SECRETARY'S ADVISORY COMMITTEE ON REGULATORY REFORM REGIONAL HEARING #2
MEETING MINUTES/SUMMARY 

March 20, 2002
Crowne Plaza North Hotel, Salon C-D
2532 West Peoria Avenue
Phoenix, Arizona 85029

Dr. Wood welcomed committee members to the second regional hearing in Phoenix. He reiterated the committee’s interest in solutions to practical problems and encouraged speakers not to dwell on payment issues, new regulations, or statutory changes.

Leslie Norwalk, CMS

Ms. Norwalk announced that Jeff Bloom had been made a full member of the committee. She introduced a new consultant to the committee, Suzanne Pattee, vice president of public policy and patient affairs with the Cystic Fibrosis Foundation. She announced that CMS has changed its policy regarding Medicare secondary payer forms. They will be now be required only every 90 days for outpatient services and reference labs on recurring patients.

Christy Schmidt, ASPE

Ms. Schmidt introduced the Spanish-language translator for the meeting and told the committee about their options for site visits: the Good Samaritan Regional Medical Center, the Phoenix Mountain Nursing Home, and the PacifiCare Desert Regional Customer Service Center.

9:15 A.M. Dr. WOOD  INTRODUCES PANEL ONE: MINIMUM DATA SET (MDS)

Tom Hoyer, CMS

Mr. Hoyer described the history of the minimum data set (MDS), which he said Secretary Thompson is personally interested in streamlining. The MDS stemmed partly from a 1986 Institute of Medicine report on nursing home quality. Congress required a minimum data set to assess patients’ status, and that assessment is to be used to plan their care. Today, MDS is on its second version, and MDS 3.0 is currently under review. MDS data are used for both quality measures and payment adjustments, much as OASIS serves both functions in home health. MDS is a highly automated process, with complex programming to support the instrument. Any changes will require new manuals, forms, training and consultation with states, which also use it. The rules for MDS come from regulations rather than congressional statutes. Responding to some of the issues raised in statements by providers, he said CMS agrees that MDS is part of the medical record, and the information found there need not be duplicated; also, the user manual is out of date, and an update is in progress. In addition, CMS is looking at a way to retroactively adjust payments in cases where no MDS was done in the required time. Any special status designations for rural providers would require a statutory change.

Q&A

The committee and Mr. Hoyer discussed burden complaints, use of the Resident Assessment Protocol Summary (RAPS), automation, use of MDS data, and quality indicators.

9:30 A.M. MDS DEMONSTRATION

Rena Shepherd, American Association of Nurse Assessment Coordinators and Sheryl Rosenfield, Nursing Consultant

Ms. Shepherd and Ms. Rosenfield performed a role-play demonstration of MDS in practice. The instrument, they said, has dramatically improved nursing home quality. The interview involves an interdisciplinary team, assessing patients’ health along with their social situations and mental state. Answers from the MDS "trigger" additional follow-up care under the RAPS system.

Q&A

The committee and the panelists discussed training for the MDS, possibly integrating MDS assessments with the physician evaluation, time limits on transmitting MDS data to CMS, who signs various parts of the MDS instrument, and features expected in MDS 3.0.

10:15 A.M. Break

Ms. Ousley, executive vice president of SunBridge, described MDS / RAPS as one of the most powerful tools in healthcare today, but one which is underutilized and misunderstood. MDS is the only uniformly collected source of data that creates a picture of patients, informing not only their care, but also wider public policy and resource utilization. Her recommendations for change include updating to MDS 3.0 sooner than planned (2004) to keep up with advances in medical technology; creating a streamlined version of the instrument to calculate payment in short-stay cases (108 elements vs. the full 500 elements); and expanding data collection across the entire continuum of long-term care.

Ms. McAllister, administrator of a 225-bed facility, said nursing homes are in a difficult state, with a shortage of nurses and nursing assistants, widespread financial trouble, and rising costs for liability insurance and employee health insurance, all of which have been inadequately reimbursed. She said she supports the use of MDS, but the instrument needs streamlining. She recommended doing only the shorter, "quarterly" version of the assessment for Medicare payment purposes on days 30 and 60, while doing the long version on days 14 and 90. In addition, CMS should create a revised and comprehensive user manual.

Ms. Burger described MDS as a good, parsimonious instrument developed in a thorough process that generates important data to improve care. The real issue, she said, is not the instrument but getting adequate staffing to use it well. Better minimum staffing ratios would help.

Mr. Steven said the AARP regards MDS as an essential tool: it’s difficult to make comparisons across facilities or over time without it. He recommended establishing a continuous quality improvement process for MDS, higher staffing levels in nursing homes, better payment for nursing home care, case-mix adjustment for all quality indicators (which some now lack), using MDS data to better spot trouble areas through predictive software, using MDS data to give clinical information to the caregiver, and using MDS data to let consumers rate and choose among facilities.

The committee and the panel discussed how nursing homes use MDS data, the role of acute care providers in assessment, the process for updating to MDS 3.0, predictive software, staffing concerns, the similarities between MDS and the OASIS home health assessment, handoffs that occur when patients move between providers, the Nursing Home Compare web database, HIPAA’s impact on standardizing data collection, state Medicaid programs’ use of MDS data, and prospects for streamlining the data collection.

11:45 A.M. PUBLIC COMMENT

Jane Orient, a physician with the Association of American Physicians and Surgeons, said the MDS instrument represented overkill and that a literate nurse can deliver the essential information with four lines of text. She challenged the notion that MDS contributed to improvements in care and said it would take a controlled experiment to see how MDS compares to regular nursing notes. Uniform data means "one size fits nobody." CMS should not intrude into medical management and should pay providers using simpler information.

Janice Dinner, associate general counsel with the Banner Health System, said EMTALA has exacerbated a crisis in Arizona, which has seen a large growth in uninsured, underinsured and undocumented immigrant patients. A physician shortage and lack of public coverage has sent patients to emergency rooms for care, and hospitals are now having trouble filling their on-call schedules with doctors. Some hospitals have seen mass resignations, and in other cases, the doctors are demanding "exorbitant" payment for serving on call. In addition, since hospitals are required to provide follow-up care and there is nowhere to send the patients, follow-up often happens back in the ER. She recommends that hospitals only be required to provide preliminary screening, that treatment rules be clarified, and that CMS find some way to entice doctors to take call.

Dan Coleman, CEO of the John C. Lincoln Health Network, described his hospital’s experiences with alleged EMTALA violations. In one case, the only violation was that a form had not been signed, which took "much grief" and many hospital resources to clear up as additional investigations from other agencies piled on. In another case, an EMTALA investigation questioned whether a transfer was inappropriate because a child’s grandparents, rather than the hospital, actually did the transfer (successfully). EMTALA enforcement makes even charity care hospitals fear their government and has pitted hospital against hospital.

Dr. Bob Gervais, a solo practitioner, described the recent shutdown of his Ambulatory Surgical Center for 17 months after a CMS investigation. All the violations were cured by "changing words on paper" he said, and the violations had nothing to do with patient care. For such cases, the time to reach compliance should be much longer (six months rather than the six days he was given), and re-inspection should be handled more promptly (within 10 days of a request), with any needed corrective actions described in plain English. In general, regulation should be subject to cost-benefit analysis before implementation.

Susan Zevan, a dietician with the Arizona Department of Economic Security, said that the nutrition assessment portion of MDS needs to be consistently done by registered dietitians. This work has been shown to be cost-effective, she said. In addition, budgets must allow for dietician follow-up time. The cost effectiveness of MDS / RAPS should be evaluated.

12:15 P.M. Break for lunch