order and need to receive treatment under a temporary detention order. All crisis stabilization units and state hospitals are required to participate in the bed registry, but private hospital participation is voluntary.

Virginia isn’t alone in exploring this solution. Neighboring Maryland has had a bed registry in place for a little over a year. And Minnesota launched a statewide registry in 2007. Other states also have bed registries, but there is large variation in the number of facilities they cover and how often they are updated.

Emergency physicians in Pennsylvania are asking their state legislature to create a registry, saying it would help cut down the time patients in mental health crisis spend in the ED generally with little or no treatment for their psychiatric conditions.

"You can go online at the Home Depot and find out if they have a certain product in the store near you or if you have to go to the next county over," said Dr. Charles F. Barbera, chairman of emergency medicine at Reading (Pa.) Health System and president of the Pennsylvania chapter of the American College of Emergency Physicians (ACEP). "But, for medicine, we don’t have a lot of that" capability.

Aside from the waiting, the lack of a statewide registry puts a burden on the ED staff, Dr. Barbera said. "What we wind up doing is getting on the phone and basically calling until we get lucky," he said.

That kind of time-consuming and haphazard bed shopping is what prompted emergency physicians in Maryland to seek a registry in 2012, said Dr. Richard Alcorta, an emergency physician and medical director for the state’s Emergency Medical Services, part of the Maryland Institute for Emergency Medical Services Systems.

Working with the Maryland Hospital Association and the state’s ACEP chapter, EMS officials there developed an online system that allows inpatient facilities to post their available psychiatric beds and emergency departments to post about patients in need of placement.

But the roll out of the registry has been a bit rocky, said Dr. Alcorta, a past president of the Maryland chapter of ACEP.

Participation in the registry is voluntary and its success relies on a critical mass of hospitals being willing to post their availability at least twice daily. At its peak, participation by inpatient facilities and EDs was around 30%, Dr Alcorta said.

Part of the problem is that the registry launched in November 2012, right as state officials and hospitals were coping with the arrival of Superstorm Sandy. That set back their training programs by several months.

The dilemma for state officials is that if inpatient facilities don’t post beds, EDs won’t post patients, and vice versa. Aside from providing a practical tool for patient placement, higher participation would give state officials much-needed data about whether there is a general lack of inpatient psychiatric beds. "I can’t answer that question today," Dr. Alcorta said.

In Minnesota, they’ve had better luck getting buy-in for the registry system. Their bed registry, which was launched in 2007, now has close to 100% participation by hospitals that report up to 3 times a day to keep the data fresh. They even expanded the registry to include crisis service providers and community-based services such as intensive residential treatment and crisis residential treatment.

"It’s just the standard of care here," said Dave Hartford, the outgoing assistant commissioner of chemical and mental health services in the Minnesota Department of Human Services. "It would be hard to function without it."

The inventory of inpatient psychiatric beds is very tight, Mr. Hartford said, and without a registry system it would take hospital personnel hours to identify available beds on some days. "This is a way to save a lot of time and have options and actually serve patients," he said.

While the registry is well accepted today, Mr. Hartford said that it took some time for hospitals to make reporting bed availability part of their standard operating procedures. During the first year, the state hired staff to remind hospital personnel to report into the registry, he said.

Doris Fuller, executive director of the Treatment Advocacy Center, which produces reports on mental health services, said she favors registries as a way to get patients mental health treatment when they need it. But registries are just a tool, she said, and don’t create more capacity in the system.

"You can have a registry, but if there are not very many beds out there, where does that leave you? Ms. Fuller said. "The fundamental problem with boarding is that there simply aren’t enough beds for the number of people who are going to be in psychiatric crisis on any given day."

Dr. Leslie Zun, chairman of emergency medicine at Mount Sinai Hospital in Chicago and an expert on behavioral emergencies, said registries could provide some helpful information about bed availability, but that’s about all.

"I think it’s putting a [bandage] on a hemorrhage," he said.

Emergency physicians would be better served, Dr. Zun said, if they focused on lining up psychiatric services for boarded patients either through an onsite consultation or telepsychiatry. And ED physicians also need to look into alternative care sites like crisis stabilization units.

[email protected]

On Twitter @maryellenny

The boarding of patients in the emergency department continues to plague hospitals. But could a registry of psychiatric bed availability help ease the problem?

More than 12% of emergency department (ED) visits were for mental health, substance abuse conditions, or both in 2007, according to government data, and those patients were two-and-a-half times more likely to be admitted to the hospital than ED patients with other conditions. But there are fewer and fewer beds available for these patients.

Nationally, there are about 26.1 inpatient psychiatric beds per 100,000 patients, down from 29.9 in 2009, according to a report from the American College of Emergency Physicians. And experts say that around 50 beds/100,000 are actually needed to meet the current demand.

The result is that patients experiencing a mental health crisis are often boarded in the ED with limited or no psychiatric treatment for hours or days.

Some states are looking at psychiatric bed registries as a way to quickly identify needed beds and ease the ED backlog.

Virginia is the latest place to begin using an online system to track the availability of inpatient psychiatric beds. In March, the Virginia Acute Psychiatric and CSB Bed Registry went live, providing data on open beds at public mental health hospitals, private hospitals, and crisis stabilization units throughout the state. The website, which is run in partnership with the state hospital association, is updated daily.

The site is designed to aid clinicians who are trying to place individuals in mental health crisis who are under an emergency custody order and need to receive treatment under a temporary detention order. All crisis stabilization units and state hospitals are required to participate in the bed registry, but private hospital participation is voluntary.

Virginia isn’t alone in exploring this solution. Neighboring Maryland has had a bed registry in place for a little over a year. And Minnesota launched a statewide registry in 2007. Other states also have bed registries, but there is large variation in the number of facilities they cover and how often they are updated.

Emergency physicians in Pennsylvania are asking their state legislature to create a registry, saying it would help cut down the time patients in mental health crisis spend in the ED generally with little or no treatment for their psychiatric conditions.

"You can go online at the Home Depot and find out if they have a certain product in the store near you or if you have to go to the next county over," said Dr. Charles F. Barbera, chairman of emergency medicine at Reading (Pa.) Health System and president of the Pennsylvania chapter of the American College of Emergency Physicians (ACEP). "But, for medicine, we don’t have a lot of that" capability.

Aside from the waiting, the lack of a statewide registry puts a burden on the ED staff, Dr. Barbera said. "What we wind up doing is getting on the phone and basically calling until we get lucky," he said.

That kind of time-consuming and haphazard bed shopping is what prompted emergency physicians in Maryland to seek a registry in 2012, said Dr. Richard Alcorta, an emergency physician and medical director for the state’s Emergency Medical Services, part of the Maryland Institute for Emergency Medical Services Systems.

Working with the Maryland Hospital Association and the state’s ACEP chapter, EMS officials there developed an online system that allows inpatient facilities to post their available psychiatric beds and emergency departments to post about patients in need of placement.

But the roll out of the registry has been a bit rocky, said Dr. Alcorta, a past president of the Maryland chapter of ACEP.

Participation in the registry is voluntary and its success relies on a critical mass of hospitals being willing to post their availability at least twice daily. At its peak, participation by inpatient facilities and EDs was around 30%, Dr Alcorta said.

