Volume 46 Issue 1 Summer 2012 OUR NEW LEADERS · Volume 46 Issue 1 Summer 2012 OUR NEW LEADERS President PALMIRA M. CATALIOTTI, FHFMA, CPA President-Elect DAVID EVANGELISTA Vice President

www.hfmametrony.org Page 1

Volume 46 Issue 1 Summer 2012

OUR NEW LEADERS

PresidentPALMIRA M. CATALIOTTI,

FHFMA, CPA

President-ElectDAVID EVANGELISTA

Vice PresidentWENDY LEO, FHFMA

TreasurerMEREDITH SIMONETTI, FHFMA

SecretaryDAVID WOODS

Immediate Past PresidentJOHN I. COSTER

2012-2013 CORPORATE SPONSORS

PLATINUM

GOLD

SILVER

BDO USA, LLP Bluemark, LLC CAB-Charles A. Barragato & CO. LLPCleverley + AssociatesCranewareDeloitte & Touche LLP Ernst & Young LLP Grant Thornton LLP HCE LLC/McBee Associates, Inc. Information Builders, Inc. Jzanus, Ltd.

KPMG, LLP Liberty Billing and Consulting Services, Inc.MCRC GroupMiller & Milone, P.C. POM Recoveries, Inc. PricewaterhouseCoopers LLP RTR Financial Services, Inc. Siemens Medical Solutions TRITECHHealthcare Management, LLCValic WeiserMazars LLP

AdreimaBetz-Mitchell Associates, Inc. Cirius Group, Inc.E-Management Associates, LLC Group J HANYS Solutions, Inc. Health/ROI Jzanus Consulting, Inc.M & T BankMBI Associates, Inc. Mullooly, Jeffrey, Rooney & Flynn LLP

MultiPlan, Inc. NTT Data Healthcare TechnologiesThe Outsource Group Physicians’ Reciprocal Insurers Pinnacle Strategies, Inc. Professional Claims Bureau, Inc. Proven Healthcare SolutionsReimbursement Services GroupSourceHOV Managed Care ProfessionalsWashington & West, LLC WithumSmith+Brown, P.C.

Avadyne HealthCBIZ KA Consulting Services, LLC Collection Bureau of Hudson Valley - CBHV Convergent Revenue Cycle Management, Inc.DGA Partners, Inc.Garfunkel Wild, P.C. Grassi & Co.HCCS - Health Care Compliance Strategies M. Leco & Associates

MCS Claim Services, Inc. Medical Data Systems (MDS) Nassau Suffolk Hospital Council, Inc.NCO Healthcare ServicesOptumThe SSI Group, Inc. TD Bank - Healthcare Lending Division Triage Consulting GroupVecna Technologies


PAST PRESIDENT2010-2011 Edmund P. Schmidt, III, FHFMA2009-2010 Cynthia A. Strain, FHFMA2008-2009 Mary Kinsella, FHFMA2007-2008 Gordon Sanit, CPA, FHFMA2006-2007 Elizabeth Carnevale 2005-2006 Jane C. Florek, CPA 2004-2005 John M. Scanlan, FHFMA

EX-OFFICIOAll Past Presidents of the

Metropolitan New York Chapter, HFMADaniel Sisto,

President, Healthcare Association of New York StateKenneth E. Raske,

President, Greater New York Hospital AssociationKevin W. Dahill,

President & CEO, Nassau-Suffolk Hospital Council


Chapter Officers and Board of Directors

Metro NY HFMA Newscast Schedule

Electronic Publication Date 10/22/12

Article Deadline for Receipt by Editor 9/19/12

OFFICERS 2012-2013President Palmira M. Cataliotti, FHFMA, CPAPresident-Elect David EvangelistaVice President Wendy Leo, FHFMATreasurer Meredith Simonetti, FHFMASecretary David WoodsImmediate Past President John I. Coster

BOARD OF DIRECTORSClass of 2013

Mario DiFiglia Richard T. Nagy, FHFMAJason Gottlieb Maryann J. ReganAnnie Lemoine

Class of 2014Martin Abschutz, CPA, CGMA Donna M. SkuraPaulette DiNapoli Robin ZieglerJames Petty, FHFMA

