Hospitals Adding Nurses, Other Workers
Fewer hospitals are employing more nurses to care for fewer patients, according to a new report in the American Hospital Association's (AHA) Hospital Statistics. The findings contradict the claims of organized nursing, which has accused hospitals of chopping their nursing staffs to save money at the expense of patient care. In fact, not only are hospitals employing more nurses, they're employing more workers overall. And that contradicts the bulletins from hospitals and their consultants, which have contended that hospitals are downsizing and restructuring to become more efficient and productive.

Data in the report show that full-time-equivalent registered nurse positions at acute-care hospitals rose slightly to 895,075 in 1996 from 893,735 in 1995. Over the same period, those hospitals' adjusted average daily patient census dropped to 799,407 from 809,238. The changes resulted in an increase in the registered nurse-to-patient census ratio of 1.12 in 1996 from 1.1 in 1995. In fact, that ratio has been creeping up for at least the past five years, AHA data show. In 1991 the ratio was 1.02. "That increase just affirms what we've been saying all along," said Marjorie Beyers, executive director of the American Organization of Nurse Executives, a subsidiary of the AHA. "Nurse staffing is driven by patient requirements for care."

Representatives of organized nursing, however, saw things differently. "Revenues are up, admissions are up, outpatient visits and surgeries are all up, while lengths of stay continue to decline," said Argene Carswell, interim executive director of the American Nurses Association. "Yet RN staffing has remained relatively constant since 1993." She said these factors should be leading to a larger increase in RN care, especially because the acuity of hospital patients has increased, requiring more intensive care.

Arkansas Department of Health's Toll-Free Number
Any hospital needing to contact the Arkansas Department of Health (ADH) on weekends or after normal working hours should call the department's 24-hour toll-free telephone number (800) 554-5738. The number should be called for all ADH service inquiries except In-Home Services.

The number is answered by the ADH's main switchboard during regular work hours (8 a.m. to 4:30 p.m., except holidays and weekends). The number is answered by the ADH's Emergency Communications Center outside regular work hours should you need to report an emergency. After dialing the toll-free number, you may reach the Division of Health Facilities Services by dialing extension 2201 during regular work hours.

HCFA Issues Stark II Rule
The Health Care Financing Administration (HCFA) published its long-awaited rule governing physician self-referral to designated health services in the January 9 Federal Register. The rule will implement the so-called "Stark II" law enacted as part of the Omnibus Budget Reconciliation Act of 1993 and the Social Security Amendments of 1994. The law itself has been in effect since January 1995.

The law prohibits physicians from referring Medicare and Medicaid patients to a broad group of healthcare services in which they or a member of their immediate family have a financial interest. The services include clinical labs, physical therapy, occupational therapy, radiology, home health, inpatient and outpatient hospital care, and others.

HCFA's rule proposes several exemptions to the prohibitions, such as allowing a physician on staff at a hospital to make referrals to that hospital for designated health services, even if the physician has an ownership interest in the hospital. Other exemptions include:

-- physician services furnished personally by another physician in the same group practice as the referring physician;
-- in-office ancillary services furnished personally by the referring physician or by another physician in the same group practice, and billed by the group practice or a wholly owned entity;
-- services furnished to prepaid health plan enrollees by an HMO, a healthcare prepayment plan, or an organization receiving prepaid payments through a Medicare demonstration program, and services furnished under certain payment rates such as an end-stage renal disease facility.

American Hospital Association senior Washington counsel Mary Grealy indicated HCFA has shown a willingness to accommodate integrated health plans under the proposal by addressing some concerns about compensation arrangements between physicians and hospitals.

Advisory Opinions
The fifth and sixth advisory opinions issued by Health and Human Services' Office of the Inspector General (OIG) under provisions of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) finally give hospitals some general guidance that can be broadly applied regarding federal anti-kickback statutes. The first four opinions concerned such specific arrangements that providers wondered whether the HIPAA provision would be helpful in any way.