Part of the problem is that the registry launched in November 2012, right as state officials and hospitals were coping with the arrival of Superstorm Sandy. That set back their training programs by several months.

The dilemma for state officials is that if inpatient facilities don’t post beds, EDs won’t post patients, and vice versa. Aside from providing a practical tool for patient placement, higher participation would give state officials much-needed data about whether there is a general lack of inpatient psychiatric beds. "I can’t answer that question today," Dr. Alcorta said.

In Minnesota, they’ve had better luck getting buy-in for the registry system. Their bed registry, which was launched in 2007, now has close to 100% participation by hospitals that report up to 3 times a day to keep the data fresh. They even expanded the registry to include crisis service providers and community-based services such as intensive residential treatment and crisis residential treatment.

"It’s just the standard of care here," said Dave Hartford, the outgoing assistant commissioner of chemical and mental health services in the Minnesota Department of Human Services. "It would be hard to function without it."

The inventory of inpatient psychiatric beds is very tight, Mr. Hartford said, and without a registry system it would take hospital personnel hours to identify available beds on some days. "This is a way to save a lot of time and have options and actually serve patients," he said.

While the registry is well accepted today, Mr. Hartford said that it took some time for hospitals to make reporting bed availability part of their standard operating procedures. During the first year, the state hired staff to remind hospital personnel to report into the registry, he said.

Doris Fuller, executive director of the Treatment Advocacy Center, which produces reports on mental health services, said she favors registries as a way to get patients mental health treatment when they need it. But registries are just a tool, she said, and don’t create more capacity in the system.

"You can have a registry, but if there are not very many beds out there, where does that leave you? Ms. Fuller said. "The fundamental problem with boarding is that there simply aren’t enough beds for the number of people who are going to be in psychiatric crisis on any given day."

Dr. Leslie Zun, chairman of emergency medicine at Mount Sinai Hospital in Chicago and an expert on behavioral emergencies, said registries could provide some helpful information about bed availability, but that’s about all.

"I think it’s putting a [bandage] on a hemorrhage," he said.

Emergency physicians would be better served, Dr. Zun said, if they focused on lining up psychiatric services for boarded patients either through an onsite consultation or telepsychiatry. And ED physicians also need to look into alternative care sites like crisis stabilization units.

[email protected]

On Twitter @maryellenny

The boarding of patients in the emergency department continues to plague hospitals. But could a registry of psychiatric bed availability help ease the problem?

More than 12% of emergency department (ED) visits were for mental health, substance abuse conditions, or both in 2007, according to government data, and those patients were two-and-a-half times more likely to be admitted to the hospital than ED patients with other conditions. But there are fewer and fewer beds available for these patients.

Nationally, there are about 26.1 inpatient psychiatric beds per 100,000 patients, down from 29.9 in 2009, according to a report from the American College of Emergency Physicians. And experts say that around 50 beds/100,000 are actually needed to meet the current demand.

The result is that patients experiencing a mental health crisis are often boarded in the ED with limited or no psychiatric treatment for hours or days.

Some states are looking at psychiatric bed registries as a way to quickly identify needed beds and ease the ED backlog.

Virginia is the latest place to begin using an online system to track the availability of inpatient psychiatric beds. In March, the Virginia Acute Psychiatric and CSB Bed Registry went live, providing data on open beds at public mental health hospitals, private hospitals, and crisis stabilization units throughout the state. The website, which is run in partnership with the state hospital association, is updated daily.

The site is designed to aid clinicians who are trying to place individuals in mental health crisis who are under an emergency custody order and need to receive treatment under a temporary detention order. All crisis stabilization units and state hospitals are required to participate in the bed registry, but private hospital participation is voluntary.

Virginia isn’t alone in exploring this solution. Neighboring Maryland has had a bed registry in place for a little over a year. And Minnesota launched a statewide registry in 2007. Other states also have bed registries, but there is large variation in the number of facilities they cover and how often they are updated.

Emergency physicians in Pennsylvania are asking their state legislature to create a registry, saying it would help cut down the time patients in mental health crisis spend in the ED generally with little or no treatment for their psychiatric conditions.

"You can go online at the Home Depot and find out if they have a certain product in the store near you or if you have to go to the next county over," said Dr. Charles F. Barbera, chairman of emergency medicine at Reading (Pa.) Health System and president of the Pennsylvania chapter of the American College of Emergency Physicians (ACEP). "But, for medicine, we don’t have a lot of that" capability.

Aside from the waiting, the lack of a statewide registry puts a burden on the ED staff, Dr. Barbera said. "What we wind up doing is getting on the phone and basically calling until we get lucky," he said.

That kind of time-consuming and haphazard bed shopping is what prompted emergency physicians in Maryland to seek a registry in 2012, said Dr. Richard Alcorta, an emergency physician and medical director for the state’s Emergency Medical Services, part of the Maryland Institute for Emergency Medical Services Systems.

Working with the Maryland Hospital Association and the state’s ACEP chapter, EMS officials there developed an online system that allows inpatient facilities to post their available psychiatric beds and emergency departments to post about patients in need of placement.

But the roll out of the registry has been a bit rocky, said Dr. Alcorta, a past president of the Maryland chapter of ACEP.

Participation in the registry is voluntary and its success relies on a critical mass of hospitals being willing to post their availability at least twice daily. At its peak, participation by inpatient facilities and EDs was around 30%, Dr Alcorta said.

Part of the problem is that the registry launched in November 2012, right as state officials and hospitals were coping with the arrival of Superstorm Sandy. That set back their training programs by several months.

The dilemma for state officials is that if inpatient facilities don’t post beds, EDs won’t post patients, and vice versa. Aside from providing a practical tool for patient placement, higher participation would give state officials much-needed data about whether there is a general lack of inpatient psychiatric beds. "I can’t answer that question today," Dr. Alcorta said.

In Minnesota, they’ve had better luck getting buy-in for the registry system. Their bed registry, which was launched in 2007, now has close to 100% participation by hospitals that report up to 3 times a day to keep the data fresh. They even expanded the registry to include crisis service providers and community-based services such as intensive residential treatment and crisis residential treatment.

"It’s just the standard of care here," said Dave Hartford, the outgoing assistant commissioner of chemical and mental health services in the Minnesota Department of Human Services. "It would be hard to function without it."

The inventory of inpatient psychiatric beds is very tight, Mr. Hartford said, and without a registry system it would take hospital personnel hours to identify available beds on some days. "This is a way to save a lot of time and have options and actually serve patients," he said.

While the registry is well accepted today, Mr. Hartford said that it took some time for hospitals to make reporting bed availability part of their standard operating procedures. During the first year, the state hired staff to remind hospital personnel to report into the registry, he said.

Doris Fuller, executive director of the Treatment Advocacy Center, which produces reports on mental health services, said she favors registries as a way to get patients mental health treatment when they need it. But registries are just a tool, she said, and don’t create more capacity in the system.

"You can have a registry, but if there are not very many beds out there, where does that leave you? Ms. Fuller said. "The fundamental problem with boarding is that there simply aren’t enough beds for the number of people who are going to be in psychiatric crisis on any given day."

Dr. Leslie Zun, chairman of emergency medicine at Mount Sinai Hospital in Chicago and an expert on behavioral emergencies, said registries could provide some helpful information about bed availability, but that’s about all.