Newscast Committee

EDITORS:Marty Abschutz, CPA, CGMA, Editor

James G. Fouassier, JD, Esq., Assistant Editor

COMMITTEE MEMBERS:Christine Appicella

Kiran Batheja, FHFMAPaulette DiNapoli

James G. Fouassier, EsquireMary Kinsella, FHFMAMichael LamotheWendy Leo, FHFMA Don MacDonald

Mike McGrath, FHFMA

Susan MontanaAndrew NatkinJustin RoobergJosephine Ross

Edmund P. Schmidt, III, FHFMAKen Sheridan

John Scanlan, FHFMACynthia Strain, FHFMAStephanie Welsher

President’s MessagePalmira Cataliotti, CPA, FHFMA .............................................................................................Page 5

Editor’s MessageMarty Abschutz, CPA ..............................................................................................................Page 7

Calendar of Events ...............................................................................................................Page 8

New MembersRobin Ziegler ..........................................................................................................................Page 9

Committee Listings 2012-2013 ........................................................................................Page 11

HFMA’s Metro NY Annual Institute Vendor Photos Redux...............................................Page 13

Supreme Court Rules on Healthcare Reform LawKathryn Ruggieri & Joseph D. Glazer,...................................................................................Page 15

HFMA Metro NY Annual Business Meeting .....................................................Page 17, 22, 26, 32

STAYING FOCUSED ON THE BOTTOM LINE or, Why A Reasonable CDM Is MoreImportant Than EverJames G. Fouassier, Esq.......................................................................................................Page 19

HFMA Region 2 Annual Fall Institute ...............................................................................Page 21

Q&A: Communicating Difficult ChangesReprinted with permission from HFMA Leadership Series....................................................Page 24

Using Business Intelligence IntelligentlyLola Butcher, Reprinted with permission from HFMA’s Leadership series ............................Page 28

Do What You Got To DoKent Radler...........................................................................................................................Page 35

HFMA Metro NY Planning Meeting ....................................................................................Page 37

Putting the Intelligence Back in BusinessTodd Nelson, Reprinted with permission from HFMA’s Leadership series..............................Page 38

HFMA Region 2 Mini LTC....................................................................................................Page 39


I am truly honored to serve as President of the Metropolitan New York Chapter of HFMA. As PresidentI look forward to building on the momentum and successes that our Chapter has enjoyed thanks to theefforts of Past Presidents and our dedicated volunteers.

Leadership Matters is this year’s national theme for HFMA. As healthcare finance professionals we areall challenged with the anticipated historic change in hospital reimbursement and the delivery of care.Traditional Fee-for-Service arrangements are migrating towards risk-based models tied to quality andinclude programs such as Value Based Purchasing, Pay for Performance, Bundled Payments, andPotentially Preventable Readmission penalties. Quality, clinical outcomes, customer satisfaction andother factors are now linked to reimbursement. So this year’s theme is very timely; strong leadershipmatters and is required to transition our industry through healthcare reform.

Two years ago, President Obama signed into law the Patient Protection and Affordable Care Act,commonly referred to as “Obamacare.” This legislation introduces Medical Homes and Accountable CareOrganizations (ACO). The expectation is that these models of care will improve healthcare outcomes,and ultimately reduce the growth in our nation’s healthcare spending. Hospital finance executives mustgain expertise in underwriting and managing risk to ensure our facilities remain financially viable withinthese new structures. As CPAs, accountants and analysts we are accustomed to calculations that involvevolume and rate, that are black and white. The anticipated transition to capitation will challenge us toexpand our skill set. We must learn to underwrite risk, understand quality indicators and the patientexperience.

As if the transition to capitation isn’t enough of a challenge, we are continuously challenged to retainreimbursement for services rendered because of government programs like the RAC, MAC, CERT, andHCRA. Meaningful Use, the HITECH Act, and the transition to ICD-10 will impact reimbursement and cashflows to our organizations. Because of all these challenges, it is evident to me that HFMA is moreimportant to our industry than ever before!

Our chapter through the continued dedication of its volunteers will remain focused on providing qualityeducational programs to our members that address the multitude of challenges we face.

