AHCA Chair Chies Cites Pursuit of Quality as Paramount
By Bill Gray
Speech delivered in Miami plots the course for the future of our profession.

The 2004 AHCA/NCAL Convention in Miami came to a close last week, marking the end of the largest gathering of forward thinkers the long-term care profession has ever seen.  It’s abundantly clear that we must devote all our energies to the pursuit of quality in long-term care service delivery if we and the people we serve are to prosper.

AHCA Board Chair and Minnesota native Steve Chies set the tone with an excellent speech detailing the mission we have before us.  “Quality is about more than achievement and success,” Chies stated.  “It is a culture, and true quality improvement requires a cultural change.”  (Click here to read Steve’s speech in its entirety.)  We know that this is true here in Minnesota, and that is why we launched our Committed to Quality program nearly one year ago.

“Innovation and creativity mark our professionalism,” says Care Providers of Minnesota President/CEO Rick Carter.  “Those of us at the AHCA Convention saw that the mood of our profession is upbeat.  There is a strong sense across the country that providers continue to discover new and better ways of doing things.  We must continue to place our focus on the pursuit of quality.  While survey and regulatory issues are important, they don’t measure quality and we must not allow them to be our sole guide.”

Carter continues, “Our own Committed to Quality program is designed to allow consumers access to the information that will tell them the most about an individual facility’s quality of care.  It focuses on customer and employee satisfaction; mission statement and visionary leadership; resident complaint process and continuous quality improvement.  These are the factors that determine quality care.  These are the factors that will help consumers make the best care decisions that they can make.”

As you know, the theme for our own convention this year is “Spotlight on Quality.”  As part of our annual gathering, you’ll hear from some of the best in the quality business, including Bryan Williams, Director of Training and Quality Management with Ritz-Carlton, on Tuesday.  Mr. Williams will share some of the secrets of the Ritz-Carlton's legendary customer service, and you'll be surprised at how much can be applied to long-term health care.  For information on our 2004 Convention and Expo, click here.

We hope you’ll join your colleagues from across the country and jump on board the long-term care quality bandwagon.  Take part in our Committed to Quality program and attend our Spotlight on Quality convention.  You’ll be helping your organization to do its very best for the customers it serves.

Bill Gray
952.851.2490
bgray@careproviders.org

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It’s Not Too Late to Vote Absentee Before Attending Convention!
By Bill Gray
You still have time to vote absentee in person at your county auditor or city or township clerk’s office.

If you haven’t already noticed, Election Day, November 2, 2004, falls smack in the middle of our three-day annual Convention and Expo.  There’s no need to fret though!  Voting via absentee ballot is a breeze.

The Minnesota Secretary of State’s office lays out the requirements.  Among those listed is the following:  A person may vote via absentee ballot if they are unable to vote in person on Election Day because they are away from home.

While there are several methods by which you can vote in this manner, only the easiest remains feasible in light of the late date -- voting in person at your county auditor or city or township clerk’s office.  Care Providers of Minnesota is pleased to provide you with a link to the Minnesota Chamber of Commerce’s Prosperity Project website, designed to assist workers across the state in easily finding voting information specific to their home address – click here and enter your zipcode to find out where you can vote absentee early, in person.

Don’t miss out on voting in this election!  Regardless of who you cast your vote for, the mere act of casting a vote is one of our most important duties as responsible citizens.

Bill Gray
952.851.2490
bgray@careproviders.org

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Don’t Forget to Register for Convention
By Jennifer Eyrich
The Big Event is LESS than THREE weeks away!

You may have heard that Convention is early this year, but has it really sunk in?  If you’re anything like us, you find it hard to believe that in JUST THREE WEEKS we’ll be IN THE MIDDLE of Convention – but it’s true!  Association staff is set to mail name badges and registration information to facilities NEXT WEEK, but there are many of you who haven’t sent in your registration yet. 

Why is it important to register now?  If we don’t receive your registration in time, we won’t be able to send your materials in advance.  And if you don’t get your materials in advance, you’ll have to spend time standing in line on-site – time you’d rather spend meeting colleagues, attending sessions, visiting the expo hall, and participating in many of the other activities at the Convention.  And if everyone waits until the last minute, the lines will be longer than usual this year.  Registration is easy – you can do it online by clicking here, or use the form that was mailed with the Education Bulletin earlier this week, or call Jennifer Baker at 952-851-2494 to have one faxed or mailed to you.

You really don’t want to miss the 2004 Convention and Expo – Spotlight on Quality.  This year’s event is full of great speakers – including Clint Maun and Bryan Williams from Ritz-Carlton – great entertainment – from hypnotists and the Medicine Show to “The Band” on Tuesday night – and a great expo hall with lots of new and familiar faces.  And, of course, lots of opportunities for continuing education credit.