"I think it’s putting a [bandage] on a hemorrhage," he said.

Emergency physicians would be better served, Dr. Zun said, if they focused on lining up psychiatric services for boarded patients either through an onsite consultation or telepsychiatry. And ED physicians also need to look into alternative care sites like crisis stabilization units.

[email protected]

On Twitter @maryellenny

Federal officials are proposing to give physicians some extra time to move to 2014 edition certified electronic health record technology and still qualify for incentives under the Medicare and Medicaid EHR Incentive Programs.

Under a proposed rule released on May 20, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC) would allow physicians, hospitals, and other eligible health care providers to continue using 2011 edition certified products or a combination of 2011 and 2014 edition certified products during the 2014 reporting period in the EHR Incentive Programs.

Though 2014 edition certified EHR products are currently available, there is a backlog of several months for the newer versions to be installed in hospitals and physician offices, according to CMS.

"Increasing the adoption of EHRs is key to improving the nation’s health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," Dr. Karen DeSalvo, national coordinator for health information technology, said in a statement.

Physicians and hospitals would need to complete the switch to 2014 edition certified products in time for the Medicare and Medicaid programs’ 2015 reporting periods.

But there are some exceptions, the proposal states that to qualify for an incentive payment under Medicaid for adopting, implementing, or upgrading certified EHRs for 2014, the provider must use 2014 edition products only.

Physicians and hospitals may have to adjust their plans for attesting to EHR meaningful use depending on which edition of the certified technology they have available. For instance, the 2011 edition technology alone does not have the functionality required to meet the Stage 2 objectives and measures.

Providers who are scheduled to begin Stage 2 for the 2014 reporting period, but can’t fully implement the functions of their 2014 edition certified technology, have the option of attest to Stage 1 objective and measures for 2014. But they must attest that they are unable to fully implement their technology due to delays, according to the proposal.

The proposal also formalizes the government’s plan to extend some of the deadlines in the "meaningful use" program. In December, CMS announced in a blog post that it would extend reporting for Stage 2 of meaningful use through 2016 and would begin Stage 3 in 2017.

The change primarily affects physicians who began attesting to meaningful EHR use in 2011 and 2012. Those physicians were scheduled to advance to Stage 3 in 2016, after 2 years working on Stage 2. The change gives them an additional year before advancing to Stage 3.

While the proposed rule responds to concerns raised by physicians and vendors about the problems in implementing 2014 edition certified products, it does not address other critiques of the meaningful use program. The American Medical Association noted that the proposed changes are helpful, but they still leave intact an all-or-nothing approach to meaningful use requirements.

"Our chief concern remains unaddressed, and we worry that current requirements will slow the adoption of technology that will help coordinate care and improve quality, and that many physicians will drop out of the meaningful use program if the current all-or-nothing approach remains in place," Dr. Steven J. Stack, the AMA’s immediate past board chairman, said in a statement. "To date, approximately 20% of eligible professionals – mostly doctors – have dropped out of the program, and we expect this number to grow unless more changes are made."

The AMA recommends using a 75% pass rate as the standard for achieving meaningful use, and allowing physicians who meet 50% of meaningful use requirements to avoid financial penalties. CMS should also do a better job of aligning the Physician Quality Reporting System, the Value Based Modifier, and meaningful use requirements.

[email protected]

On Twitter @maryellenny

Federal officials are proposing to give physicians some extra time to move to 2014 edition certified electronic health record technology and still qualify for incentives under the Medicare and Medicaid EHR Incentive Programs.

Under a proposed rule released on May 20, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC) would allow physicians, hospitals, and other eligible health care providers to continue using 2011 edition certified products or a combination of 2011 and 2014 edition certified products during the 2014 reporting period in the EHR Incentive Programs.

Though 2014 edition certified EHR products are currently available, there is a backlog of several months for the newer versions to be installed in hospitals and physician offices, according to CMS.

"Increasing the adoption of EHRs is key to improving the nation’s health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," Dr. Karen DeSalvo, national coordinator for health information technology, said in a statement.

Physicians and hospitals would need to complete the switch to 2014 edition certified products in time for the Medicare and Medicaid programs’ 2015 reporting periods.

But there are some exceptions, the proposal states that to qualify for an incentive payment under Medicaid for adopting, implementing, or upgrading certified EHRs for 2014, the provider must use 2014 edition products only.

Physicians and hospitals may have to adjust their plans for attesting to EHR meaningful use depending on which edition of the certified technology they have available. For instance, the 2011 edition technology alone does not have the functionality required to meet the Stage 2 objectives and measures.

Providers who are scheduled to begin Stage 2 for the 2014 reporting period, but can’t fully implement the functions of their 2014 edition certified technology, have the option of attest to Stage 1 objective and measures for 2014. But they must attest that they are unable to fully implement their technology due to delays, according to the proposal.

The proposal also formalizes the government’s plan to extend some of the deadlines in the "meaningful use" program. In December, CMS announced in a blog post that it would extend reporting for Stage 2 of meaningful use through 2016 and would begin Stage 3 in 2017.

The change primarily affects physicians who began attesting to meaningful EHR use in 2011 and 2012. Those physicians were scheduled to advance to Stage 3 in 2016, after 2 years working on Stage 2. The change gives them an additional year before advancing to Stage 3.

While the proposed rule responds to concerns raised by physicians and vendors about the problems in implementing 2014 edition certified products, it does not address other critiques of the meaningful use program. The American Medical Association noted that the proposed changes are helpful, but they still leave intact an all-or-nothing approach to meaningful use requirements.

"Our chief concern remains unaddressed, and we worry that current requirements will slow the adoption of technology that will help coordinate care and improve quality, and that many physicians will drop out of the meaningful use program if the current all-or-nothing approach remains in place," Dr. Steven J. Stack, the AMA’s immediate past board chairman, said in a statement. "To date, approximately 20% of eligible professionals – mostly doctors – have dropped out of the program, and we expect this number to grow unless more changes are made."

The AMA recommends using a 75% pass rate as the standard for achieving meaningful use, and allowing physicians who meet 50% of meaningful use requirements to avoid financial penalties. CMS should also do a better job of aligning the Physician Quality Reporting System, the Value Based Modifier, and meaningful use requirements.

[email protected]

On Twitter @maryellenny

Federal officials are proposing to give physicians some extra time to move to 2014 edition certified electronic health record technology and still qualify for incentives under the Medicare and Medicaid EHR Incentive Programs.

Under a proposed rule released on May 20, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology (ONC) would allow physicians, hospitals, and other eligible health care providers to continue using 2011 edition certified products or a combination of 2011 and 2014 edition certified products during the 2014 reporting period in the EHR Incentive Programs.

Though 2014 edition certified EHR products are currently available, there is a backlog of several months for the newer versions to be installed in hospitals and physician offices, according to CMS.

"Increasing the adoption of EHRs is key to improving the nation’s health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," Dr. Karen DeSalvo, national coordinator for health information technology, said in a statement.

Physicians and hospitals would need to complete the switch to 2014 edition certified products in time for the Medicare and Medicaid programs’ 2015 reporting periods.

But there are some exceptions, the proposal states that to qualify for an incentive payment under Medicaid for adopting, implementing, or upgrading certified EHRs for 2014, the provider must use 2014 edition products only.