We will present to our membership for the first time ever, The Metropolitan New York HFMA Fall Academyon October 24, 2012 at the Marriott in Uniondale, NY. The Academy will offer a several breakout sessions


in areas such as: Revenue Cycle, Managed Care, Finance, Corporate Compliance,Health Information Management, Information Technology, and Medical GroupManagement. The day will conclude with a reception providing our membershipwith the opportunity to network and share experiences.

The Joseph A. Levi Annual Institute Committee is already hard at work planningfor our premier event. The Annual Institute will be held on March 7-8, 2013 at theLaGuardia Marriott. The AI has grown significantly in recent years attracting attendees from our regionand beyond. The AI is renowned for providing a forum where policy makers, CEO’s and CFO’s meet todiscuss current challenges and to explore what may lie ahead.

While Education is the primary mission of our chapter, we also greatly value the social events thatpromote camaraderie and networking. This year’s golf outing is set for September 24, 2012 at NorthHempstead Country Club in Port Washington. Make sure to register early as our golf outing sells outquickly. Additionally, the committee has plans for more social events including Chinese New Year, A Dayat the Belmont Racetrack, family bowling, and a Long Island Ducks baseball game.

In late October or early November, National HFMA will be issuing a survey to measure membersatisfaction within our Chapter. Our goal is to receive only extremely satisfied responses from ourmembers. Our Chapter leadership will be working diligently to address and correct any issues that arebrought to our attention so that we can achieve this goal. If you have any concerns or issues that needto be addressed please contact me directly at [email protected] so that I can appropriatelyrespond to them.

Our website at www.hfmametrony.com is an outstanding resource for information on upcoming seminars,social events, seminar handouts, contact information, current and past issues of newscast and so muchmore. Newscast is our Chapter’s award winning on-line newsletter publication that is published quarterly.The Newscast committee will continue to provide technical articles, news about our chapter and ofcourse photographs from our seminars and social events.

I encourage you to volunteer to assist our Chapter on any of its Committees. I know from my personalexperience that your active involvement will prove to be valuable to your professional growth. I lookforward to a successful year thanks to your continued support.

Regards,

Palmira Cataliotti, CPA, FHFMAPresident


By Marty Abschutz


Although it’s “Summertime,” the living is hardly easy (apologies to George & Ira Gershwin and DuBose Heyward).By now, you’ve each had an opportunity to formulate some thoughts on the Supreme Court’s June 28 decision onthe Affordable Care Act (ACA). Kathryn Ruggieri and Joseph D. Glazer have identified some things that providersshould keep in mind as ACA is implemented further. Jim Fouassier writes about the importance of the chargedescription master (and defending it) in light of recent litigation.

Rich Henley, former National Chair and Chapter President, has a questions and answer session on managingchange. We have another humorous piece from Kent Rader, who did a great job at our Annual Institute. Businessintelligence is the subject of articles by Todd Nelson and Lola Butcher.

Traditionally, our summer issue introduces our Chapter’s new officers and Board members. Congratulations toPalmira Cataliotti, our new President, and the rest of the officers and Board. See page three for the completelisting. Palmira has set a new standard for getting the President’s message in timely; she submitted it to me morethan one month before the deadline!

Also, check out the new Committee Listings (page nine) and the upcoming education opportunities, includingwebinars that are free to members.

Yes, we have pictures! Among the events covered are the Annual Business Meeting, the Region 2 Mini LeadershipTraining Conference, the annual Chapter Planning Meeting and a repeat of the vendor pictures from our AnnualInstitute held this past March.

Our Fall issue will be published in late October. Please get anything you want in the issue to me by September19. I’m looking for some more discussion on the Supreme Court decision and other articles that will assist ourmembers in thriving in the changing environment.

