Guest guest Posted January 17, 2012 Report Share Posted January 17, 2012 and Chad thank you so much for your remarks. The commentaries going back and forth seems to be dividing our profession. We are losing site of the fact that we are all trying to meet the needs of our communities and we each serve provide unique services. Instead of fighting one another we need to remain a solid group, with one mission. I , like Chad, have worked in both settings and they each have their challenges. Currently I manage a CARF accredited outpatient facility in a Level 1 Trauma Center. Much of our case mix is either uninsured or underinsured. We are charged with finding funding sources for many of them or they would receive no care at all becoming further burdens on the taxpayers, as opposed to returning them to functional members of the community. We are all in this together for the well being of the clients we serve. Engelberg, PT Manager, Outpatient Rehabilitation Orlando Health myormc.com facebook.com/orlandohealth youtube.com/orlandohealth @orlandohealth on twitter 1222 S. Orange Ave. , MP 77 or 100 W. Gore St. Suite 104 Orlando, Fl 32806 tel: 321 841-6581 From: PTManager [mailto:PTManager ] On Behalf Of Chad Yoakam Sent: Monday, January 16, 2012 8:27 PM To: PTManager Subject: RE: Re: gravy train? Thank you very much for the excellent response to the " gravy train " remark below. I would like to add my perspective as well as this is perhaps the worst possible time to divide our profession. I have worked in both the private practice setting as well as the hospital based setting so, I have seen both sides and have enjoyed them both. Some thoughts to consider..... 1. Most hospitals are non-profit (not all, but, most). In a nutshell this means that they must take on Medicare and Medicaid patient as mentioned earlier in this string. Please check the reimbursement....not exactly a " gravy train " . Hospitals don't have the option of not taking Medicare/Medicaid patients as many private practices do. In my area we are already seeing private practices exercising this option which in-turn, loads the hospital based practices with a higher proportion of these patients. Our hospital's patient mix is approximately 45% Medicare (not including Medicaid). 2. Hospitals (such as mine) often have sliding fee scales (aka patient assistance programs) which discount services to qualifying patient for all services, not just therapy patients. This cuts reimbursement because we are helping the un-insured/under-insured which again, can be turned away by private practices. 3. Hospitals have tremendous profit margin reducing overhead that private practices do not have. This includes non-revenue producing employees such as housekeepers, maintenance staff, billing office employees, CNAs, medical records staff, compliance officers, risk managers, central sterile staff, biomedical engineering staff, central supply/materials management (the people that keep all the supplies available for patient care), admissions/registration personnel, transcription, etc. We have very large facilities with large utility bills, etc. If my understanding is correct, this is why some Medicare rules that have been created have not been applied to hospitals (i.e. the therapy cap which is coming soon to a hospital near you!) 4. Last year, our hospital (a 25 bed critical access hospital in a rural community of 7,000 people) had a medical malpractice and liability insurance bill exceeding well over 1 million dollars. My guess is that most small private practices pay a fraction of this. I might add that this the 2nd largest expense of most hospitals second only to payroll. 5. Hospital based clinics must follow the same laws that are not enforced on private practices. For example, I know many private practice docs that refer only to the private PT practice in-town because they feel we (the hospital) are a corporate giant (LOL!). I'm not just sure, I'm positive, that the private practice in town not only does not discourage this but, encourages it and enjoys the steady referrals (not a gravy train?). We, by the way, make available to all the patients in our hospital a list of all the PT services available in the area so that patients do have a choice (I know this is not done everywhere but, my organization is certainly not juicing up our " gravy train " ). With the current proposed legislation that will cut the Physician Fee Schedule by 27.4% unless congress acts by the end of February will cut reimbursement to the hospitals on the PFS just as it will cut reimbursement to private practices. Please think about what will happen when many of the private practices realize that it isn't profitable to continue to accept Medicare/Medicaid patients. I suspect hospitals will see even more of these patients and will be expected to break even when it is hard to cover the costs now. From my seat we will be asked to tighten our belt even more than we have in the last 2 years (last year our hospital was stuck with approximately $8 million dollars in bad debt and un-reimbursed care and an additional $8 million in contractural adjustments, etc.). Again, this does not seem like much of a gravy train to me. In fact, if I were a betting man I would bet that we see a significant number of hospitals close in the next 5 years if this trend continues. Bottom line, research should be done to ensure a well-informed position on something before one makes a generalized comment that simply is not true and is divisive to our profession. Chad Yoakam, MS, PT Livingston HealthCare From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf Of Zarosinski, Sent: Monday, January 16, 2012 4:02 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: RE: Re: outpatient referrals by nonstaff MDs I have owned a Private Practice and now I manage the Rehab Dept. of a large hospital. Our hospital system does not require our employed physicians to refer to the hospital's outpatient clinics. However, we do cultivate a culture around easing the way of our patient's through our multiple layers of care. We compete with private practices and physician owned practices just as you do. I am sure that not all hospitals operate like we do. That said, it seems that many who post on this list serve seem to be dividing our profession by labeling hospital outpatient systems as the enemy. That is painful given that many hospital Rehab Directors are quite active in the APTA, operate excellent practices that meet Joint Commission