Hotel Rooms -
If you tried to reserve a room in the Care Providers of Minnesota Room Block at the Hyatt late last week or early this week and were unsuccessful, we apologize for the inconvenience.  Rooms ARE still available at the Hyatt at the $115/Single rate, and the computer glitch that was causing confusion has been resolved.  If you experience further difficulty with reservations, contact Jennifer Eyrich at 952-851-2483.

See you the Day After Halloween!

Jennifer Eyrich
952.851.2483
jeyrich@careproviders.org

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Candidate Forums Continue to Build Momentum for Long Term Care
By Bill Gray
Jackson and Brainerd combined to bring nearly 100 people together with candidates for open house seats.

Here are summaries of the most recent candidate forums hosted by the Long Term Care Imperative. 

But first, a reminder to members that the Care Can't Wait! Campaign is in full swing, and we're asking you to engage in a "reverse door-knocking" event in which you will knock on the candidate's door to make sure they know how dire the long-term care situation is.  If you have not received the materials, or if you’re just looking for some advice or encouragement, please call Bill Gray at the Association office.

Jackson:

October 7 saw one of the biggest long-term care candidate forums of the season as over 60 people gathered at The Pines Good Samaritan Assisted Living Community in Jackson to hear District 22B House candidates Rod Hamilton (R) and Richard Peterson (DFL) discuss our issues.  Minnesota Public Radio covered the event, as did the local Jackson radio station and newspaper.  District 22B is an open seat currently held by retiring Representative Elaine Harder.

Peterson focused his comments on the need to reinstate cuts to long-term care that have been made over the last two years.  He cited cutting corporate tax code loopholes as one way to raise the needed extra funds.  Hamilton noted his belief that any further cuts to long-term care will have a measurable impact on care quality, and cited discontinuing the metro vs. rural rate disparity as one way to address the need for more funding in Jackson.  Both indicated that district door knocking had identified healthcare and education as the issues most important to the people of District 22B.

Questions from the floor dealt mainly with the private pay surcharge and the need to be able to offer competitive, fair wages for long-term care workers.  One human resources director recounted the departure of a nursing assistant for a higher paying job taking care of pigs on a pig farm.  Both candidates listened carefully and expressed concern and dismay.  Both vowed to change things once elected.

At the end of the program, both candidates were asked to sign the Care Can’t Wait Legislator Commitments.  Peterson signed both, while Hamilton chose to take the information with him and consider it.

Brainerd:

The District 12A seat is also open this year, and the Long Term Care Imperative hosted a forum October 13 at the Woodland Good Samaritan Village in Brainerd.  After serving two terms, Representative Dale Walz is vacating the seat, and three candidates are vying to replace him:  Larry Anderson of the Independence Party, Republican Paul Gazelka, a State Farm Insurance agent, and former long-time legislator Don Samuelson of the DFL.  Samuelson narrowly lost his seat in the State Senate in 2002, and he hopes to return to St. Paul through this House election.

Anderson displayed considerably less knowledge than his opponents about long term care issues, but he seemed willing to learn and listen.  He understands the legislative process well, having spent many years as the legislative liason for the Hennepin County courts.  Rather than raising taxes, he favors more efficiency from government, which he believes can be achieved through partnerships with non-profit organizations.

Gazelka said he appreciated the reimbursement issues facing long term care providers, and especially the risk of losing staff to other fields if wages do not go up.  He supports additional funding, but is not willing to raise taxes to do it.  Instead, he proposed two solutions:  repeal rate equalization; and tweak the metro / rural / deep-rural reimbursement tiers so that Brainerd moves up.  He objected strongly to the fact that certain cities smaller than Brainerd are classified as “metro”.

Samuelson was the most willing to support an increase, and in fact has already drafted a bill for an 8% increase, with 5% dedicated to staff.  Given the size of the projected deficit, he argued, the only way to avoid cuts to education and to health and human services is to raise the income or sales tax.

To the question of “what long term care reform would you propose,” Anderson would raise awareness of the fact that there is an under-65 population in many nursing homes; Gazelka would promote long term care insurance as a financing option; and Samuelson would improve and increase assisted living and home and community based alternatives. 

After the forum, administrator Mike Deuth presented the candidates with the Care Can’t Wait commitment cards, and all three agreed to sign, though Mr. Gazelka could not commit to spending time in a facility on November 26.

