CMS NEWS: CMS ISSUES GUIDANCE ON HOSPITAL EMERGENCY SERVICES REQUIREMENTS

[CAL/AAEM News Service]

CMS ISSUES GUIDANCE ON HOSPITAL EMERGENCY SERVICES REQUIREMENTS

Source: Centers for Medicare & Medicaid Services (http://www.cms.hhs.gov/)
Date: April 26, 2007


Guidance Applies to Specialty and All Other Hospitals Except Rural Critical Access
Hospitals 

CMS Continues to Implement the Strategic Plan for Specialty Hospitals Reported to
Congress in August, 2006

             The Centers for Medicare & Medicaid Services (CMS) issued guidance today
clarifying the responsibility of hospitals provide emergency services if they participate
in the Medicare program.  The guidance makes it clear that nearly all hospitals ‑
including specialty hospitals and others without emergency departments ‑ must be
able to evaluate persons with emergencies, provide initial treatment, and refer or
transfer these individuals when appropriate.  The guidance does not apply to critical
access hospitals (CAHs), which are small, rural hospitals that are subject to separate
regulation.

The guidance was issued in a Survey and Certification letter.  The announcement was made
at the annual meeting between CMS and the Directors of the State Agencies that contract
with CMS to survey hospitals and other Medicare providers and suppliers to ensure
compliance with quality of care standards.

            Survey and Certification letters guide State Agency surveyors in determining
whether hospitals meet all conditions of participation required to participate in the
Medicare program.  Today’s letter reiterates Medicare’s long-standing requirement that
hospitals have appropriate policies and procedures in place to address individuals’
emergency care needs 24 hours per day, 7 days per week. 

            “Any hospital participating in Medicare, regardless of the type of hospital
and apart from whether the hospital has an emergency department must have the capability
to provide basic emergency care interventions.” said Leslie V. Norwalk, Esq., Acting
Administrator of the Centers for Medicare & Medicaid Services.  “The guidance we are
issuing today is part of an overall strategy to ensure quality care by assuring the rapid
response to emergencies for all people with Medicare.”  

Three key requirements are (a) the capability to appraise the emergency situation, (b)
providing initial treatment, and (c) referral when appropriate.  The letter clarifies
that the Medicare Conditions of Participation (CoPs) do not permit a hospital to rely
upon 9-1-1 services as a substitute for the hospital’s own ability to provide these
services.  

 

In a separate development, CMS issued a proposed rule on April 13, 2007 that would
increase transparency and public disclosure concerning emergency services.  The FY 2008
acute care hospital inpatient prospective payment system (IPPS) proposed rule would
require a hospital to notify all patients in writing if a doctor of medicine or doctor of
osteopathy is not present in the hospital 24 hours a day, seven days per week.  The
hospital would be required to disclose how it would meet the medical needs of a patient
who develops an emergency condition while no doctor is on site.  CMS also invited
comments on whether current requirements for emergency service capabilities in hospitals
with and without emergency departments should be strengthened in certain areas, such as
the types of clinical personnel that should be present at all times and their
competencies; the type of emergency response equipment that should be available; and
whether hospital emergency departments should be required to operate 24 hours per day, 7
days per week.

Although the survey guidance issued today applies to all hospitals, it also implements
one element of the Strategic and Implementing Plan for Specialty Hospitals that CMS
reported to Congress in August of 2006, in accordance with the provisions of section 5006
of the Deficit Reduction Act of 2005.  Other actions CMS has taken to implement the
Plan’s elements include the following:


1.      Continue making improvements in the inpatient hospital and ambulatory surgical
center (ASC) payment systems to address the perception that specialty hospitals select
more profitable DRGs and more profitable patients within those DRGs.

Inpatient Prospective Payment System (IPPS).  In the FY 2006 and 2007 final IPPS rules,
CMS refined selected diagnosis related groups (DRGs), including the cardiac DRGs, to
reflect the severity of a patient’s illness.  In the FY 2008 proposed IPPS rule, CMS is
proposing a more comprehensive revision to the DRGs that would further improve the
accuracy of inpatient acute care payments, while providing additional incentives for
hospitals to engage in quality improvement efforts.  The proposed rule would replace the
existing 538 DRGs with 745 new DRGs to account more fully for the severity of the
patient’s condition. 