2012 IMPORTANT DATES

September 7, 2012 Mid Year Reimbursement Seminar TBA

September 24, 2012 Annual Golf Outing North Hempstead Country ClubPort Washington, NY

October 15, 2012 Region 2 Annual Fall Institute Saratoga City Center, Saratoga, NY

October 24, 2012 Metro NY HFMA Fall Academy Marriott Hotel,Uniondale, NY

A selection of FREE Webinars (Check www.hfma.org for more):

July 31, 2012 2011 Medicaid Cost Reports (RHCF 4/RHCF2) (Region 2)

August 8, 2012 Patient Statements: Telling a Story to Collect More in Less Time

August 21, 2012 2013 Proposed Rule Changes to OPPS and ASCs

August 28, 2012 Medicare’s Final Inpatient Prospective Payment System Rule for FY 2013


The Metropolitan New York Chapter of HFMA Proudly Welcomes the Following New Members!

By Robin Ziegler, Membership Committee Chair

MetroNY HFMA is pleased to welcome the following new members to our Chapter. We ask our current membership to rollout the red carpet to these new members and help them see for themselves the benefits of HFMA membership. Encouragethem to attend seminars and other Chapter events. We ask these new members to consider joining a Committee to not onlyhelp the Chapter accomplish its work, but to expand their networks of top notch personal and professional relationships.See the list of MetroNY HFMA Committee Chairs, along with their contact information, listed in this eNewsletter.

Samuel Sia Associate Professor, Columbia University

Stephen Cheek, Senior ConsultantGallagher Fiduciary Advisors

Steven M Lazarus, Senior ManagerDeloitte Financial Advisory Services

Paul Dunphey Vice President of Revenue Cycle OperationsNew York Presbyterian Hospital

Kevin Brannigan Bank of America Merrill Lynch

Phil Pucciarelli Bank of America Merrill Lynch

Hal D McNeil Chief Finance Officer, McNeil Enterprises, Inc

Charle Rhyee Cowen and Company

James Choe Associate, Cowen & Company

Anthony Nappo Portfolio Manager, Alliance Bernstein

Kevin Kemmerer Consultant, Warburg Pincus LLC

Naomi B. Renelus Project Manager, Montefiore Medical Center

Christopher E Blume Managing Director, Goldman Sachs

Suprit N. Patel

Patrick Severson Managing Director, Warburg Pincus LLC

Craig S. MaurerManager, McGladrey

Rosemary Coluccio Director, Affiliate Financial Consulting, PPFA

Linda Early Assistant Director, New York Hospital Queens

Cassandra A. Pinckney Manager, New York Hospital Queens

Ellen Caruso Manager, New York Hospital Queens

Jill TroySupervisor, New York Hospital Queens

Jennifer MeyersDirector, Marwood Group

Brett CaughranSenior Analyst, Maverick Capital

Kelvin Barnes PFS Supervisor, New York Hospital Queens

Patricia Abamonte Supervisor PFS, New York Hospital Queens

Kathy Winkler Suervisor PFS, New York Hospital Queens

Ernesto Macasaet Supervisor, New York Hospital Queens

Theresa Lillis, Compliance OfficerWinthrop University Hospital

Paola Benitez North Shore University Hosp

Angela Ridley, Vice President FinanceWyckoff Heights Medical Center

Dana Vartabedian

Catherine Moser Director of Healthcare, Connex International

Jonathan Artz Sales Associate, FDSI Logistics

Robert S Ruotolo, Jr. Vice President, Lockton

Patrick Hickey Aon

Mohamed AI Eraij Exec. Director, National Guard Health Affair

Vito F Morgese Vice President, USI Insurance Services

Robert Pottharst

Jayshree Patel Director of Outpatient Services, HealthlROI

Steve VanRossem Director of Patient AccountingCatholic Health Services of L.I.

Elzbieta Parys-Lyons Director, North Shore LIJ

Peter Barden, Assistant Vice PresidentNorth Shore-LIJ Health System

Joseph JordanChief Medical Officer, Intercede Health

Christine Kern, )perations Manager, InsuranceMiller & Milone, P.C.

Maleeha Arshad Project Manager-Revenue Cycle ManagementWestchester Institute for Human Development(WIH)

Michael Burke SVP & Vice Dean, Corporate CFONYU Langone Medical Center

Hong Zheng, Financial AnalystNew York Presbyterian Hospital

Michael Geoghegan Senior Manager, Deloitte Consulting

Deion NobleAssistant Controller - Financial ReportingNYUMC Langone Medical Center


The Metropolitan New York Chapter of HFMA Proudly Welcomes the Following New Members!