Bill Gray
952.851.2490
bgray@careproviders.org

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Senate Hearings Continue on Health Care Reform
By Patti Cullen
Members Invited to Speak Before Senate Panel

The Senate DFL Caucus has invited members to participate in the remaining community health care forums convened by Senators Linda Berglin (DFL-Minneapolis) and Becky Lourey (DFL-Kerrick).  Senator Lourey is Chair of the Senate Health and Family Security Committee; Senator Berglin is Chair of the Senate Health, Human Services and Corrections Budget Division.  Several forums have already been held on this topic, generally billed as “health care reform”.  Forum organizers have stated that the purpose is to hear concerns and recommendations for solutions to the health care crisis, and have noted this also includes long-term care.  The remaining forums are set for Northeastern Minnesota on October 18, and Northwestern Minnesota on October 20.

Monday, Oct. 18
            Duluth, 10 a.m. to Noon
            The Inn at Lake Superior, 350 Canal Park Dr., Duluth

            Mora, 3:30 to 5:30 p.m.
            Kanabec History Center, 805 West Forest Ave., Mora

Wednesday, Oct. 20
            Brainerd, 10 a.m. to Noon
            Brainerd Public Library, 416 South 5th St., Brainerd

            Bemidji, 4:30 to 6:30 p.m.
            Minnesota State University, American Indian Resource Center - Great Room
            (next to Diamond Point Park)

Please contact Lisa McCalpine-Wittenmyer at (651) 296-4915, if you have any questions or plan to attend the forum.

Patti Cullen
952.851.2487
pcullen@careproviders.org

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The Latest Information- Flu Vaccine Update
By Pam Guyer
More Information and Links

Care Providers of Minnesota has been in frequent contact with the Minnesota Department of Health (MDH), who is fully aware of the potential crisis of the flu vaccine shortage, and is working with the county public health agencies to set up a redistribution system.  We also know some counties are more receptive than others in dealing with this issue and we are advocating for you to receive vaccine.  We are pleased that MDH along with media sources have long term care as their priority focus.

"Our primary objective right now is to help get the limited supply of vaccine to those who need it most," Kris Ehresmann, chief of the State Health Department's immunization department, said.  "We simply cannot let long term care facilities go without vaccine, particularly because these people don't even have the option to go to walk-in clinics.  Specifically, we are asking companies and clinics who may have ordered extra vaccine this year to consider allowing nursing homes and others a chance to buy it."  MDH has had success in receiving vaccine from large companies such as 3M, Polaris and Marvin Windows.  Unfortunately, it appears there are some Minnesota clinics that have not been as generous.  Inundated with phone calls, the Health Department set up a special hot line for information about flu-shot clinics.  The number is 612-627-3950 in the metro area or 1-800-657-3903 for outstate.

Results indicate that Minnesota has about 414,000 doses of flu shots in the state, but is short 377,000 doses, mostly vaccine that was ordered by long-term care facilities and other providers from the maker Chiron.

The Centers for Disease and Prevention (CDC) is currently investigating the status of the remaining doses of vaccine in the US, that is, how many doses are pre-booked, unsold, and to determine what the most effective use of these doses is within the constraints of the free market.  "We're sorry for the people who need flu vaccine and may not be able to get it this year," said Dr. Julie Gerberding, Director of the CDC. "But we will take every step that we can take to get an equitable distribution of vaccine as quickly as we can."  She said the CDC will keep a stockpile of about 4.5 million doses for use when they find the most critical shortages. She said the CDC is also stockpiling antiviral drugs that can be used to treat or prevent flu infections.

The CDC is preparing recommendations relating to the use of antiviral medications and to respiratory hygiene/cough etiquette strategies, which we will disseminate as soon as they are finalized and released.  The CDC is also checking whether and how one could use Vaccines for Children (VFC) as vaccines for adults.  Also, the CDC is collecting reports of influenza vaccine price gouging, to review and forward as appropriate to the Food and Drug Administration (FDA).  These can be sent to Jim Harrison at JHarrison@cdc.gov. 

AHCA/NCAL is surveying state affiliates to ascertain specific areas that are in the most critical need of the flu vaccine.  The survey will be a valuable tool in demonstrating to the CDC the difficult situation faced by all settings in long-term health care, including MR/DD.  Survey information will be provided to state and federal authorities. 

Finally, a strong consistent message to patients/residents, families and others is needed to ensure that they understand that we are advocating for high-risk individuals.  Facilities need to begin planning as if they may NOT receive any flu vaccines this year (knowing that everyone is working to prevent this from happening).  Facilities should:

• Become knowledgeable about antiviral medicines and consult with the medical director.
• Encourage stringent infection control measures.
• Be proactive if flu symptoms appear in the facility.
• Stay in contact with state associations and health officials.

AHCA expects the CDC's Healthcare Infection Control Practice Advisory Committee to release its recommendations relating to the use of antiviral medications and to respiratory hygiene/cough etiquette strategies very soon.  You may have used these in past years and be familiar with them.  They have been found to be very effective.

