Thursday, April 26, 2012

Inspector General Calls for More Disaster Preparations

CQ HealthBeat reports that a new report by the Office of Inspector General for the Department of Health and Human Services concludes that nursing homes were not adequately prepared for Hurricane Katrina.  An report also concludes that many still lack enough safeguards in case of flood, fire or storm. 

Find "Gaps Continue to Exist in Nursing Home Emergency Preparedness and Response During Disasters: 2007-2010 (April 2012)" at the Office of Inspector General (Report OEI-06-09-00270). 

The Centers for Medicare and Medicaid Services (CMS) requires that homes have detailed written emergency plans and also train staff on how to be prepared for disasters. The OIG’s office reviewed national survey data on those preparations.

In addition, OIG staffers visited 24 nursing homes that were struck by wildfires, floods and hurricanes in 2007 through 2010. Overall, disaster hit 210 nursing homes in seven states during that period, prompting evacuations and “shelter in place” decisions by administrators.

“Administrators and staff from 17 of the 24 selected nursing homes reported facing substantial challenges in responding to disasters, whether they evacuated or sheltered residents in place,” said the OIG report, which was requested by Senate Aging Committee Chairman Herb Kohl, D-Wisc. Kohl had held a hearing on this issue.

The report says, “Challenges included difficulty following emergency plans as written, logistical problems related to transportation and communication, and negative effects of evacuation on resident health. Further, most nursing homes that experienced challenges reported that they had not collaborated with local emergency management agencies to prepare for disasters.”

CQ HealthBeat reports that "Often the homes did not follow checklist tasks recommended by CMS" and that the report indicated that "state long-term care ombudsmen didn’t have any contact with nursing home residents until the disaster was over, and other state officials who deal with the licensing of nursing homes played a limited role."

OIG officials interviewed nursing home administrators, local emergency managers, state officials who oversee nursing homes and representatives from state long term care ombudsman programs.

Most nursing homes met the CMS requirements for both written plans and training, said the OIG report. But there were gaps, and many of them were the same ones identified by the OIG in an earlier study. The 2006 study was the result of the numerous hurricanes in 2004 and 2005, including Katrina, and the concerns they raised about how nursing homes could keep their residents safe.  Find "Nursing Home Emergency Preparedness and Response During Hurricanes (August 2006) at the OIG (Report OEI-06-06-00020)

On paper, the homes appeared to be ready for problems. Among more than 16,000 nursing homes surveyed in 2009 and 2010, the OIG found 92 percent met federal regulations for emergency planning, though that was a slight decrease from the 94 percent that were in compliance in 2004-05. A lower percentage, 72 percent, met standards for training, compared to 80 percent in the earlier report.

In real life, the experiences were different. “For example, one administrator of a nursing home that was flooded reported that its emergency plan did not include procedures for responding to floods, although the nursing home was in a flood plain,” said the OIG. “Administrators of two nursing homes reported that they did not consult their written emergency plans to prepare for evacuation. They reported piecing together transport by calling upon other nursing homes and local emergency entities to evacuate their residents.”

The OIG recommended that:
• CMS should be even more specific about items that should be included in emergency planning lists. The agency also should specify minimum federal standards for the frequency and extent of disaster response training, exercises and drills.
• CMS should develop better guidance for state officials on how they are to review the homes’ emergency plans.
• CMS should do more to promote the use of emergency preparedness checklists by homes.
• The Administration on Aging should develop models for state long term care ombudsmen to follow during disasters to help protect nursing home residents.

CQ HealthBeat reports that Marilyn Tavenner, CMS acting administrator, in a letter agreed with all of the recommendations and said they would be implemented. 

Finally, in a memorandum report (OEI-06-09-00271), the OIG outlines specific guidance that CMS can consider when revising the checklist for health care facilities.


"Nursing Homes Need to Step Up Disaster Preparations, OIG Says"
By Jane Norman, CQ HealthBeat Associate Editor

CMS Contracts With 27 ACOs Covering 375,000 Medicare Beneficiaries

In a press release dated April 10, CMS announced contracts with 27 Accountable Care Orgnizations, launching a new program authorized by the Affordable Care Act that is intended to help physicians, hospitals, and other health care providers work together to improve care for people with Medicare.

