By all accounts 2010 is shaping up to be a tough year to lobby for any legislation tied to a fiscal note. As Sharon Adkins, MSN, RN, executive director of the Tennessee Nurses Association succinctly noted, “Anything with a dollar sign is dead in the water.”
Amid massive budget cuts, a continuing decline in sales tax revenues, concerns over the job market and Governor Bredesen’s emphasis on education, healthcare advocates know they have their work cut out to get state legislators’ attention. Yet, Tennessee healthcare associations are ready to fight for initiatives and issues deemed too urgent to put on hold.
Tennessee Hospital Association
“Our number one issue this year is the budget,” stated Beth Berry, senior vice president of government affairs for THA. “On July 1 of 2010, hospitals are going to see a 15 percent cut. Our number one job is to help the General Assembly understand just how devastating these cuts will be to hospitals.”
Berry said there would be 7 percent across-the-board cuts and that hospitals would lose the entire essential access fund because state dollars were being eliminated to draw down the federal match. With a one-third state, two-third federal funding formula, the state saves $133 million, but the hospitals lose nearly $400 million. “If that weren’t bad enough, the budget proposal has another $230 million of hospital cuts,” Berry continued. All told, she said if the governor signs the budget as proposed, hospitals in Tennessee stand to lose three-quarters of a billion dollars beginning this summer.
“I have to say, I don’t envy the job of the General Assembly this year. They have a lot of tough choices to make,” noted Berry. However, she continued, THA wants to make sure every avenue is explored to try to avoid the Draconian cuts hospitals currently face. Berry said the state should use all the rainy day funds first and make sure that TennCare has used its reserve funds before eliminating the state dollars needed to draw down federal money.
Another measure being explored is the possibility of some sort of fee similar to the bed tax that skilled nursing facilities pay to generate the state’s portion of the federal match program. Having hospitals take on the state’s responsibility is something THA and its membership have been extremely reluctant to do, but Berry said in light of the devastating alternative, it is at least being considered.
“You’re talking about impacting the financial viability of hospitals in this state,” she said. “You’ve got a lot of sole, rural providers. I’m not sure how they survive a hit like this.”
Although this is not a year to overload legislators, Berry said there are other issues on the radar screen. However, she continued, “Some ideas we’ve wanted to deal with are probably going to get put on the back burner.”
Still, Berry said THA would always view maintaining a health Certificate of Need program in the state as a top priority. “Every year someone wants to come in and make a change. There is always a legislator who wants to come in and do away with CON,” she said, adding the reason given is typically to create a “free market.” In light of the regulatory nature of healthcare, Berry noted, “We completely disagree with that position because there is nothing about healthcare that’s a free enterprise.”
Also of major concern is the pending Medicaid Integrity Program (MIP), which is a CMS-driven auditing program similar to RAC. However, the parameters for MIP are considerably different than RAC and place few limitations on the auditors. “It’s going to make the RAC program look like the greatest program ever,” said Berry. “This is a disaster in the making that many aren’t even aware of,” she added.
THA does hope to work with legislators to hammer out a bill that puts some limits on how many claims MIP auditors could ask for at one time, outlines a formal notice period, potentially limits the ‘look back’ period, limits a contractor’s ability to extrapolate data from a small number of claims, and sets up a process to request information. “We’re basing this on comments that CMS has made that auditors, in some areas, will look to state statutes and rules for certain procedures. There’s no guarantee what we’re trying to do will help, but we’ve got to try something,” Berry stated.
For more legislative priorities, go online to www.tha.com and click on special topics.
Tennessee Medical Association
“Our top priority would be to fix the doctor shopping legislation that passed last year,” said Yarnell Beatty, general counsel for TMA. “For 2010, we’re trying to fix some problems with the legislation that have been found through experience.”
At issue are disparities in the severity of punishment for all parties involved. “The Assembly passed a bill in 2007 for TennCare enrollees that would make it a felony for a patient to go into a doctor’s office and not tell the doctor they’ve received the same or similar controlled drugs,” explained Beatty. However, noted Gary Zelizer, TMA director of governmental affairs, last year legislators extended the mandate to discourage doctor shopping by anyone in the state but made the crime a misdemeanor for those not on TennCare rolls. Further complicating the issue, in last year’s bill, it became a felony for doctors to not report suspected doctor shopping … but only for patients not on TennCare. “It’s so convoluted,” said Beatty. “You can imagine how confused everyone is.”
Working through the two statutes, it’s a felony to doctor shop on TennCare … but for those who are uninsured or have coverage through an entity other than TennCare, it’s a misdemeanor to doctor shop for the patient but a felony for the physician if the issue goes unreported.
Zelizer said, “That’s a discrepancy we think is inappropriate. Not only do we think it’s inappropriate, but by making it a felony to not report, we have disincentivized those doctors from checking the controlled substance database.”
The proposed solution is to strike the prescriber felony portion of the law and replace it with an administrative fine by the prescriber’s licensing board. Furthermore, the revised legislation clarifies to whom prescribers should report. Zelizer said the current law only says ‘local law authorities’ but doesn’t specify what should be done if a physician or nurse practitioner located in one county is seeing a patient who lives in another. The updated legislation specifies it should be law enforcement agents in the county where the prescriber is located.
Because of the fiscal note for the cost of prosecution and incarceration that would come with increasing non-TennCare doctor shopping from a misdemeanor to a felony, the discrepancy for patients probably won’t be addressed this year. The prescriber portion, however, could be corrected without costing the state additional funds.
Another major issue for the organization is to ensure a mechanism is in place to provide for independent review of healthcare claims that have been denied. “Currently,” said Beatty, “If a claim is denied, the physician’s only recourse is to go through the insurance company’s own internal review process.” TMA would like to add a final step that allows an independent party to review the case after the internal review process has been exhausted.