Below is a repeat of the Q&A that went out in an email to membership on Monday. 

Question: Our LTC Pharmacy had contracted with Chiron and now we don't have any vaccines available. Do we have time to find alternative sources?
Answer: At this point in time, a major manufacturer of flu vaccine, Chiron, will not be distributing any influenza vaccine for this flu season, however the federal government is working on releasing some of the vaccine in the near future.  As we stated in last week's email, the Minnesota Department of Health is working to assess where the state's supply of vaccines are located and how to redistribute them.  Members are advised to contact their county or city health office.  Click here to find your local health department's contact information.  There is no influenza disease circulating now.  Minnesota's first confirmed influenza case is usually not reported until late November or early December.

Question: Can our residents or direct care workers use the "spray" vaccine, which is still available?
Answer: FluMist, the intranasal flu vaccine, is a viable option for healthy 5 - 49 year old individuals who are contacts of infants under 6 months of age or are healthcare workers who provide direct patient care.  FluMist is not recommended for healthcare workers taking care of severely immunocompromised people requiring a protective environment.

Question: What else can you do to protect yourself from the flu? 

• Cover your nose and mouth with a tissue when you cough or sneeze and dispose of the tissue afterward.
• If you don't have a tissue, cough or sneeze into your sleeve.
• Clean your hands after you cough or sneeze with soap and warm water, or an alcohol-based hand cleaner.
• If you get the flu, avoid exposing others. Stay home from work or school.
• Cover your cough.

Question: what can you do to prevent the spread of the flu in my nursing home or Assisted Living Facility?
Answer:  There is a wealth of information on the Centers for Disease Control website that will help you in minimizing the spread of the flu.  You can access this information by clicking here.  This information goes beyond the basic daily precautions and includes an overview of the use of anti-viral drugs which can be very helpful, particularly in long term care.   

Question: Are residents of housing with services/assisted living considered high risk as well?
Answer: Yes, most residents would because the following categories are most of the individuals deemed "high risk" of flu complications:

• Adult age 65 and older
• Adult or child who has
  • heart disease
  • lung disease including asthma
  • metabolic disease including diabetes
  • kidney disease
  • immune deficiency
  • blood disorder 
• Pregnant woman
• Resident of a nursing home or other chronic-care facility
• I am a healthcare worker and I:
  • Provide direct, face-to-face care of patients, AND
  • Spend the majority of my day or extended periods of time with those patients

Question: What if your clinic has no vaccine?
Answer:  As we have stated, MDH is assessing the vaccine situation right now and trying to make sure that as many high-risk people as possible will eventually be able to go either through their county health office, their regular provider or a flu shot clinic to get the vaccine.  As new clinics are scheduled, they will be searchable on the Find a Flu Shot page.

Pam Guyer
952.851-2485
pguyer@careproviders.org

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St. Cloud, East Grand Forks to Host Workforce Forums
By Jonathan Lips
Meetings are part of a series of regional forums addressing Minnesota’s healthcare workforce.

The final two in a series of healthcare workforce forums will occur as follows:

• Monday, October 25, 12:30-4:30, at the CentraCare Health Plaza in St. Cloud.
• Thursday, October 28, 9:30-2:00, at the Northland Community and Technical College in East Grand Forks.

Three years ago, various healthcare organizations sponsored a series of regional forums on the healthcare workforce shortage and several hundred people attended statewide.  The 2004 Forums will provide updated information on the healthcare workforce.  Many new initiatives have been developed since 2000, and participants will learn about innovative regional and statewide projects now underway.  Facilitated discussions will allow participants to discuss creative approaches – both ongoing and under consideration – to address the current and future workforce shortage.

For more information about the forums, including a brochure that describes the day, contact the Rural Health Resource Center at (218) 727-9390 or click here.

Jonathan Lips
952.851.2480
jlips@careproviders.org

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Long-Term Care Imperative Op-Ed Published in Star Tribune
By Bill Gray
Piece by Carter, Kvenvold, calls on Minnesota to address the future of its aging citizens, and those that care for them.

We were happy to see that our op-ed piece on the long-term care crisis Minnesota is facing, published in the Star Tribune this past Saturday.  The piece, which has run in this newsletter previously, can be read in its entirety by clicking here.

Exposure of this magnitude is very helpful to our efforts to raise the profile of the long-term care crisis in advance of the 2005 Legislative Session.  You may wish to print the piece out and share it with your local community.  Care Providers of Minnesota will continue working to make sure that long-term care receives the attention it deserves in 2005.