Brenda Turner Business Analyst, MedeAnalytics

Teresa E. Rost Director of Sales, NIT Health

Tony NadresDirector of ReimbursementSt. Joseph Medical Center

Charles Occhipinti, Jr.

Donald Taylor Director, Patient Financial Services, HBCS

Alicia A. Weissmeier Attorney, Miller & Milone, P.C.

Eileen Mohn Jzanus

Anna M. Kruska Coding Consultant, Jzanus Consulting Inc

Mary Lynch Consultant, Jzanus Consulting Inc

Sanda Jeffar Jzanus Consulting Inc.

Alanna Brown Consultant, Jzanus Consulting Inc

Kristie Del VecchioConsultant, Jzanus Consulting Inc

Andrew Reid Consultant, Jzanus Consulting Inc

Theresa Rybicki Consultant, Jzanus Consulting Inc

Jean McCaffrey Consultant, Jzanus Consulting Inc

Danielle Wright Consultant, Jzanus Consulting Inc

Kathleen McNulty Consultant, Jzanus Consulting Inc

Lisa RyanConsultant, Jzanus Consulting Inc

Donna Cabbie Consultant, Jzanus Consulting Inc

Kate McEneryConsultant, Jzanus Consulting Inc

Sharyl Lang Director, Jzanus Consulting Inc

Sonya Manuel DRG Coordinator, Jzanus Consulting Inc

Cecelia Alana Consultant, Jzanus Consulting Inc

Melissa ZimolkaConsultant, Jzanus Consulting Inc

Andrew R WeingartnerConsultant, Jzanus Consulting, Inc.

Viji SunderrajConsultant, Jzanus Consulting Inc

Jessica C Lee Consultant, Jzanus Consulting Inc

Stephanie Perdue Consultant, Jzanus Consulting Inc

Juan Santiago Consultant, Jzanus Consulting Inc

Stephanie BakshConsultant, Jzanus Consulting Inc

Jennifer McInnis Consultant, Jzanus Consulting Inc

Silmar Berenhaus Consultant, Jzanus Consulting Inc

Zinaida Tolmasova Consultant, Jzanus Consulting Inc

Lisa Dunne Consultant, Jzanus Consulting Inc

Christine NegronConsultant, Jzanus Consulting Inc

Edward ApannaJzanus Consulting Inc

Jerome Emilcar Claim ConsultantJzanus Consulting Inc

Gretchen BartelsConsultant, Jzanus Consulting Inc

Roberta HoraceConsultant, Jzanus Consulting Inc

Monika SzaboExecutive Assistant, Jzanus Consulting Inc

Renee MinutelloDirector of Accounts PayableSaint Vincent Catholic Medical Centers

Eugenia R ClementsManager, Patient Financial ServicesWinthrop University Hospital

Kimberly McKennaManager, Medisys Management, LLC

Sharon ScheuermannSenior Associate, Dubraski & Associates

Suzanne RivaSenior Manager, Business Intelligence AnalyticsNorth Shore LIJ Health System

Melanie Greco Director Patient AccountingCatholic Health Services of L.I.

Diane BerenbergDirector Patient Financial ServicesCatholic Health Services of L.I.

Anthony J. VuozzoAdministrative Director for Access CareSt. John’s Episcopal Hospital

Patricia Franza

Kaitlin A. Smith

Tina Donnelly

Clara M Howell Administrative AssistantMount Sinai Medical Ctr - FPA

Joey Melancon Manager, Contracting, Amerigroup

Preciosa Olviera Winthrop University Hospital



Advisory CouncilJohn Coster

[email protected] (516) 240-8147

Ed Schmidt [email protected](516) 572-4834

Cindy Strain [email protected] (516) 796-3700

Mary Long Kinsella [email protected]

(212) 297-5445

54th AnnualInstitute

David [email protected](212) 979-4566

Donna [email protected]/Christina Milone

[email protected](516) 509-0277

Bob [email protected](516) 616-0200 x201

Jim Argutto [email protected](631) 761-1028

AuditingJohn Scanlan


Gordon Sanit [email protected](516) 918-7065

Al [email protected](914) 365-3508

BylawsDavid Woods


Fred [email protected](516) 393-2250

Palmira Cataliotti [email protected]