The OIG's fifth opinion involved a joint venture arrangement between a radiology group and a hospital system planning to establish an imaging center together. The OIG's opinion allows the two partners to open the center, even though one of the physicians who owns the radiology group also serves as a director of a radiology department within the hospital system. To comply with the law, the system may not allow the radiologists it employs to refer to the center, must inform the medical staff of the joint venture but in no way induce them to use it, won't be allowed to track referrals to the imaging center, and will continue to use its own radiology units.

OIG chief counsel on the matter, D. McCarty Thornton, said although the arrangement raises "questions" and doesn't fall under any anti-kickback safe harbor, it doesn't necessarily break the law. Thornton gave the joint venture a go-ahead because it did not provide for either partner to generate referrals and both parties invested equal amounts of money in the center.

In its sixth advisory opinion, the OIG told a company that owns two hospitals it could not stock ambulances with medical supplies used when transporting patients to those hospitals. The opinion said the stocking appears too much like an inducement for business.

Disclosure Law Now Effective
Hospitals are now required to provide more information to Medicare patients and the government about home health care options. The new law, a provision of the Balanced Budget Act of 1997, is intended to ensure that healthcare providers are committed to putting the best interest of the patient first. Under the new law, hospitals are required to:

-- provide Medicare patients with a list of Medicare-certified home health services available in the area in which the patient resides;
-- provide an opportunity to any Medicare-certified home health services provider to be included on the list;
-- and, provide the Health Care Financing Administration with information on the number of Medicare discharges and self-referrals.

OIG Work Plan Released
A work plan released by the Office of the Inspector General (OIG) shows no indication that federal agents intend to reduce the number or intensity of their healthcare fraud initiatives. In fact, the OIG's fiscal 1998 plan calls for intensifying the scrutiny of the healthcare field. However, the work plan gives healthcare providers some advance notice of the types of practices it will be delving into during the next 12 months.

In addition to its ongoing investigations aimed at violations of the 72-hour rule and duplicate billings, referrals to hospital-owned home health services and physician practices, and coding problems, OIG will be examining other areas, including:

-- the adequacy of the Health Care Financing Administration's oversight of private accreditation and state certification activities;
-- how often Medicare prospective payment system (PPS) hospitals report Medicare patients leaving against medical advice as a possible indicator of the hospitals trying to circumvent Medicare's PPS transfer policy;
-- the extent to which Medicare home health payments go toward the care of Medicare beneficiaries or cover home health agencies' overhead costs;
-- the extent to which Medicare is improperly paying hospitals and skilled nursing facilities (SNFs) for hospice patients;
-- which physicians bill excessive visits to Medicare patients in SNFs;
-- the appropriateness of mental health services provided nursing facility residents;
-- the appropriateness of payments made to physicians, durable medical equipment suppliers, and other Part B services providers on behalf of hospice patients;
-- and, whether physicians are improperly billing for care rendered by physician assistants.

Feed The Children Needs Medical Equipment
Feed The Children urges hospitals to donate unneeded medical equipment for use in third world countries to help needy children and their families. Although many doctors and nurses volunteer to help those in need, vital medical services are often unavailable because of the lack of proper equipment. By providing the much-needed medical equipment to third world countries from Angola to Romania to Honduras, Feed The Children is bridging the gap between patients in need and medical professionals who want to help.

Feed The Children is an international, nonprofit, Christian organization providing food, clothing, medical equipment and other necessities to people who lack these essentials because of famine, drought, flood, war, or other calamities. Headquartered in Oklahoma City, Oklahoma, Feed The Children has provided assistance to all 50 states, the District of Columbia, and 75 foreign countries. More than 90% of Feed The Children's budget goes directly to program services. To donate equipment or to request further information, contact Neal Towner or JoAnn Orf at Feed The Children, (800) 627-4556 or (405) 942-0228.