Physicians and hospitals may have to adjust their plans for attesting to EHR meaningful use depending on which edition of the certified technology they have available. For instance, the 2011 edition technology alone does not have the functionality required to meet the Stage 2 objectives and measures.

Providers who are scheduled to begin Stage 2 for the 2014 reporting period, but can’t fully implement the functions of their 2014 edition certified technology, have the option of attest to Stage 1 objective and measures for 2014. But they must attest that they are unable to fully implement their technology due to delays, according to the proposal.

The proposal also formalizes the government’s plan to extend some of the deadlines in the "meaningful use" program. In December, CMS announced in a blog post that it would extend reporting for Stage 2 of meaningful use through 2016 and would begin Stage 3 in 2017.

The change primarily affects physicians who began attesting to meaningful EHR use in 2011 and 2012. Those physicians were scheduled to advance to Stage 3 in 2016, after 2 years working on Stage 2. The change gives them an additional year before advancing to Stage 3.

While the proposed rule responds to concerns raised by physicians and vendors about the problems in implementing 2014 edition certified products, it does not address other critiques of the meaningful use program. The American Medical Association noted that the proposed changes are helpful, but they still leave intact an all-or-nothing approach to meaningful use requirements.

"Our chief concern remains unaddressed, and we worry that current requirements will slow the adoption of technology that will help coordinate care and improve quality, and that many physicians will drop out of the meaningful use program if the current all-or-nothing approach remains in place," Dr. Steven J. Stack, the AMA’s immediate past board chairman, said in a statement. "To date, approximately 20% of eligible professionals – mostly doctors – have dropped out of the program, and we expect this number to grow unless more changes are made."

The AMA recommends using a 75% pass rate as the standard for achieving meaningful use, and allowing physicians who meet 50% of meaningful use requirements to avoid financial penalties. CMS should also do a better job of aligning the Physician Quality Reporting System, the Value Based Modifier, and meaningful use requirements.

[email protected]

On Twitter @maryellenny

Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.

The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.

Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.

Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.

CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.

The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.

The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.

The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.

But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:

•  Are there diagnoses to support the indications for which the drugs were prescribed?

• Was the patient deceased or out of state at the time of an alleged office visit?

•  Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?

• Has the physician been subject to disciplinary actions by the state medical board?

• Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?

• Has a public insurance program restricted or revoked the physician's prescribing privileges?

CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.

But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.

Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.

[email protected]

On Twitter @maryellenny

Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.

The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.

Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.

Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.

CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.

The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.

The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.

The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.

But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:

•  Are there diagnoses to support the indications for which the drugs were prescribed?

• Was the patient deceased or out of state at the time of an alleged office visit?

•  Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?

• Has the physician been subject to disciplinary actions by the state medical board?

• Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?

• Has a public insurance program restricted or revoked the physician's prescribing privileges?

CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.

But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.

Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.

[email protected]

On Twitter @maryellenny

Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.

The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.

Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.

Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.

CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.

The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.

The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.

The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.

But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:

•  Are there diagnoses to support the indications for which the drugs were prescribed?

• Was the patient deceased or out of state at the time of an alleged office visit?

•  Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?

• Has the physician been subject to disciplinary actions by the state medical board?

• Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?

• Has a public insurance program restricted or revoked the physician's prescribing privileges?

CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.

But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.

Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.

[email protected]

On Twitter @maryellenny

Are the physicians and nurses in your hospital suffering from change fatigue?

There’s a new model of care that supporters say could help alleviate the weariness from continual quality improvement projects and process changes. It’s called an Accountable Care Unit, and though the name sounds a lot like an Accountable Care Organization, the two ideas have little in common.

Accountable Care Units (ACUs) are essentially geographic-based hospital units where the staff are held accountable for their patients’ outcomes. The four defining features of an ACU are unit-based teams, structured interdisciplinary bedside rounds, unit-level performance reporting, and unit-level nurse and physician coleadership.

Under this collaborative care model, hospitalists are assigned to a "home" unit where nearly all of their patients are located. The physician-leader partners with a nurse-manager to run the unit, and together with a team that includes allied health professionals, they conduct daily bedside rounds. A unique piece of the ACU model is the accountability. Instead of trying to discern performance based on facility-level or physician service line data, the hospital provides the ACU with unit-level data to help improve outcomes.

ACUs, which are the brainchild of hospitalist Dr. Jason Stein at Emory University in Atlanta, are currently up and running in multiple units across the Emory system, along with hospitals in seven U.S. states and more than 15 hospitals in Australia. The care model can be found in medical units, surgical units (including neurosurgery, orthopedic surgery, and general surgery), intensive care units, emergency departments, obstetrics units, pediatric units, psychiatry units, and long-term acute care units.

To help hospitals launch ACUs across their facilities, Dr. Stein founded Centripital, nonprofit organization whose mission is to train hospital professionals to work together in "high performing, patient-centered teams." The company has licensed implementation tools, including customized workflow diagrams, comprehensive training for front-line staff, and a train-the-trainer program with feedback tools so local leaders can spread the success of an initial ACU within their system.

Dr. Stein describes the model as a "Swiss Army knife" for the hospital. The idea is that instead of constantly ramping up for the next quality improvement project, the structure of the ACU allows physicians and nurses to target improvements without fundamentally changing their workflow.

"Whatever the metric is, whether it’s a clinical outcome or a utilization outcome, ... if you choose to focus on any of those items, we think you’re very likely to improve those outcomes," said Dr. Stein, who is the director for quality and research in Emory’s division of hospital medicine.

Dr. Stein launched the first ACU in 2010 in a 24-bed medical unit at Emory University Hospital. During the first year, the length of stay fell from an average of 5 days to 4.5 days. And in-hospital mortality dropped from 2.3 deaths per 100 encounters to 1.1 deaths. Initial results also have been similar in other hospitals that have launched ACUs, he said.

Costs, continuity, and ‘accountability’

At Emory, the gains were achieved at little cost to the system, Dr. Stein said, other than compensation for a part-time physician medical director and some staff training.

The biggest challenge in making the shift to an ACU model of care is the creation of unit-based teams, he said. "Physicians need to be able to share time and space throughout the day with the nurses with whom they share patients," Dr. Stein said.

One potential downside to making geography the primary driver of how physicians are assigned to patients is that there can be a break in the continuity of care. For example, if a patient cared for in an ACU must be transferred to the intensive care unit, after recovery the patient could potentially be transferred to a unit with a different team of physicians.

But Dr. Stein said it’s a manageable problem and one that is worth the trade-off.

Accountability on an ACU has multiple meanings. The first level of accountability is between members of the care team.

"There’s accountability at the bedside every day, because we are either showing up prepared to offer perspectives and answer questions in a structured way, or we’re not," Dr. Stein said. "That’s a massive daily accountability moment."

The second level comes from being able to review data that’s specific to the ACU. Dr. Stein recommends that ACU teams hold quarterly meetings that include specialty directors and service line chiefs to review unit-level performance reports. That type of public reporting among peers can be very powerful, he said.

The structure of the ACU model or a similar version of it "is probably the type of model that will make the most sense for the future," said Dr. Elizabeth Harry, a hospitalist at Presbyterian/ St. Luke’s Medical Center in Denver.