Bill Gray
952.851.2490
bgray@careproviders.org

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Instruction on Private Room Differential Claims
By Patti Cullen
Noridian Administrative Services Clarifies Coding Process

The purpose of this article is to update providers on the instructions for Medicare claims that include private room differential in non-medically necessary private rooms in a skilled nursing facility (SNF).  Providers have submitted claims with a value code 31 (patient liability for amount for noncovered services).  However, inclusion of this value code instructs the system to also look for a corresponding 32-occurrence code (date beneficiary notified of intent to bill).  Neither of these codes is required for the private room differential.  The claims would be billed just like any other SNF claim. 

Please bill the differential in the following manner:
The revenue codes 110 or 140 should show the total charges, the covered charges, and the amount of the differential as noncovered. Instead of using the field locators, you can indicate the room differential, the value code 31 and the 32-occurrence code in the remarks field.  If the benefits have exhausted, that can be listed in the remarks field as well. 

An example:

REV	RATE	TOT UNIT	COV UNIT	TOT CHRG	COV CHRG	NCOV CHRG
0140	$200.00	10	10	$2000.00	$1550.00	$450.00

The remarks field would read: Private room not medically necessary.  Private diff:  $45 x 10 days=$450.00 VC 31 06/01/04 OC 32 06/01/04 Benefits Exhaust 05/31/04

Patti Cullen
952.851.2487
pcullen@careproviders.org

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Noridian Announces Web Based Training Workshops
By Patti Cullen
Web Training Available from Medicare A Fiscal Intermediary for Minnesota

Did you know that you can attend Medicare Part A workshops without leaving your office?  You can register for Internet based workshops by going to the Noridian Administrative Services (NAS) website and clicking on the Education tab.  Select Medicare Part A Education, then Educational Workshops and finally choose the workshop you would like to attend.  A separate confirmation with log-in information will be sent to you prior to the WebEx. 

NAS has scheduled the following Webex workshops that may be attended through the Internet on the following topics:

• Skilled Nursing Facility Consolidated Billing
• Rural Health Clinic
• Critical Access Hospital
• Swing Bed Consolidated Billing

For more information on dates and times and to register for these workshops visit Noridian Administrative Services website.

Patti Cullen
952.851.2487
pcullen@careproviders.org

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Long Term Care Ad Hoc Committee
By Pam Guyer
October's Meeting Reveals New Information

Commissioner Mandernach's Long Term Care Ad Hoc Committee was full of important information at the most recent meeting held October 7, 2004.  It is apparent that the new Health Policy, Information & Compliance Monitoring Division is busy responding to the survey bill that passed in the last legislative session, among other activities.

OHFC Investigation Reports Posted:
They have begun posting the Office of Health Facility Complaint (OHFC) surveys on their website along with the 2567's.  We asked they include the definitions of "substantiated", "unsubstantiated", and "inconclusive" to the website so that consumers have a better understanding of the result of the OHFC investigation.  The posting of the OHFC investigations will follow the same process as the survey reports and include reports for the past two years.

Nurse Specialist:
They are in the process of hiring a nurse specialist who will work with the Division as a liaison between the Minnesota Department of Health (MDH) and external organizations including providers and advocates of nursing home services.  Representatives of nursing homes and the Ombudsman Office along with MDH staff will begin second interviews next week to narrow candidates down to two or three, which will move on to interviews with Mr. Giese.  This new position will report directly to him.

671/672 Online:
The Centers for Medicare and Medicaid services (CMS) forms 671 and 672 will be available to be completed on-line.  There will be edit checks built in to the program as you enter your data.  These are important forms because this information translates to your OSCAR Report and information such as Resident Characteristics and Facility Staffing on Medicare's Nursing Home Compare website.

Communication Initiatives:
In response to the Management Administration division's report as well as the Communications Sub-Committee of the Long Term Care Ad Hoc Committee, MDH is beginning regional replication of the Long Term Care Ad Hoc Committee with a pilot in the Duluth area of the state.  Representation from Care Providers of Minnesota, MHHA, and Christine Campbell will be organizing this regional Stakeholders group.

Cross-referencing:
The current cross-referencing approach spelled out in MDH Information Bulletin 04-9, Federal SNF/NF Deficiencies Related to Outcome, Assessment and/or Care Planning Findings, will continue.  The Data Sub-Committee, Chaired by Patsy Riley, Stratis Health Executive Director, will proceed in an evaluation process, drawing on research expertise when necessary.  Commissioner Mandernach was very clear that should this group become aware, at any point in time, that this approach has any detrimental affect on any resident in Minnesota, this process will be ended and the Information Bulletin will be rescinded.