HMO Enrollment Grows
HMO enrollment surged 18.5% in 1996 to 70 million, the highest growth rate in a single year since 1987, according to the Competitive Edge HMO Directory 7.2 by InterStudy. Between July 1, 1996, and January 1, 1997, HMO enrollment increased by 6.6 million. As of January 1, 1997, some 651 HMOs were in operation. Also, 45 new HMOs received their licenses and 27 HMOs either merged or consolidated in the second half of 1996. Enrollment in Medicare and Medicaid HMOs also rose in the second half of 1996.

According to a nationwide study of employer health benefits, 85% of workers at firms with 10 or more employees are now enrolled in managed health plans, up from 77% in 1996 and 52% in 1993. That translates to over 75.6 million workers and their families in HMOs last year, compared to 68.5 million a year earlier. The dramatic increase is a result of employers' efforts to control health costs and employees' desire for lower premiums and out-of-pocket costs.

JCAHO Information on Web
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has announced a complete directory of all accredited organizations is now available on the Internet. "Quality Check" can be found on the Joint Commission web site at http://www.jcaho.org. The directory includes the accredited organization's name, address, telephone number, accreditation decision based on the most recent triennial survey, accreditation date, and current accreditation status and effective date. The information will be updated weekly to assure accurate and current information. Quality Check also offers JCAHO performance reports in an easy-to-use format that includes all information now available in the printed version.

The JCAHO's future Internet plans include providing links between Quality Check and accredited organizations. In 1998, the JCAHO will contact each accredited organization to update demographic information and to gather e-mail addresses for those organizations interested in being linked to the Joint Commission web site. In the meantime, any hospital identifying incorrect information regarding the organization on the web site, should describe the correct information in a letter on the hospital's letterhead, and send it to: Joint Commission on Accreditation of Healthcare Organizations, Demographics Update Unit/AST, One Renaissance Blvd., Oakbrook Terrace, IL 60181, or fax it to (630) 792-5005.

CDC Guidelines Issued
The Centers for Disease Control and Prevention (CDC) has issued new guidelines for immunization of healthcare workers. The recommendations don't contain major departures from existing practices, but the tone used in the recommendations has become stronger to reflect the CDC's belief that immunization is important to facilities. The new guidelines break down into three groups:

-- diseases for which all healthcare workers should be vaccinated unless they show documented immunity: hepatitis B, influenza, measles, mumps, rubella, and varicella;
-- diseases for which vaccination may be indicated in certain cases or may be available in the future: tuberculosis, hepatitis A, meningococcal disease, pertussis (if vaccine becomes available for adults), typhoid, and vaccina;
-- and, diseases for which healthcare workers do not face increased risk, but may warrant vaccination anyway: tetanus, diphtheria, and pneumococcal disease.

Regulatory Compliance -- Home Health
As the OIG shifts the focus of its investigations along the patient continuum of care, home health has begun to surface as a target in an effort to complete the OIG mission. As part of the balanced budget agreement signed by President Clinton in August, an initiative has been created to combat fraud and abuse in home health and in turn, protect beneficiaries while saving taxpayers' money. The new anti-fraud provisions include:

-- the ability to bar convicted healthcare felons from ever receiving Medicare payments again, and to exclude the family members of sanctioned providers so they can't simply transfer the business to a relative and stay in operation;
-- the authority to require providers to report their Social Security and Employer Identification Numbers so that checks for a history of health fraud can be conducted;
-- the ability to establish a prospective payment system that will pay providers a flat rate, in advance, for a patient's care, eliminating incentives for providing unnecessary care. It also will end "periodic interim payments" that are made in advance and not justified until the end of each year;
-- a clear definition limiting the hours and days that home care can be provided;
-- a clear definition of skilled services so agencies can no longer provide the full range of home health services for patients who need only to have blood drawn;
-- billing based on the location of service delivered rather than the location of the agency, so providers will no longer get high urban reimbursement rates for care delivered in low-cost areas;
-- and, authority to develop standards and deny payment to agencies that bill for services in excess of these standards.