Dr. Harry helped implement an ACU at her institution about a year and a half ago and now serves as the medical director for that unit. So far, they have been able to reduce length of stay on the unit from an average of 5.3 days to 4 days and reduce costs by more than $800,000 since implementation.

"But more importantly," she said, "the ACU has been able to get physicians, nurses, pharmacists, case management, and therapy out of their individual silos and encourage collaboration."

"Having solo practitioners who care about their patients is not enough," Dr. Harry said. The model of care also needs to simplify the environment and increase communication among everyone who cares for patients to avoid errors and mitigate potential harm.

Dr. Harry also advises against taking the ACU model apart and applying just one piece. "It’s the combination of geographic units, interdisciplinary rounds, paired leadership, and data monitoring that will achieve results," she said.

Dr. Stein said he expects the model will continue to take hold. "There’s an understanding that we need a convergent solution," he said. "We need a solution that stops nibbling around the edges."

Care teams find new energy

Palmetto Health in Columbia, S.C., launched its first ACU in April, so it’s too soon to tell if they will see significant improvements in quality or cost. But the model has already brought "new life" to the physicians and nurses on the unit, said Carolyn Swinton, chief nursing officer at Palmetto Health Richland, a level I trauma academic medical center.

"There were team members on that unit who had been there for 20 years who we thought had lost their spark and their commitment, and they knocked it out of the park," Ms. Swinton said. "They were very engaged."

Palmetto Health wanted to try out the ACU concept as part of a broader push to improve the experience for patients and families. And they also saw it as a way to standardize the communication and care processes within the hospital, Ms. Swinton said.

So last fall, they traveled to Emory University to observe the ACU model in action and receive training about how to implement it. Earlier this year, they selected a unit where they already had strong physician engagement. The providers on the unit held a retreat where they developed a unit covenant and even practiced how they would talk to patients during the interdisciplinary bedside rounds.

Palmetto modified the Emory approach to the ACU slightly. In addition to having providers from pharmacy and social work, they added a nurse technician who could provide information about ambulation, toileting, and dietary intake.

The effect on morale within the unit was immediate.

"There was one nurse who was in tears," Ms. Swinton said. "She said it meant so much to her to have an opportunity to show her commitment and her skill and her passion for this work."

And Ms. Swinton said she also heard from the unit’s attending physician that the new process made her day easier, because everyone on the team knew the plan of care.

"The team is happy; you can feel it," she said. "On the unit, people are stepping up. They’re collaborating."

The next step is to begin rolling out the ACU concept unit by unit. They have identified a slate of units and plan to switch over one unit at a time every 120 days, Ms. Swinton said.

[email protected]

On Twitter @maryellenny

Are the physicians and nurses in your hospital suffering from change fatigue?

There’s a new model of care that supporters say could help alleviate the weariness from continual quality improvement projects and process changes. It’s called an Accountable Care Unit, and though the name sounds a lot like an Accountable Care Organization, the two ideas have little in common.

Accountable Care Units (ACUs) are essentially geographic-based hospital units where the staff are held accountable for their patients’ outcomes. The four defining features of an ACU are unit-based teams, structured interdisciplinary bedside rounds, unit-level performance reporting, and unit-level nurse and physician coleadership.

Under this collaborative care model, hospitalists are assigned to a "home" unit where nearly all of their patients are located. The physician-leader partners with a nurse-manager to run the unit, and together with a team that includes allied health professionals, they conduct daily bedside rounds. A unique piece of the ACU model is the accountability. Instead of trying to discern performance based on facility-level or physician service line data, the hospital provides the ACU with unit-level data to help improve outcomes.

ACUs, which are the brainchild of hospitalist Dr. Jason Stein at Emory University in Atlanta, are currently up and running in multiple units across the Emory system, along with hospitals in seven U.S. states and more than 15 hospitals in Australia. The care model can be found in medical units, surgical units (including neurosurgery, orthopedic surgery, and general surgery), intensive care units, emergency departments, obstetrics units, pediatric units, psychiatry units, and long-term acute care units.

To help hospitals launch ACUs across their facilities, Dr. Stein founded Centripital, nonprofit organization whose mission is to train hospital professionals to work together in "high performing, patient-centered teams." The company has licensed implementation tools, including customized workflow diagrams, comprehensive training for front-line staff, and a train-the-trainer program with feedback tools so local leaders can spread the success of an initial ACU within their system.

Dr. Stein describes the model as a "Swiss Army knife" for the hospital. The idea is that instead of constantly ramping up for the next quality improvement project, the structure of the ACU allows physicians and nurses to target improvements without fundamentally changing their workflow.

"Whatever the metric is, whether it’s a clinical outcome or a utilization outcome, ... if you choose to focus on any of those items, we think you’re very likely to improve those outcomes," said Dr. Stein, who is the director for quality and research in Emory’s division of hospital medicine.

Dr. Stein launched the first ACU in 2010 in a 24-bed medical unit at Emory University Hospital. During the first year, the length of stay fell from an average of 5 days to 4.5 days. And in-hospital mortality dropped from 2.3 deaths per 100 encounters to 1.1 deaths. Initial results also have been similar in other hospitals that have launched ACUs, he said.

Costs, continuity, and ‘accountability’

At Emory, the gains were achieved at little cost to the system, Dr. Stein said, other than compensation for a part-time physician medical director and some staff training.

The biggest challenge in making the shift to an ACU model of care is the creation of unit-based teams, he said. "Physicians need to be able to share time and space throughout the day with the nurses with whom they share patients," Dr. Stein said.

One potential downside to making geography the primary driver of how physicians are assigned to patients is that there can be a break in the continuity of care. For example, if a patient cared for in an ACU must be transferred to the intensive care unit, after recovery the patient could potentially be transferred to a unit with a different team of physicians.

But Dr. Stein said it’s a manageable problem and one that is worth the trade-off.

Accountability on an ACU has multiple meanings. The first level of accountability is between members of the care team.

"There’s accountability at the bedside every day, because we are either showing up prepared to offer perspectives and answer questions in a structured way, or we’re not," Dr. Stein said. "That’s a massive daily accountability moment."

The second level comes from being able to review data that’s specific to the ACU. Dr. Stein recommends that ACU teams hold quarterly meetings that include specialty directors and service line chiefs to review unit-level performance reports. That type of public reporting among peers can be very powerful, he said.

The structure of the ACU model or a similar version of it "is probably the type of model that will make the most sense for the future," said Dr. Elizabeth Harry, a hospitalist at Presbyterian/ St. Luke’s Medical Center in Denver.

Dr. Harry helped implement an ACU at her institution about a year and a half ago and now serves as the medical director for that unit. So far, they have been able to reduce length of stay on the unit from an average of 5.3 days to 4 days and reduce costs by more than $800,000 since implementation.

"But more importantly," she said, "the ACU has been able to get physicians, nurses, pharmacists, case management, and therapy out of their individual silos and encourage collaboration."

"Having solo practitioners who care about their patients is not enough," Dr. Harry said. The model of care also needs to simplify the environment and increase communication among everyone who cares for patients to avoid errors and mitigate potential harm.

Dr. Harry also advises against taking the ACU model apart and applying just one piece. "It’s the combination of geographic units, interdisciplinary rounds, paired leadership, and data monitoring that will achieve results," she said.