(516) 663-2311

CentralRegistration

Robin Ziegler [email protected](516) 338-1100 x314

Diane Masi [email protected]

(516) 551-5839

John [email protected] (516) 240-8147

CertificationCoaching

Jim Petty [email protected] (516) 876-6022

John Scanlan [email protected]

(718) 283-3911

Kiran Batheja [email protected]

(718) 604-5578

Art Cusack [email protected] (516) 546-4198

Certified MembersKiran Batheja


Michael McGrath [email protected]

(516) 656-5374

CommunityOutreach

Josephine Vaglio [email protected]

(516) 248-2422

Continuing CareSteven Stella


Ann [email protected] (516) 663-8077

Corp. Compliance/Internal Audit

Ann Amato [email protected] (516) 632-3405

Regina [email protected](973) 972-3113

Terry [email protected](516) 663-2003

CPE’sJohn Scanlan


DCMS/BalancedScorecard


(516) 551-5839



(516) 663-2311

David Evangelista [email protected] (718) 206-6930

Exec. Comm.& Planning


(516) 663-2311

David Evangelista [email protected] (718) 206-6930

Finance/Reimbursement

/Audit

Mario [email protected]

(516) 705-1936

Kwok Chang [email protected] (212) 979-4324

Rachele [email protected](646) 227-3156

Rich [email protected](516) 298-8942/Joe [email protected](718) 250-6755

Founders AwardsPaulette DiNapoli


General Education

Maryann Regan [email protected]

(516-576-5601

Rich [email protected](212) 420-2516

Diane [email protected](516) 630-3911


(516) 551-5839

Committee Name Chair Co-Chair Vice Chair 1 Vice Chair 2


HIM/URAnnie Lemoine

[email protected] (516) 326-0808 x3312

Stacey Levitt [email protected](646) 732-5052

HistorianMichael McGrath

[email protected](516) 759-2200 ext. 5374

Paul Cheng, [email protected](347) 581-7573

Legal AffairsFred Miller


Managed CareDonna Skura


James [email protected]

(631) 638-4012

Rich [email protected](631) 444-4175

Patrick [email protected]

(212) 430-6620

MSPMichael McGrath


Kiran Batheja [email protected]

(718) 604-5578

MembershipMarketing



(516) 551-5839

Medical Grp Mgmt.

Josephine Vaglio [email protected]

(516) 766-0521

Jackie Namwila [email protected](347) 446-0159


Art Cusack [email protected] (516) 546-4198

MISJohn Mertz


Nicole [email protected]

(646) 471-7217

NewscastMarty Abschutz

[email protected](732) 906-8700 ext 109

James [email protected]

(631) 638-4012

Sue [email protected]

(631) 244-5661

NominatingJohn Coster


Patient FinancialServices

Jason [email protected](212) 297-4549

Paulette DiNapoli [email protected]

(516) 576-5638

Ned Rina [email protected](631) 465-6876

PPDDJohn Coster


Webmaster andPersonnelPlacement

Mary Long Kinsella [email protected] (212) 297-5445


Public Relations &Communications

Region 2

Emily [email protected]

(614) 263-1043

Michael [email protected]

(646) 227-2396

Zach [email protected](212) 213-0877 ext 441

Region 2CollaboratonCommittee


Wendy [email protected]

(516) 454-0700

Wendy [email protected]

(516) 454-0700


Ed [email protected](516) 572-4834


Gordon Sanit [email protected](516) 918-7065

Don [email protected]

(973) 872-1596

Ryan AwardMary Long Kinsella [email protected] (212) 297-5445



Meredith Simonetti [email protected]

(631) 465-6877Jonthan Segal


Committee Name Chair Co-Chair Vice Chair 1 Vice Chair 2

Social EventsKiran Batheja



SponsorshipMichael McGrath



(516) 663-2311

Yerger AwardDana Keefer


Julia Tsien [email protected]

(718) 589-2232


Photos selected by Marty Abschutz Photos by Dennis Hodge



Supreme Court Rules on Healthcare Reform LawBy: Kathryn Ruggieri, Director, Revenue Cycle Management Services andJoseph D. Glazer, Director, Financial Services, BESLER Consulting