MDH Environmental F-tag review:
During the time period from March 4, 2004 through August 5, 2004, a total of 208 SNF/NF and NF facilities were surveyed.  Of these facilities, 115 had a total of 195 deficiencies submitted for review.  For the purposes of this study the following deficiencies were reviewed: F252 = 2, F253 = 11, F256 = 1, F258 = 2, F323 = 38, F371 = 59, F372 = 5, F456 = 5, F460 = 1, F463 = 4, F464 = 2, F465 = 55, F467 = 8 and F468 = 2.  Eighteen of these had changes as follows: 3 did not contain adequate information to be issued as deficiencies and 15 had changes in the scope and/or severity or tag under which they were cited.  The review reveals that, of the deficiencies submitted, surveyors were accurate 91% of the time in assigning the scope and severity and correct citation tag.  In 3 cases, documentation was moved from one tag (F465) to another (F253), which have very similar regulatory language and guidelines.  F465 is used when the deficiency is strictly environmental, and F253 should be used when the environmental issue affect resident quality of life. 

The MDH conclusions of this study are as follows:

• The survey agency is correctly identifying and issuing deficiencies accurately;
• The survey agency should review with survey and supervisory staff the differences between tags F465 and F253 to clarify citations under these tags. 

Nursing Home Report Cards:
MDH will be testing the nursing home report card software program with groups of AARP members because they did not receive much feedback from people attending the State Fair.  The timeline for the development of the report card has been extended due to the re-issuing of the Department of Human Services request for proposal.  They have listed the timeline now to be from December 2004 to July 2005.  If you would be open to having them get feedback on how the nursing home report card from real live nursing home residents or assisted living tenants and are willing to offer your location, please contact Pam Guyer at pguyer@careproviders.org.

NA/R Survey Training Video:
MDH has sent a NA/R Survey Training Video or CD to all facilities and technical training school.  Beverly offered their Hillcrest of Wayzata location as a site for the taping.  The script was reviewed several times by Care Providers of Minnesota before taping.  You may notice how incredibly positive the staff are in their comments!  Kudos to the staff at Hillcrest of Wayzata!  None of those comments were scripted and were totally spontaneous!    

Pam Guyer
952.851-2485
pguyer@careproviders.org

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Minnesota Gets Poor Return on Tax Dollars According to Report
By Patti Cullen
The return Minnesota gets on federal taxes paid by residents ranks us 47th.

Using newly released data from the U.S. Census Bureau's Consolidated Federal Funds Report, the Tax Foundation has completed its full 2004 report showing which states receive more than a dollar of federal spending for each dollar sent to Washington, and which receive less.  (The Tax Foundation is a well-respected national organization whose mission is to educate taxpayers about tax policy and the total tax burden borne by Americans at all levels of government.)  The full report confirms that when it comes to federal taxing and spending, some states clearly benefit at the expense of others.

All taxpayers know that the federal government uses tax and spending policy to redistribute income from citizens with high incomes to those who make little, but citizens are less aware about geographically based income redistribution.  Tax Foundation Senior Economist, Scott Moody, compares the federal tax burden in each state with Census Bureau data (2003) on federal spending in each state.  The result is a ranking of which states got the “best deal” in 2003 from Uncle Sam’s tax and spending policies.

“During fiscal 2003, taxpayers in New Mexico benefited the most from the give-and-take with Uncle Sam,” said Moody.  New Mexico received $1.99 in federal outlays for every $1.00 the state’s taxpayers sent to Uncle Sam.  Other big winners were Alaska ($1.89), Mississippi ($1.83), and West Virginia ($1.82).

If some states are beneficiaries, then naturally some must be benefactors—those states where so much is collected in federal taxes that any federal spending they receive is overwhelmed.  Combining the third highest tax burden per capita with the ninth lowest federal spending, New Jersey had the lowest federal spending-to-tax ratio (57¢).  Other states that had low federal spending-to-tax ratios in FY 2003 are New Hampshire (64¢), Connecticut (65¢), Minnesota (70¢), Nevada (70¢), and Illinois (73¢).

What Affects Rankings?
Federal spending on defense and other procurement dollars are often funneled to the states of powerful Members of Congress, and state governments can grab more federal grant money by skillfully manipulating their spending to comply with federal regulations.  However, demography may be more influential than politics.  States with more residents on Social Security, Medicare and other large federal entitlements are bound to rank fairly high.  Similarly, the high spending levels in Virginia, Maryland and the District of Columbia are explained by the predominance of federal employees.

On the tax side of the equation, states with higher incomes per capita—New Jersey stands out—pay much higher federal taxes per capita because of the income tax’s progressive structure.  The citizens in these high-income, high-tax states do not always live better or save more than people in low-income, low-tax states because the cost of living is usually that much higher or more.