Dr. Stein said he expects the model will continue to take hold. "There’s an understanding that we need a convergent solution," he said. "We need a solution that stops nibbling around the edges."

Care teams find new energy

Palmetto Health in Columbia, S.C., launched its first ACU in April, so it’s too soon to tell if they will see significant improvements in quality or cost. But the model has already brought "new life" to the physicians and nurses on the unit, said Carolyn Swinton, chief nursing officer at Palmetto Health Richland, a level I trauma academic medical center.

"There were team members on that unit who had been there for 20 years who we thought had lost their spark and their commitment, and they knocked it out of the park," Ms. Swinton said. "They were very engaged."

Palmetto Health wanted to try out the ACU concept as part of a broader push to improve the experience for patients and families. And they also saw it as a way to standardize the communication and care processes within the hospital, Ms. Swinton said.

So last fall, they traveled to Emory University to observe the ACU model in action and receive training about how to implement it. Earlier this year, they selected a unit where they already had strong physician engagement. The providers on the unit held a retreat where they developed a unit covenant and even practiced how they would talk to patients during the interdisciplinary bedside rounds.

Palmetto modified the Emory approach to the ACU slightly. In addition to having providers from pharmacy and social work, they added a nurse technician who could provide information about ambulation, toileting, and dietary intake.

The effect on morale within the unit was immediate.

"There was one nurse who was in tears," Ms. Swinton said. "She said it meant so much to her to have an opportunity to show her commitment and her skill and her passion for this work."

And Ms. Swinton said she also heard from the unit’s attending physician that the new process made her day easier, because everyone on the team knew the plan of care.

"The team is happy; you can feel it," she said. "On the unit, people are stepping up. They’re collaborating."

The next step is to begin rolling out the ACU concept unit by unit. They have identified a slate of units and plan to switch over one unit at a time every 120 days, Ms. Swinton said.

[email protected]

On Twitter @maryellenny

Are the physicians and nurses in your hospital suffering from change fatigue?

There’s a new model of care that supporters say could help alleviate the weariness from continual quality improvement projects and process changes. It’s called an Accountable Care Unit, and though the name sounds a lot like an Accountable Care Organization, the two ideas have little in common.

Accountable Care Units (ACUs) are essentially geographic-based hospital units where the staff are held accountable for their patients’ outcomes. The four defining features of an ACU are unit-based teams, structured interdisciplinary bedside rounds, unit-level performance reporting, and unit-level nurse and physician coleadership.

Under this collaborative care model, hospitalists are assigned to a "home" unit where nearly all of their patients are located. The physician-leader partners with a nurse-manager to run the unit, and together with a team that includes allied health professionals, they conduct daily bedside rounds. A unique piece of the ACU model is the accountability. Instead of trying to discern performance based on facility-level or physician service line data, the hospital provides the ACU with unit-level data to help improve outcomes.

ACUs, which are the brainchild of hospitalist Dr. Jason Stein at Emory University in Atlanta, are currently up and running in multiple units across the Emory system, along with hospitals in seven U.S. states and more than 15 hospitals in Australia. The care model can be found in medical units, surgical units (including neurosurgery, orthopedic surgery, and general surgery), intensive care units, emergency departments, obstetrics units, pediatric units, psychiatry units, and long-term acute care units.

To help hospitals launch ACUs across their facilities, Dr. Stein founded Centripital, nonprofit organization whose mission is to train hospital professionals to work together in "high performing, patient-centered teams." The company has licensed implementation tools, including customized workflow diagrams, comprehensive training for front-line staff, and a train-the-trainer program with feedback tools so local leaders can spread the success of an initial ACU within their system.

Dr. Stein describes the model as a "Swiss Army knife" for the hospital. The idea is that instead of constantly ramping up for the next quality improvement project, the structure of the ACU allows physicians and nurses to target improvements without fundamentally changing their workflow.

"Whatever the metric is, whether it’s a clinical outcome or a utilization outcome, ... if you choose to focus on any of those items, we think you’re very likely to improve those outcomes," said Dr. Stein, who is the director for quality and research in Emory’s division of hospital medicine.

Dr. Stein launched the first ACU in 2010 in a 24-bed medical unit at Emory University Hospital. During the first year, the length of stay fell from an average of 5 days to 4.5 days. And in-hospital mortality dropped from 2.3 deaths per 100 encounters to 1.1 deaths. Initial results also have been similar in other hospitals that have launched ACUs, he said.

Costs, continuity, and ‘accountability’

At Emory, the gains were achieved at little cost to the system, Dr. Stein said, other than compensation for a part-time physician medical director and some staff training.

The biggest challenge in making the shift to an ACU model of care is the creation of unit-based teams, he said. "Physicians need to be able to share time and space throughout the day with the nurses with whom they share patients," Dr. Stein said.

One potential downside to making geography the primary driver of how physicians are assigned to patients is that there can be a break in the continuity of care. For example, if a patient cared for in an ACU must be transferred to the intensive care unit, after recovery the patient could potentially be transferred to a unit with a different team of physicians.

But Dr. Stein said it’s a manageable problem and one that is worth the trade-off.

Accountability on an ACU has multiple meanings. The first level of accountability is between members of the care team.

"There’s accountability at the bedside every day, because we are either showing up prepared to offer perspectives and answer questions in a structured way, or we’re not," Dr. Stein said. "That’s a massive daily accountability moment."

The second level comes from being able to review data that’s specific to the ACU. Dr. Stein recommends that ACU teams hold quarterly meetings that include specialty directors and service line chiefs to review unit-level performance reports. That type of public reporting among peers can be very powerful, he said.

The structure of the ACU model or a similar version of it "is probably the type of model that will make the most sense for the future," said Dr. Elizabeth Harry, a hospitalist at Presbyterian/ St. Luke’s Medical Center in Denver.

Dr. Harry helped implement an ACU at her institution about a year and a half ago and now serves as the medical director for that unit. So far, they have been able to reduce length of stay on the unit from an average of 5.3 days to 4 days and reduce costs by more than $800,000 since implementation.

"But more importantly," she said, "the ACU has been able to get physicians, nurses, pharmacists, case management, and therapy out of their individual silos and encourage collaboration."

"Having solo practitioners who care about their patients is not enough," Dr. Harry said. The model of care also needs to simplify the environment and increase communication among everyone who cares for patients to avoid errors and mitigate potential harm.

Dr. Harry also advises against taking the ACU model apart and applying just one piece. "It’s the combination of geographic units, interdisciplinary rounds, paired leadership, and data monitoring that will achieve results," she said.

Dr. Stein said he expects the model will continue to take hold. "There’s an understanding that we need a convergent solution," he said. "We need a solution that stops nibbling around the edges."

Care teams find new energy

Palmetto Health in Columbia, S.C., launched its first ACU in April, so it’s too soon to tell if they will see significant improvements in quality or cost. But the model has already brought "new life" to the physicians and nurses on the unit, said Carolyn Swinton, chief nursing officer at Palmetto Health Richland, a level I trauma academic medical center.

"There were team members on that unit who had been there for 20 years who we thought had lost their spark and their commitment, and they knocked it out of the park," Ms. Swinton said. "They were very engaged."