requirements ( which are very stringent and cost a lot resources to meet) and have to figure out ways to serve the uninsured. When I was in private practice, I had access to many contracts that the hospital systems in town could not get. In fact, the best contracts in town are not available to my hospital system but are available to private practitioners. This is just business. No one gets everything. Here in Oregon, our system is going to be part of an ACO. I envision that we will need some help in treating the extra 600,000 Oregonians that are going to become insured. Will the reimbursement be good? I don't think so. Will we need to come up with a new model to deliver care? I think so. Will that involve practices that are not a part of our system? I think so. However, we will choose carefully. Our average number of visits per patient is between 6 - 7. Our outcomes are great and our patients are satisfied. So, we will want to partner with practices that can match our outcomes and our average number of visits. I am hopeful that there will be many colleagues who will want to work with us. From: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> ] On Behalf Of selenahorner Sent: Saturday, January 14, 2012 2:41 PM To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Subject: Re: outpatient referrals by nonstaff MDs Historically, hospital systems like to keep the gravy train going within their own system. From acute care to rehab to home health to outpatient services, the unwritten rule is to keep the patient within the hospital system, not for continuity of care as much as increased profits. Hospital systems are jumping on the ACO bandwagon and are buying out physician practices within surrounding communities. Generally speaking, hospital systems do have outpatient physical therapy satellites in communities. This means there isn't inconvenience to patients in various communities surrounding the large hospital headquarters. Reality... hospital systems have physicians who use hospital referral pads when making referrals. People who have this piece of paper in their hot little hands contact or choose from services on that sheet of paper. The choices on that sheet of paper only direct the hospital patients to hospital locations for services. It is completely unheard of for a hospital system to provide options outside of the system. It is also unheard of for that piece of paper to communicate freedom of choice for services. Hospital systems have monopolized this way for years without divulging facts & the freedom of choice to patients within their system. Hospital systems have a very large chunk of a population in any area who utilize services. Hospital systems monitor referral patterns. Private practices and freedom of choice have been ignored for years on this particular topic. I'm not for more and more regulations. I think it creates increased cost to verify medical staff privileges. Does this truly limit freedom of choice? Not completely. Remember, patients have the freedom to choose and that freedom isn't captured by any hospital system anyways because full disclosure doesn't occur in the real world. It forces hospital systems to grant every physician within their system medical staff privileges. Remember, the unwritten rule is to refer within the system. The only logical way to determine departmental impact of this - because really, you are all talking money and the loss of revenue - is to dig into your databases and analyze your top 25 referral sources. How many of those referral sources are not already within the hospital system? And... from that, how many of those currently within the hospital system do not have medical staff privileges? To understand the full " effect " of this, what's the data indicate? And, for those of you in private practice. Now would be a nice time to question your top referral sources and learn who has privileges where. You can educate them on their options for where to refer for physical therapy services based on this new regulation. If you happen to have referral sources without privileges and you just happen to compete with a hospital system - especially a hospital system that isn't a team player in the community, you could share a referral source NPI number and contact your Medicare payer questioning if they have paid for services at the hospital site. Selena Horner, PT ton, MI > > Good afternoon for those practicing in hospitals that see outpatients how is the new CMS interpretations affecting you if the doctor is not on staff of the hospital they can no longer refer to the hospital. I copied the language and the link below it was effective November 18, 2011. > > http://www.cms.gov/transmittals/downloads/R72SOM.pdf > > §482.56( Standard: Delivery of Services > Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital's medical staff to order the services in accordance with hospital policies and procedures and State laws. > Interpretive Guidelines §482.56( > Rehabilitation services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient. The practitioner must have medical staff privileges to write orders for these services. Privileges must be granted in a manner consistent with the State's scope of practice law, as well as with hospital policies and procedures governing rehabilitation services developed by the medical staff and approved by the governing body. Practitioners who may be granted privileges to order rehabilitation services include physicians, and may also, in accordance with hospital policy, be extended to Nurse Practitioners, Physicians' Assistants, and Clinical Nurse Specialists as long as they meet the parameters of this requirement. Although the following licensed professionals are also considered " practitioners " in accordance with Section 1842((18)© of the Social Security Act, they generally would not be considered responsible for the care of the patient or qualified to order rehabilitation services: Certified registered nurse anesthetist (Section 1861(bb)(2) of the Act); Certified nurse-midwife (Section 1861(gg)(2) of the Act); Clinical social worker (Section 1861(hh)(1) of the Act); Clinical psychologist (for purposes of Section 1861(ii) of the Act and as defined at 42 CFR 410.71); or registered dietician or nutrition professional. > > L. , PT, DPT, MBA > Director, Physical Rehabilitation Services > East Orange General Hospital > phone > fax > pager > " An ounce of prevention is worth a pound of cure. 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