Under the new Medicare Shared Savings Program (Shared Savings Program), 27 Accountable Care Organizations (ACOs) have entered into agreements with CMS, taking responsibility for the quality of care furnished to people with Medicare in return for the opportunity to share in savings realized through improved care.

The Shared Savings Program and other initiatives related to Accountable Care Organizations were authorized by the Affordable Care Act, the health care law of 2010. Participation in an ACO is purely voluntary for providers and beneficiaries and people with Medicare retain their current ability to seek treatment from any provider they wish.

Accounding to CMS, the first 27 Shared Savings Program ACOs will serve an estimated 375,000 beneficiaries in 18 States. This brings the total number of organizations participating Medicare shared savings initiatives on April 1 to 65, including the 32 Pioneer Model ACOs that were announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011. In all, as of April 1, more than 1.1 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

According the CMS, anyone who has multiple doctors may have experienced the frustration of fragmented and disconnected care: lost or unavailable medical charts, trouble scheduling an appointment or talking to a doctor, duplicated medical procedures, or having to share the same information over and over with different doctors.

Accountable Care Organizations are designed to lift this burden from patients, while improving care and reducing costs. The Shared Savings Program was created by the Affordable Care Act after a number of efforts in the private sector showed that improving care can lead to lower costs. The selected ACOs include more than 10,000 physicians, 10 hospitals, and 13 smaller physician-driven organizations in both urban and rural areas. Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving. CMS is reviewing more than 150 applications from ACOs seeking to enter the program in July.

To ensure that savings are achieved through improving and providing care that is appropriate, safe, and timely, an ACO must meet strict quality standards. For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and the patient and caregiver experience of care.

CMS also announced today that five ACOs are participating in the Advance Payment ACO Model beginning April 1. This model will provide advance payment of expected shared savings to rural and physician-based ACOs participating in the Shared Savings Program that would benefit from additional start-up resources. These resources will help build the necessary care coordination infrastructure necessary to improve patient outcomes and reduce costs, such as new staff or information technology systems. CMS is reviewing more than 50 applications for Advance Payments that start in July.

To learn more about the ACOs announced today, visit:

For more information on the Advanced Payment ACO Model, including the participating ACOs, visit:


Debt Collectors Find Their Way Into Hospitals

The New York Times reports that “Hospital patients waiting in an emergency room or convalescing after surgery are being confronted by an unexpected visitor: a debt collector at bedside.”  Go to to find the article, "Debt Collector is Faulted for Tough Tactics in Hospitals," in the NYT Business Day (April 24, 2012).

The online article, by Jessica Silver-Greenberg , continues: “This and other aggressive tactics by one of the nation’s largest collectors of medical debts, Accretive Health, were revealed on Tuesday by the Minnesota attorney general, raising concerns that such practices have become common at hospitals across the country.”

The article also indicates tactics of embedding debt collectors as employees in emergency rooms who would be expected to demand that patients pay before receiving treatment.

To patients, the debt collectors may look indistinguishable from hospital employees.  They may demand that the patient pay outstanding bills and may discourage the patient from seeking emergency care at all.  According to reported allegations, Accretive Health employees were told to stall patients entering the emergency room until they had agreed to pay a previous balance. 

The report indicates that in some cases these workers would have access to health information while asking patients to pay overdue bills, what the Minnesota attorney general speculates may be a violation of federal privacy laws.  The Minnesota general asserts that “the hounding of patients violated the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to provide emergency health care regardless of citizenship, legal status or ability to pay,” and that “by giving its collectors access to health records, Accretive violated the Health Insurance Portability and Accountability Act.” In addition, the attorney general says that the company broke state collections laws by failing to identify themselves as debt collectors when dealing with patients.

It is noted that hospitals “have long hired outside collection agencies to pursue patients after they have left hospital facilities,” and “to achieve promised savings, hospitals turn over the management of their front-line staffing — like patient registration and scheduling — and their back-office collection activities.”

According to the New York Times report, “Accretive says that it trains its staff to focus on getting payment through revenue cycle operations. Accretive fostered a pressurized collection environment that included mandatory daily meetings at the hospitals in Minnesota, according to employees and the newly released documents. Employees with high collection tallies were rewarded with gift cards. Those who fell behind were threatened with termination.”

The Minnesota attorney general is currently in discussions with state and federal regulators about a coordinated response to Accretive Health’s practices across the country.