Palmetto Health wanted to try out the ACU concept as part of a broader push to improve the experience for patients and families. And they also saw it as a way to standardize the communication and care processes within the hospital, Ms. Swinton said.

So last fall, they traveled to Emory University to observe the ACU model in action and receive training about how to implement it. Earlier this year, they selected a unit where they already had strong physician engagement. The providers on the unit held a retreat where they developed a unit covenant and even practiced how they would talk to patients during the interdisciplinary bedside rounds.

Palmetto modified the Emory approach to the ACU slightly. In addition to having providers from pharmacy and social work, they added a nurse technician who could provide information about ambulation, toileting, and dietary intake.

The effect on morale within the unit was immediate.

"There was one nurse who was in tears," Ms. Swinton said. "She said it meant so much to her to have an opportunity to show her commitment and her skill and her passion for this work."

And Ms. Swinton said she also heard from the unit’s attending physician that the new process made her day easier, because everyone on the team knew the plan of care.

"The team is happy; you can feel it," she said. "On the unit, people are stepping up. They’re collaborating."

The next step is to begin rolling out the ACU concept unit by unit. They have identified a slate of units and plan to switch over one unit at a time every 120 days, Ms. Swinton said.

[email protected]

On Twitter @maryellenny

Medicare’s "two-midnight" rule governing when a patient should be admitted to the hospital is confusing physicians, draining hospital resources, and ultimately harming patients, according to hospitalists, nurses, and patient advocates.

The providers testified before the House Ways & Means Committee on May 20, seeking relief from the two-midnight rule and greater oversight of Medicare’s Recovery Audit Contractors (RACs), who will ultimately enforce the controversial policy.

On Oct. 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will begin implementing the two-midnight rule, which states that generally Medicare beneficiaries should be classified as inpatients if they are staying in the hospital for two or more midnights. But if the admitting physician expects their stay to be shorter, they should be classified as outpatients for payment purposes, according to the rule.

But CMS delayed full enforcement of the rule for 6 months and Congress extended the delay through March 31, 2015. RACs are barred from conducting postpayment audits based on the rule during that time. However, Medicare Administrative Contractors (MACs) are performing prepayment reviews on a sample of a short-stay inpatient claims to determine hospital compliance with the two-midnight rule.

And, based on feedback from hospitals, CMS officials are considering a new payment methodology for short inpatient hospital stays. They are seeking public comment on how to define a short stay and how to determine those payment amounts, according to Sean Cavanaugh, director of the Center for Medicare and CMS deputy administrator.

Dr. Ann Sheehy, a hospitalist at the University of Wisconsin in Madison, said the time-based nature of the two-midnight rule means that sometimes the decision whether to admit a patient or keep them under observation is based on what time of day they arrive at the hospital, not on their clinical needs.

For instance, a Medicare beneficiary who is hospitalized with pneumonia at 1 a.m. on a Tuesday and is released after 40 hours would fail to meet the two-midnight standard and would be considered an outpatient. But, if the same patient arrived at 10 p.m. on Tuesday, the stay would exceed two midnights and the patient would be classified as an inpatient, said Dr. Sheehy, who is a member of the Society of Hospital Medicine’s Public Policy Committee.

And patients who require intensive care over a 24- to 48-hour period, such as patients with diabetic ketoacidosis, would not necessarily be classified as inpatients despite the level of services they require, she said.

"Now, a short stay, even in the intensive care unit, can be considered outpatient," Dr. Sheehy said.

[email protected]

On Twitter @maryellenny

Medicare’s "two-midnight" rule governing when a patient should be admitted to the hospital is confusing physicians, draining hospital resources, and ultimately harming patients, according to hospitalists, nurses, and patient advocates.

The providers testified before the House Ways & Means Committee on May 20, seeking relief from the two-midnight rule and greater oversight of Medicare’s Recovery Audit Contractors (RACs), who will ultimately enforce the controversial policy.

On Oct. 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will begin implementing the two-midnight rule, which states that generally Medicare beneficiaries should be classified as inpatients if they are staying in the hospital for two or more midnights. But if the admitting physician expects their stay to be shorter, they should be classified as outpatients for payment purposes, according to the rule.

But CMS delayed full enforcement of the rule for 6 months and Congress extended the delay through March 31, 2015. RACs are barred from conducting postpayment audits based on the rule during that time. However, Medicare Administrative Contractors (MACs) are performing prepayment reviews on a sample of a short-stay inpatient claims to determine hospital compliance with the two-midnight rule.

And, based on feedback from hospitals, CMS officials are considering a new payment methodology for short inpatient hospital stays. They are seeking public comment on how to define a short stay and how to determine those payment amounts, according to Sean Cavanaugh, director of the Center for Medicare and CMS deputy administrator.

Dr. Ann Sheehy, a hospitalist at the University of Wisconsin in Madison, said the time-based nature of the two-midnight rule means that sometimes the decision whether to admit a patient or keep them under observation is based on what time of day they arrive at the hospital, not on their clinical needs.

For instance, a Medicare beneficiary who is hospitalized with pneumonia at 1 a.m. on a Tuesday and is released after 40 hours would fail to meet the two-midnight standard and would be considered an outpatient. But, if the same patient arrived at 10 p.m. on Tuesday, the stay would exceed two midnights and the patient would be classified as an inpatient, said Dr. Sheehy, who is a member of the Society of Hospital Medicine’s Public Policy Committee.

And patients who require intensive care over a 24- to 48-hour period, such as patients with diabetic ketoacidosis, would not necessarily be classified as inpatients despite the level of services they require, she said.

"Now, a short stay, even in the intensive care unit, can be considered outpatient," Dr. Sheehy said.

[email protected]

On Twitter @maryellenny

Medicare’s "two-midnight" rule governing when a patient should be admitted to the hospital is confusing physicians, draining hospital resources, and ultimately harming patients, according to hospitalists, nurses, and patient advocates.

The providers testified before the House Ways & Means Committee on May 20, seeking relief from the two-midnight rule and greater oversight of Medicare’s Recovery Audit Contractors (RACs), who will ultimately enforce the controversial policy.

On Oct. 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will begin implementing the two-midnight rule, which states that generally Medicare beneficiaries should be classified as inpatients if they are staying in the hospital for two or more midnights. But if the admitting physician expects their stay to be shorter, they should be classified as outpatients for payment purposes, according to the rule.

But CMS delayed full enforcement of the rule for 6 months and Congress extended the delay through March 31, 2015. RACs are barred from conducting postpayment audits based on the rule during that time. However, Medicare Administrative Contractors (MACs) are performing prepayment reviews on a sample of a short-stay inpatient claims to determine hospital compliance with the two-midnight rule.

And, based on feedback from hospitals, CMS officials are considering a new payment methodology for short inpatient hospital stays. They are seeking public comment on how to define a short stay and how to determine those payment amounts, according to Sean Cavanaugh, director of the Center for Medicare and CMS deputy administrator.

Dr. Ann Sheehy, a hospitalist at the University of Wisconsin in Madison, said the time-based nature of the two-midnight rule means that sometimes the decision whether to admit a patient or keep them under observation is based on what time of day they arrive at the hospital, not on their clinical needs.