On June 28, 2012 in one of the most anticipated decisions in many years, the United States Supreme Court voted by a 5-4majority to uphold major provisions of The Patient Protection and Affordable Care Act of 2010 (PPACA). Led by Chief JusticeJohn Roberts, the Supreme Court concluded that the “individual mandate,” one of the most controversial aspects of the law,was constitutional as a valid exercise of the Federal government’s taxing power. In addition to upholding the requirementthat all individuals maintain some sort of insurance coverage, the Court also sanctioned the expansion of Medicaid providedunder the PPACA. Importantly, however, the Court held that the Federal government could not withhold all Medicaid fundsfrom States that choose not to expand Medicaid coverage pursuant to the PPACA. How that aspect of the Court’s rulingimpacts Medicaid expansion will likely be a State-by-State issue. The stage is now set for the PPACA to continue to be oneof the key issues in the upcoming Presidential and Congressional elections.

In upholding the PPACA, the Court ensured that healthcare reform under the Act will continue, at least until the Federalelections this November. This removes some of the uncertainty under which healthcare providers have been acting whilethe legal challenge was pending.

Healthcare providers should now proceed with the expectation that the PPACA will be implemented according to schedule.While the upcoming election could change things, it would take a Republican sweep of the Presidency and both Houses ofCongress to even begin the process of repealing provisions of the PPACA.

In order to best prepare financially, hospitals should pay special attention to the following areas as the PPACA is fullyimplemented. Now is the time for improved clinical and financial collaboration to be proactive in improving patient caredelivery models while minimizing financial penalties today and in future years.

The Hospital Readmission Reduction Program commences on October 1, 2012. The initial focus will be onreadmissions related to heart attack, heart failure and pneumonia. Hospitals with higher than expected readmissionrates will experience reductions in their Medicare rates. It is expected that the Federal Fiscal Year (FFY) 2013financial impact of the Readmission Reduction Program totals $300 million nationally. Hospitals can also expectup to a 2% reduction in base DRG rates in 2014 and up to a 3% reduction in base DRG rates in 2015. CMS willexpand the program to include COPD, CABG, PTCA and other vascular procedures. It is estimated the readmissionpayment reductions will total $7.1 billion over ten years. There are very few hospitals nationally that will notexperience a payment reduction. Hospitals focused on the reduction of readmissions are best positioned to limit thefinancial impact of this program.

The Value Based Purchasing (VBP) program will reward hospitals that deliver high quality care with value basedincentive payments to hospitals that meet specified performance standards. These standards will begin with a subsetof the measures in the current Pay for Reporting program but will be expanded to include efficiency and outcomemeasures. Effective October 1, 2012, all hospitals will experience a 1% reduction in base DRG rates. Incentivepayments will then be made to the qualifying providers. In other words, hospitals will need to “earn their moneyback.”

Beginning in FFY 2012, CMS publicly reported the first eight hospital acquired conditions (HAC) under the inpatientquality reporting program. Beginning October 1, 2014, hospitals in the top quartile with respect to national HACrates will experience a 1% payment reduction in base DRG rates.


Hospitals should prepare for changes to Medicare Disproportionate Share Hospital Reimbursement, which underthe PPACA is set to begin on October 1, 2013. Those changes will reduce Medicare DSH payments to 25% of theircurrent levels.

Hospitals should pay greater attention to the Medicare Cost Report Worksheet S-10, which reflects uncompensatedcare provided by a hospital. In conjunction with the decrease in Medicare DSH payments, an uncompensated carefund is being created. Although it is unclear exactly how the Centers for Medicare and Medicaid Services willdetermine how to allocate that fund, it is likely that the S-10 will pay a role in that allocation. The S-10 also is asignificant determinant of Electronic Health Record payments to hospitals.

State-by-State changes in Medicaid will likely accelerate following the Supreme Court’s decision. Many States hadheld up implementing Medicaid changes and expansion until a final decision on the PPACA’s constitutionality wasissued. Now that the constitutionality has been settled, expansion measures will become more prominent. Hospitalsshould work with their Associations and other advocates to attempt to shape these expansion efforts to ensure thatproviders’ views are considered in the expansion. Once the specifics of each State’s expansion become clearer,hospitals will have to work with consultants and internal staff to adjust to those changes.