Patti Cullen
952.851.2487
pcullen@careproviders.org

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Independent National Commission Tasked With Overseeing Quality First Criteria
By Pam Guyer
Care Providers of Minnesota's Committed to Quality meets Quality First

The independent commission charged with overseeing the criteria of Quality First and recommending goals for long term care quality improvement was announced at a press conference in Washington D.C. on October 12.  The National Commission for Quality Long Term Care will be co-chaired by former Nebraska Senator Bob Kerrey and former Speaker of the House Newt Gingrich.  They will rely on advice from experts, but act independently from any individual, group or industry.  The National Quality Forum (NQF) convenes the commission.

Kerrey is a former presidential candidate and most recently a member of the independent, bipartisan 9-11 Commission.  Gingrich, currently heads the Gingrich Group in Washington, D.C.  They will preside over a distinguished group including two sitting governors, a former U.S. senator, physicians, long term care providers and medical and health policy researchers. 

Commission members include:

• Idaho Governor Dick Kempthorne,
• Virginia Governor Mark Warner, AARP
• CEO Bill Novelli;
• Former Senator David Durenberger, now of the National Institute of Health Policy in Minneapolis;
• Monsignor Charles J. Fahey, Fordham University in the Bronx;
• Richard Payne, M.D., Duke Institute on Care at the End of Life at Durham, NC;
• Sister Mary Jean Ryan, SSM Health Care in St. Louis;
• Michael Kellogg, Kellogg School of Management, Northwestern University;
• Judith A. Salerno, M.D., National Institute on Aging, Bethesda, MD;
• Sandra Smoley, RN, Fair Oaks, CA, and
• Jeannette Takamura, MSW, PhD, Columbia School of Social Work, New York.

Rick Carter, President/CEO of Care Providers of Minnesota said, "This National Commission will play an important role moving long term care forward.  Care Providers of Minnesota has long believed that we must be transparent about facilities' quality efforts to gain the confidence of consumers of long term care in Minnesota.  We have actualized this through our Committed to Quality agenda and sharing the information for consumers on www.carelinkusa.com."

"To say this is an unprecedented move on the part of associations advocating on behalf of the long term care community is an understatement," said Hal Daub, President/CEO of AHCA.  "We support this team of individuals with national stature and integrity who are accountable to no one but the American public.  Frankly, we are confident that we can meet the challenge that may be raised because we have our own quality care programs in place that surpass what many government officials and health care consumers demand."  In addition to AHCA/NCAL, other long term care associations supporting the commission include the Alliance for Quality Nursing Home Care (The Alliance), and the American Association of Homes and Services for the Aging (AAHSA).

If your organization has not yet made the Quality First pledge, you can do it online by clicking here.  It only takes a few minutes!  Also, don't forget to submit your information to meet the various elements of Committed to Quality at quality@careproviders.org.  We have a number of facilities that have completed all six components and you don't want to be left behind!  If you have questions, please contact Pam Guyer at pguyer@careproviders.org

Pam Guyer
952.851-2485
pguyer@careproviders.org

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New Tests Added to List of Waived Tests Under CLIA
By Patti Cullen
Additions effective October 1, 2004

The latest tests approved by the Food and Drug Administration (FDA) as waived tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) are listed below.  The complete list of CLIA approved waived tests can be found on the Centers for Medicare & Medicaid Services (CMS) website.

The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. 

CPT Code/Modifier	Effective Date	Description
86318QW	3-23-2004	Acon® H. pylori Test Device
82010QW  82962	4-15-2004	Abbott Medisense Precision Xtra Advanced Diabetes Management System (K040814)
85018QW	5-4-2004	HemoCue Hemoglobin 201 /HemoCue Hemoglobin Microcuvette System
83001QW	5-11-2004	Synova Healthcare MenocheckPro (Professional Use)
82274QW  G0328QW	5-26-2004	Beckman Coulter Hemoccult ICT

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed.  To ensure that Medicare and Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level.

Patti Cullen
952.851.2487
pcullen@careproviders.org

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CMS Issues Clarification on Role of Non-Physician Practitioners
By Patti Cullen
Implementation Date: October 25, 2004

Section 483.40 (c)(4) at Title 42 of the Code of Federal Regulations (CFR) did not define what the law meant by "initial" physician visit and therefore left the meaning open to interpretation, which impacted access to medically necessary care by other providers.  Therefore, the Centers for Medicare & Medicaid Services (CMS) has increasingly been asked to clarify "initial" visit and to allow Non-Physician Practitioners (NPPs) to provide medically necessary visits when needed prior to the initial visit by the physician.