For instance, a Medicare beneficiary who is hospitalized with pneumonia at 1 a.m. on a Tuesday and is released after 40 hours would fail to meet the two-midnight standard and would be considered an outpatient. But, if the same patient arrived at 10 p.m. on Tuesday, the stay would exceed two midnights and the patient would be classified as an inpatient, said Dr. Sheehy, who is a member of the Society of Hospital Medicine’s Public Policy Committee.

And patients who require intensive care over a 24- to 48-hour period, such as patients with diabetic ketoacidosis, would not necessarily be classified as inpatients despite the level of services they require, she said.

"Now, a short stay, even in the intensive care unit, can be considered outpatient," Dr. Sheehy said.

[email protected]

On Twitter @maryellenny

Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.

On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.

©Jan Mika/iStockphoto.com

In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.

Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.

HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.

If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.

[email protected]

On Twitter @maryellenny

Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.

On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.

©Jan Mika/iStockphoto.com

In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.

Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.

HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.

If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.

[email protected]

On Twitter @maryellenny

Patients undergoing treatment with nonformulary drugs will soon get a speedier decision from their health plans about whether those drugs can be covered.

On May 16, the Health & Human Services (HHS) department released a final rule outlining standards for health plans participating in the Affordable Care Act’s insurance exchanges in 2015. The rule creates an expedited process for determining coverage for nonformulary drugs in emergency situations.

©Jan Mika/iStockphoto.com

In 2015, health plans in the ACA exchanges will have no more than 24 hours to make a decision on whether to cover a nonformulary drug when it is requested under "exigent circumstances." These situations include when a patient’s diagnosis may seriously jeopardize their life, health, or ability to regain maximum function. It also includes situations in which a patient is undergoing a current course of treatment using a nonformulary drug, according to the final rule.

Under the rule, patients or their designees – including prescribing physicians – can request coverage of a nonformulary drug.

HHS said the 24-hour review period begins as soon as a request is received, and cautioned insurers not to hold up the review if "largely procedural" information is missing from the request. The agency also instructed health plans not to require "irrelevant or overly burdensome information" in the application.

If a request for a nonformulary drug is approved, health plans must make it available for the duration of the emergency situation.

[email protected]

On Twitter @maryellenny

Doctors will continue to drop out of the federal government’s Electronic Health Records Incentive Programs unless officials ease some program requirements, the American Medical Association warned in a May 8 letter to government officials.

The AMA offered a laundry list of needed changes from abandoning the "all-or-nothing" approach for meeting meaningful use standards to removing requirements that are outside the control of physicians.

"In any other grading system a 99% is an A+, but it’s a fail in the meaningful use program, which just seems entirely inconsistent with what Congress intended, which was to foster the adoption of these tools," Dr. Steven J. Stack, an emergency physician and immediate past chairman of the AMA’s board of trustees, said in an interview.

In the letter to officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the AMA advocated for ending the "all-or-nothing" approach, which requires physicians to successfully meet all meaningful use requirements to earn incentives. The AMA instead recommended a 75% threshold for qualifying for incentives and a 50% threshold to avoid penalties.

The AMA also urged the government not to measure activities outside of the physician’s control, such as whether a patient views or downloads information from a portal.

While the government has been touting widespread participation in the Electronic Health Records Incentive Programs, the AMA said that physicians are beginning to abandon the program. The AMA said that partial data from 2013 showed that there was already a 20% drop out rate in the meaningful use program. It will only grow if the program continues as is, Dr. Stack said.

But there’s time to make changes both to Stage 2 and Stage 3 of the program, Dr. Stack added.

"We don’t see this as a done deal. We see this as a live program that requires ongoing adjustment and tailoring," he said. "The federal government, in order to advance the policy objective of fostering electronic health record adoption and health information exchange, should have a mid-course correction immediately for Stage 2 to make it more possible to have flexibility and a better opportunity for success for the clinicians and the hospitals."

[email protected]

On Twitter @maryellenny

Doctors will continue to drop out of the federal government’s Electronic Health Records Incentive Programs unless officials ease some program requirements, the American Medical Association warned in a May 8 letter to government officials.

The AMA offered a laundry list of needed changes from abandoning the "all-or-nothing" approach for meeting meaningful use standards to removing requirements that are outside the control of physicians.

"In any other grading system a 99% is an A+, but it’s a fail in the meaningful use program, which just seems entirely inconsistent with what Congress intended, which was to foster the adoption of these tools," Dr. Steven J. Stack, an emergency physician and immediate past chairman of the AMA’s board of trustees, said in an interview.

In the letter to officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the AMA advocated for ending the "all-or-nothing" approach, which requires physicians to successfully meet all meaningful use requirements to earn incentives. The AMA instead recommended a 75% threshold for qualifying for incentives and a 50% threshold to avoid penalties.

The AMA also urged the government not to measure activities outside of the physician’s control, such as whether a patient views or downloads information from a portal.

While the government has been touting widespread participation in the Electronic Health Records Incentive Programs, the AMA said that physicians are beginning to abandon the program. The AMA said that partial data from 2013 showed that there was already a 20% drop out rate in the meaningful use program. It will only grow if the program continues as is, Dr. Stack said.

But there’s time to make changes both to Stage 2 and Stage 3 of the program, Dr. Stack added.

"We don’t see this as a done deal. We see this as a live program that requires ongoing adjustment and tailoring," he said. "The federal government, in order to advance the policy objective of fostering electronic health record adoption and health information exchange, should have a mid-course correction immediately for Stage 2 to make it more possible to have flexibility and a better opportunity for success for the clinicians and the hospitals."

[email protected]

On Twitter @maryellenny

Doctors will continue to drop out of the federal government’s Electronic Health Records Incentive Programs unless officials ease some program requirements, the American Medical Association warned in a May 8 letter to government officials.

The AMA offered a laundry list of needed changes from abandoning the "all-or-nothing" approach for meeting meaningful use standards to removing requirements that are outside the control of physicians.

"In any other grading system a 99% is an A+, but it’s a fail in the meaningful use program, which just seems entirely inconsistent with what Congress intended, which was to foster the adoption of these tools," Dr. Steven J. Stack, an emergency physician and immediate past chairman of the AMA’s board of trustees, said in an interview.

In the letter to officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the AMA advocated for ending the "all-or-nothing" approach, which requires physicians to successfully meet all meaningful use requirements to earn incentives. The AMA instead recommended a 75% threshold for qualifying for incentives and a 50% threshold to avoid penalties.

The AMA also urged the government not to measure activities outside of the physician’s control, such as whether a patient views or downloads information from a portal.

While the government has been touting widespread participation in the Electronic Health Records Incentive Programs, the AMA said that physicians are beginning to abandon the program. The AMA said that partial data from 2013 showed that there was already a 20% drop out rate in the meaningful use program. It will only grow if the program continues as is, Dr. Stack said.

But there’s time to make changes both to Stage 2 and Stage 3 of the program, Dr. Stack added.

"We don’t see this as a done deal. We see this as a live program that requires ongoing adjustment and tailoring," he said. "The federal government, in order to advance the policy objective of fostering electronic health record adoption and health information exchange, should have a mid-course correction immediately for Stage 2 to make it more possible to have flexibility and a better opportunity for success for the clinicians and the hospitals."

[email protected]

On Twitter @maryellenny