Health Insurance Not Wanted
Putting a new spin on the rising number of uninsured Americans, a study has found that workers offered insurance by their employers are increasingly turning it down. In an article in the November Health Affairs, economists at the federal Agency for Health Care Policy and Research report that those most likely to decline coverage were making less than $7 an hour, were young and unmarried with little schooling, and were Hispanic or black. The authors theorize that workers are rejecting coverage partly because employers want them to make a larger contribution toward the premium.

OMB Criticizes HCFA's Y2K Efforts
The federal Office of Management and Budget (OMB) is critical of the Health Care Financing Administration's (HCFA) efforts toward converting its computers to process claims in 2000. OMB's comments were made in a recent report in which it says less than half of HCFA's claims processing contractors have completed year 2000 assessments on their systems. Although HCFA and the Department of Health and Human Services (HHS) are restrained under current law from influencing the contractors, HHS is drafting legislation to change that situation. Congress has directed the OMB to report periodically on how governmental agencies are progressing in preparing for the year 2000 issue.

Organ Programs Eyed For Failure Rates
Organ transplant programs are getting a closer look from the federal government. Health and Human Services Secretary Donna Shalala wants to review 29 heart, kidney, and liver transplant programs that consistently have shown lower-than-expected survival rates between 1988 and 1994. She recently asked the United Network for Organ Sharing to report on its review of the programs. Meanwhile, the Clinton administration wants to require hospitals to form partnerships with regional organ procurement groups so that they can better educate their employees about candidates for organ donation and how to approach grieving families. HHS estimates the plan would increase the number of donors by 20% within two years.

Organ Transplant Survival Rates Rise
Organ transplants are working better and recipients are living longer than ever before, according to a report released by HHS. Across the board, survival rates for organ transplants are rising and reached all time highs as measured at one and three years after surgery. Kidney transplant recipients led the way in the improvement parade with survival rates of 95% at one year and 89% at three years. The United Network for Organ Sharing (UNOS), which develops and administers national organ allocation policy, prepared the report using data from 97,000 transplants in 742 transplant programs across the country.

For the first time, the UNOS compared recent patient survival rates, gathered from May 1992 to April 1994, with historical data, gathered between January 1988 and April 1992. The report shows increases ranging from 7% to 12% for the success of the transplants at one year for patients in 1992-94 compared with 1988-93. The largest increases were recorded for heart-lung, lung, and liver transplants.

However, the report shows there remains room for improvement. The analysis identified 15 kidney, 13 liver, and 15 heart programs that had lower-than-expected survival rates in both the current report and a previous edition compiled in 1994. In response, the UNOS will review procedures and case mixes at those centers, a spokeswoman said.

A complete copy of the report, including center-specific data, is available on the World Wide Web at www.unos.org. Finally, HHS underscored that the biggest hurdle for successful transplantation remains a shortage of donated organs. The current waiting list exceeds 55,000, and the gap between needed and available organs is growing.

MEDLINE -- for Free
The big news in the world of medical librarians is that the mother of all sources, the National Library of Medicine's (NLM) MEDLINE database -- more than 9 million citations from 3,800 journals in 30 countries -- has opened shop to the public as PubMed for free. Enter www.ncbi.nlm.nih.gov/PubMed in your browser and try it out. This is the database previously available only through subscribing medical libraries, or through subscription from specialized vendors (which have been paying $12,000 to $16,000 per month to NLM for access). Though some Web sites have offered free MEDLINE access, this is the first time that NLM itself has offered free, direct, no-ads access.

PubMed has a sophisticated new interface with a redesigned, user friendly search engine that can understand ordinary English words. Many of the articles have direct links to the full-text online versions provided by the publishers. A "related articles" button brings up a list of other articles on the same subject.