To ensure that all residents of nursing facilities have appropriate access to medical care, CMS has defined "initial visit" (comprehensive assessment) according to Survey and Certification memorandum (S&C-04-08) released on November 13, 2003 to State Survey Agencies and Medicare Part A and B contractors.  Prior to release of that memorandum, NPP visits could not be paid prior to the initial visit by the physician in a SNF per 42 CFR 483.40 (c)(4) and (e) and in a NF per requirements at 42 CFR 483.40(f).

The Medicare Claims Processing Manual is now being revised so that NPPs may provide other covered, medically necessary visits prior to and after the initial visit by the physician.  This instruction states that Medicare policy requires a face-to-face visit with the resident for the SNF/NF discharge day management service.  The revision also states that a split/shared evaluation and management visit may not be reported in the SNF/NF setting.  This definition will now permit medically necessary visits to be provided by NPPs prior to and after the "initial" (comprehensive assessment) by the physician.  Medicare contractors are being instructed to implement this payment policy revision as soon as possible.

The CMS reminds providers of the following:

• Payment requirements for NPPs may differ from Federal survey and certification requirements.
• Medicare will pay only a physician for the initial/comprehensive evaluation and management visit in a SNF or NF.
• When an NPP reports this service (using a CPT code in the 99301-99303 range) prior to the performance of the initial visit and reporting by the physician, the Medicare carrier should not pay it as billed.  Accurate billing can then be determined only through a post-pay medical review.
• The Medicare carrier will pay the physician who reports the initial visit (comprehensive assessment) using one of the SNF/NF CPT codes in the 99301-99303 range.
• Medicare will pay the NPP for covered, medically necessary evaluation and management visits prior to and after the initial/comprehensive visit reported by the physician and also for other required visits to comply with federal regulations at the option of the physician in the SNF setting and at the option of the State in the NF setting.  Such visits should be reported with the appropriate CPT code in the 99301- 99313 range.
• Medicare will pay for annual NF assessments (other than the initial comprehensive assessment performed and reported by the physician), readmissions to the facility, or a major change in status in the resident when such services are submitted by the NPP using a CPT code of 99301 or 99302.
• Payment for services rendered by nurse practitioners (NPs) and clinical nurse specialists (CNSs) employed at a NF may be reassigned to the NF by the NP or CNS. In such cases, the NF should bill the appropriate Medicare carrier for the professional service using the UPIN of the NP or CNS.
• When a NF employs a physician assistant (PA), the NF will always bill the Medicare carrier for the professional service using the PA's UPIN.
• Medicare will pay for the SNF/NF discharge day management day service when it is performed face-to-face by the physician or NPP with the patient and is reported for the actual day of service.

Implementation:
Medicare will implement these instructions on October 25, 2004.

Related Instructions:
Survey and Certification memorandum (S&C-04-08), dated November 13, 2003, titled Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs,) can be found by clicking here. 

Patti Cullen
952.851.2487
pcullen@careproviders.org

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Association Staff Change
By Bill Gray
Webmaster Tony Gomes Departing

Members should note that Tony Gomes, the Association’s Websites Coordinator for the past four years, is leaving the Association effective Friday, October 15.  Tony has accepted a career advancement opportunity.  We thank him for his excellent service to the members of Care Providers of Minnesota, and wish him all the best.

Byron Patterson, the Association’s Systems Administrator, will be taking over the duties of Interim Websites Coordinator.  Byron will be assisted in dealing with member inquiries by Judy Dathe and Nancy McCoy.

Bill Gray
952.851.2490
bgray@careproviders.org

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The Right Tool for the Job
By Jonathan Lips
Workforce Committee creates human resources toolkit for members.

The Association’s workforce committee, led by chair Diana Rockstad of Birchwood Companies, is pleased to announce the addition of a Human Resources toolkit to the Association website.  Click here to check it out.

The toolkit has four “compartments”: 

(1) Membership Has Its Privileges, which describes professional human resources associations you can join and some of the benefits of membership;

(2) Let’s Go Surfin’ Now, which lists websites having good, free information;

(3) I Ain’t Got Time To Read . . . Unless It Helps Me Do My Work, where we have compiled reading and reference materials you might find helpful; and

(4) Just The Facts, Ma’am, which links the reader to fact sheets on human resources laws.

The Committee hopes every HR professional will find something in the toolkit useful, but please note that the primary goal was to put some basic information together in one place.  Many organizations are privileged to have one or more full time staff dedicated to human resources, but not every company can assign HR in that way.  For some Association members, the person who handles HR must do so in addition to other important work.  And, with so much to know in this area, even the brightest person might struggle to find basic, foundational information if s/he has limited time to look.

We encourage all HR staff to review the site and let us know what you think.  We hope to build it up over time, and to add more advanced-level information, and we will appreciate your suggestions.

Jonathan Lips
952.851.2480
jlips@careproviders.org

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