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Issue: March 2008
March 01, 2008
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Government report: Some specialty hospitals may not be Medicare compliant

However, critics point to flaws in the study methodology and potentially questionable motives.

Issue: March 2008

ORTHOPRACTICE trends

A recent government report indicates that at least one-third of physician-owned specialty hospitals may be violating Medicare requirements, but some are criticizing the investigation and its findings.

To assess the capability of physician-owned specialty hospitals to manage medical emergencies, the Office of the Inspector General (OIG) examined the data of 109 physician-owned specialty hospitals listed by the Centers for Medicare & Medicaid Services (CMS). The OIG gathered information by reviewing staffing policies and an 8-day staffing schedule, examining emergency management policies and conducting hospital administrator interviews.

According to the Conditions of Participation (COP), hospitals participating in Medicare must have written policies for dealing with emergency care, always have a physician on-call or on duty and provide round-the-clock nursing services given or supervised by a registered nurse. While hospitals are considered noncompliant if they use 9-1-1 services to substitute for their own emergency services, calling 9-1-1 to transfer a patient is allowed.

Staffing data

In its report, the OIG found that 66% of the specialty hospitals included 9-1-1 as part of their emergency response procedures.

“Most notably, 34% of hospitals use 9-1-1 to obtain medical assistance to stabilize a patient, a practice that may violate Medicare requirements,” the group wrote. In addition, 46% called 9-1-1 for patient transfers.

A review of the hospitals’ staffing schedule for 8 days revealed that 7% of centers did not have nurses on duty or physicians on-call and that seven hospitals failed to have a registered nurse on duty and one hospital failed to have a physician on call or on duty during at least 1 of the 8-sampled days, the group wrote.

The group also discovered that 55% of the hospitals had an emergency department — a practice not required by Medicare, but may be state mandated. More than half of these centers had only one bed, the group noted. Similarly, hospital administrators reported that 28% of the centers always had a physician on-site, which is also not required by Medicare.

Recommendations

In addition, the OIG noted that some written policies did not include basic information regarding emergency management.

“Almost one-quarter of all physician-owned specialty hospitals have policies that do not address appraisal of emergencies, initial treatment of emergencies, or referral and transfer of patients,” they wrote.

Based on the findings, the OIG recommended that CMS do the following:

  • create a system for the tracking and identification of these hospitals;
  • ensure that the hospitals have a registered nurse on duty at all times and an on-call physician if one is not on-site;
  • make certain that these hospitals are not using 9-1-1 services as a substitute for their ability to provide initial emergency treatment and appraisal; and
  • mandate that the hospitals have details for handling medical emergencies in their written policies.

CMS has agreed with all of these recommendations.

Challenging methodology

However, some have questioned the methods, conclusions and motives behind the report. Robert James Cimasi, the president of Health Capital Consultants, called the report a regrettable incident.

“The report that was put out is replete [with] information that has been spun and twisted in its interpretation,” he told Orthopedics Today. “This in no way reflects any type of work that had any scientific validity, any statistical validity and it clearly has been engendered with an underlying agenda here with a preordained conclusion. Aside from that, the timing of this report, in terms of how this has come out when there is numerous legislative efforts to limit physician investment in various provider entities, makes it suspect to the motivation of the people that conducted this survey and under whose behest they undertook this.”

He also said that the report used flawed methodology to reach its conclusions. “There’s been no attempt to try to compare the actual results in these physician-invested hospitals with those that are coming out of general, short-term acute care community hospitals,” Cimasi said. “If they did that, I think that it would show what everyone has known for a long time: That these physician-owned facilities have had a tremendous track record and are highly rated in terms of the outcome that they have had with their patients and the quality of care they can provide. There has been no effort to be able to characterize the relationship, if any, between having an emergency room and what that actually does for the patients in that small percentage of the cases where there is some sort of emergency that arises.”

Not true flaws

David M. Glaser, JD, agreed that the report appeared to have an agenda and noted that the OIG reported that 34% of the hospitals “may” be in violation of the Medicare’s conditions regarding 9-1-1 use, a phrasing which underscore the potential illegitamacy of that claim.

“The only way a hospital is violating that condition is if it is not providing initial treatment to the patient,” he told Orthopedics Today. “Providing initial treatment while making a referral to another hospital is entirely consistent with the COP. If the hospital called 911 and then did nothing for the patient while waiting, for the ambulance to arrive, that would violate the COP, but I think we can safely say that is not what would occur in 34% of the hospitals. The hospital is providing care to the patient and arranging for a transfer.”

He also noted that a recent CMS rule stipulated that hospitals must notify patients if there is not a doctor on-site at all times.

“There’s really only one question in my mind, which is if the patients are fully informed, I have a very difficult time seeing what the problem is here,” he said.

Some of the findings were not true flaws, but rather characteristics of specialty hospitals, he said. “The first thing is that they are not emergency rooms,” Glaser said. “It’s sort of like if you pick on emergent care and say urgent cares are not capable of treating heart attacks. Well, they are not designed to and specialty hospitals aren’t emergency rooms. So, complaining that they don’t have emergency departments, that is a weird discovery.”

He also noted that some of the findings could be applied to other types of hospitals and the volume of transfers in the report is not indicative of inferior care.

“Is the theory that we should close that first hospital because it had to send the patient to that second one?” Glaser said. “That is a strange conclusion to draw and that seems sort of what this report is suggesting. The fact that some patients have to get transferred suggests that the first hospital is inherently defective — that is a flawed premise.”

For more information:

  • Robert James Cimasi, is the president of Health Capital Consultants, 9666 Olive Blvd, Suite 375, St. Louis, MO 63132; 314-994-7641; e-mail: rcimasi@health-capital.com.
  • David M. Glaser, JD, is a health care attorney at Frederikson & Byron, P.A., 200 South Sixth St., Suite 4000, Minneapolis, MN 55401; 612-492-7143; e-mail:dglaser@fredlaw.com.

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