Zelizer said there has been a good bit of dialogue between providers, carriers and the Department of Commerce and Insurance on changing the process. “There’s been some common ground among the three stakeholders, but there is still some discussion about how it will look at the end of the day,” he noted.
A key patient safety measure being supported by the TMA, Zelizer continued, is to reinstate mandatory unusual incident reporting by physicians who perform Level 3 office-based surgery, which are procedures that utilize general anesthesia. “Over the years, more and more surgical procedures are being done in the physicians’ offices. For a number of years, as part of a statute that was passed in 2002, physicians had to report an unusual incident to the Department of Health. That statute that was passed in 2002 was deleted last year,” he said. Zellizer added, however, mandatory reporting for unusual incidents is still on the books for Level 2. “Not only is there an inequity, but we think from a patient safety standpoint there needs to be a report to the board.” The new legislation would require reports be made to the Board of Medical Examiners.
Julie Griffin, assistant director of governmental affairs, said, “TMA will be supporting the effort to remove the exemptions in the smoke-free workplace statute that passed three years ago.” She noted the legislation, spearheaded by the Campaign for a Healthy and Responsible Tennessee (CHART) would ban smoking in ’21 & over’ establishments. “Public health is a key issue for the members of the Tennessee Medical Association. Our membership always wants to promote healthier lifestyles.” She added secondhand smoke is a danger for those employed by exempt establishments. “We believe every person who goes into work should have a right to breathe (clean) air.”
Another issue on the radar for 2010 is raising the cap for what patients or their representatives could be asked to pay for copies of healthcare records. The current cap has been in place since 1997.
For more legislative priorities, go online to www.tnmed.org and click on government affairs to download the 2010 legislative package.
Tennessee Medical Group Management Association
Deborah Hudson, CMPE, immediate past president of TMGMA, said that as an association, the group doesn’t form a separate state legislative agenda. Instead, she explained, TMGMA partners with TMA. “Their issues are our issues,” she said noting administrators’ concerns mirror those of the physicians with whom they work. Hudson serves as the TMGMA liaison to TMA and weighs in on topics impacting practices.
On a national level, she said the biggest concerns for the Medical Group Management Association and its state affiliates are over the impact of healthcare reform in general and the 21.2 percent cutback on Medicare reimbursement.
“We’re one of the only industries in the world that performs services and then asks Medicare, ‘OK, what are you going to pay me for it?’” she said. “It puts you in a very precarious position. As a practice manager, you have to be flexible. You always have to be calculating the worst case scenario.”
The hope is that Congress will permanently fix the much-despised Sustainable Growth Rate (SGR) formula used to calculate reimbursements. The House passed a bill on Nov. 19, 2009 that eliminates the accumulated reimbursement cut and creates a new payment formula based on the Medicare Economic Index, which looks at inflation in medical practice operational costs. Although, Senate support of HR 3961 seems unlikely, the legislators did agree to put a 60-day moratorium on the scheduled 21 percent cut — which was to have gone into effect on Jan. 1, 2010 — while lawmakers continue to search for a compromise on SGR.
“We’re hopeful they will find a way to make some permanent way that healthcare can be affordable and that we can continue to see Medicare patients,” Hudson said. “We don’t want to stop seeing Medicare patients, but if the reimbursement is lower than our cost, we can’t continue to make bad business decisions.”
For more information, go online to www.tmgma.com.
Tennessee Nurses Association
“Our number one concern … in view of all the budget cuts and in view of what’s happening with decreasing reimbursements for services … is access. Our top priority is ensuring the citizens of our state have access to care,” said Sharon A. Adkins, MSN, RN, executive director of the TNA.
“We realize this is going to be a very difficult legislative session,” she continued. For that reason, the TNA doesn’t have plans at this point to introduce specific legislation. Instead, Adkins said, they plan to monitor bills that are already in the works and support any legislation that truly fosters access to safe, quality care.
Another top priority — and one that could potentially tie into education where some dollars are likely to be spent — is increasing the number of school nurses in elementary and secondary education.
“Not only are more children in school with chronic conditions but also in our underserved areas, sometimes the school nurse is the only healthcare provider that student sees,” said Adkins.
She added school nurses are vital in dealing with chronic issues and in health promotion to head off potential problems. “It was actually a school nurse in New York that was the first to identify the H1N1 virus,” Adkins pointed out.
The American Nurses Association and the National School Nurses Association call for a ratio of one nurse to 750 students at the very minimum. “In Tennessee, right now by statute, the ratio of nurses to students is 1:3,000 … so you can see, we have a long way to go,” pointed out Adkins.
Currently, TNA is working with educators to build a coalition to address the situation. Knowing that students who are ill are not optimal learners, Adkins said TNA would be vigilant to see if there was any way to improve the situation through pending education legislation.
Another ongoing issue for the association is ensuring there is an adequately trained nursing workforce to meet the demands of the future. Adkins said there is continuing concern that scholarship funding be made available for nursing students … and particularly those who want to advance their education with an eye toward becoming nursing faculty.
“The issues of healthcare are becoming more complex. We need a quality, well educated nursing profession to deal with those,” she said.
Adkins added, “We’re afraid there is a perception because of the recession that the nursing shortage is no longer an issue, and that is not true.”
Due to the economic crisis, some nurses have delayed retirement while others have shifted from part-time work to full-time schedules bringing the nation temporary respite from workforce shortages. “When the recession is over, they’ll go back to part time and retire,” warned Adkins. “And then there will be a huge hole in the healthcare system … and that’s also going to hit as baby boomers are retiring so there will be more demand and fewer nurses.”
For more legislative priorities, go online to www.tnaonline.org and link to government affairs.
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