CMS is also transitioning from basing DRG weights on hospital charges to estimated
hospital costs.  Studies by the Medicare Payment Advisory Commission have indicated that
hospitals charge significantly more than their costs for some types of services, such as
medical supplies and radiology.  As a result, certain services are relatively more
profitable, potentially contributing to the development of specialty hospitals which
focus on high margin conditions.  By basing DRG weights on estimated costs, rather than
hospital charges, hospital payments will be more closely aligned with the actual costs of
patient care, and the incentive for hospitals to take higher margin cases will be
reduced.  In October 2006, CMS began to phase in the new cost-based weights.  The
phase-in will take three years. 

ASC Payment System.  Consistent with its payment reform goals, CMS published its proposal
for reforming the payment system for ambulatory surgical centers on August 23, 2006.  The
proposal was intended to improve payment accuracy under the revised ASC payment system by
more logically aligning payment rates across payment systems to eliminate financial
incentives favoring one care setting over another.  The proposal would significantly
expand the list of covered ASC services and provide ASC payment generally based on the
Ambulatory Payment Classification relative payment weights used in the Outpatient
Prospective Payment System to improve access to surgical services and payment accuracy. 
At the same time, the proposed rule recommended capping ASC payments at the physician
non-facility practice expense payment rate for services that are frequently performed in
the physician office setting and that would be new to the ASC list of covered procedures
in CY 2008.  CMS is reviewing the public comments on that proposed rule and expects to
publish a final rule in the summer of 2007, with the revised ASC payment system to be
implemented January 1, 2008. 
 

2.      Transparency and Required Disclosure of Hospital Investment and Ownership
Information.

Disclosure to Patients of Physician Ownership in Hospital.  In the FY 2008 IPPS proposed
rule issued on April 13, 2007, CMS proposed to require hospitals to disclose to patients
whether they are owned in part or in whole by physicians, and if so, to make available
the names of the physician owners.  In addition, as a condition of continued medical
staff membership, physicians would be required to inform patients of their ownership
interests in a hospital at the time they refer patients to that hospital.

Disclosure to CMS.  Using its existing authority, CMS will be requiring hospitals to
disclose information concerning physician investment and compensation arrangements.  By
July 2007, approximately 500 hospitals will be required to complete a Financial
Relationship Disclosure Report and submit information to CMS for review.  CMS is studying
ways to implement a regular mandatory disclosure process that will apply to all Medicare
participating hospitals.


3.      Transparency in Emergency Services Capability.

Disclosure to Patients.  The FY 2008 IPPS proposed rule would require a hospital to
notify all patients in writing if a doctor of medicine or doctor of osteopathy is not
present in the hospital 24 hours a day, 7 days per week.  The hospital would also be
required to disclose how it would meet the medical needs of a patient who develops an
emergency condition while no doctor is on site.

 

4.       Obligations of Hospitals with Specialized Capabilities to Accept Appropriate
Transfer of Individuals with Emergency Medical Conditions, as Required by the Emergency
Medical Treatment and Labor Act (EMTALA)

Accepting Emergency Transfers.  The FY 2007 IPPS rule added language to the EMTALA rules
clarifying that every participating hospital with specialized capabilities, regardless of
whether or not it operates an emergency department (ED), must accept an appropriate
transfer for which it has capacity and the necessary specialized capabilities to treat
the patient.

5.      Changes to Enrollment Form to Capture Type of Hospital.

Identifying the Type of Hospital.  CMS is developing changes to the Medicare provider
enrollment application form and accompanying instructions that would clearly identify
specialty hospitals as a separate category of hospitals.  Implementation of the revised
form is expected by September 2007. 

For more information on the emergency services guidance issued today, see:

http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage 

For more information about Specialty Hospitals, including the DRA Report to Congress,
see: 

http://www.cms.hhs.gov/PhysicianSelfReferral/ 


Cyrus Shahpar & Brian Potts 
Managing Editors, CAL/AAEM News Service
University of California, Irvine

The CAL/AAEM Archives are available at: http://maillists.uci.edu/mailman/public/calaaem/



       
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