Some States have stated that despite the Supreme Court’s ruling, the State will not implement various provisionsof the PPACA. This puts hospitals in a very precarious position. With DSH funding scheduled to be reduced, if a Statedoes not take steps to implement the PPACA, it is possible that hospitals in such a State will also be excluded fromthe new uncompensated care pool. The impact on hospital funding could be substantial. Hospitals should workclosely with their advocates to ensure that any State that wants to register its continuing objection to the PPACAdoes so in a manner that does not hurt hospitals and other providers in the State.

Hospitals will experience Medicare payment reductions in just a few months. Additional reductions will continue over thenext few years. It will imperative for hospitals to focus on these areas to minimize the financial impact wherever possible.

Kathy Ruggieri is the Director responsible for BESLER Consulting’s Revenue Cycle Product line and has been amember of our revenue cycle team for over twelve (12) years. Kathy has over twenty-five (25) years ofexperience in healthcare financial management and has extensive knowledge of all components within therevenue cycle. Her background is very diverse having experience in acute care hospitals in addition to skillednursing facilities, psychiatric facilities and home healthcare. Kathy Ruggieri can be reached at (732) 392-8227 or [email protected] or visit us at www.besler.com.

Joe is the Director responsible for BESLER Consulting’s Financial Services product line and serves as DeputyGeneral Counsel. He provides advice and advocacy to healthcare providers regarding complex regulatory,administrative, and reimbursement matters, including Medicare disproportionate share hospital payments,Medicare wage index calculations, and issues potentially implicating the fraud and abuse laws. Joe Glazer canbe reached at (732) 392-8236 or [email protected] or visit us at www.besler.com.





STAYING FOCUSED ON THE BOTTOM LINEor, Why A Reasonable CDM Is MoreImportant Than Ever

By James G. Fouassier, Esq.


Health care reform, bundled payments, ACOs, “Pay forPerformance,” quality metrics, “value based purchasing.”New, different looking trees keep sprouting up everywhere onthe landscape of health care financing. It’s no wonder manyof our colleagues are starting to lose sight of the forest.Maybe it’s a good idea from time to time to reflect on the oldsayings that some of our predecessors had framed on theiroffice walls: “You Can’t Run This Place on Love and Kisses;”and “No Margin - No Mission.”

There isn’t much about the consequences of health carereform and new reimbursement models on which financeprofessionals can agree - at least not yet - but many arestarting to come to the stark realization that regardless of theprecise design, methodology, paradigm or process by whichwe eventually will get paid, more and more of our money willbe coming from the patient directly. The Payment Plan of theFuture portends larger deductibles, bigger copayments,excluded services, limited benefits. This of course is to saynothing about the millions of patients - primarilyundocumented aliens - who will remain uninsured becausethey are excluded from the scope of health care reform.

In the past I’ve railed at length about insurers and otherpayors negotiating deeply discounted rates and then “selling”those rates to their members by way of high deductible or“consumer oriented” plans; about the trouble of collectingmore than marginal self pay balances from patients; about“silent PPOs” and other abusive payor practices; about thecomplications of doing business with ERISA regulated selffunded plans replete with benefit limitations, individual claimssubmission rules, and appeal processes not subject tostandard state law. Today I want to regale you with somethingdifferent. Leave aside for the moment just how you got intothis mess; the question for today is how you manage thoselarger and larger self pay balances? “We have to do a betterjob collecting what our patients owe us, right?” Sure, butwhere do we start? How about at the beginning (and I don’tmean at registration or admission; discussions about the easeor difficulty of collecting copayments up front is a story foranother day). By the “beginning,” rather, I mean thedevelopment of the charge description master itself.

“Cost plus a reasonable margin” is what the imaginary CFOwould tell me is the principle of charge description master(“CDM”) development. I defy anyone reading this to tell me

that his or her organization does a great job of capturingcosts; anecdotal reports from our colleagues indicate that thebest among us do only a marginal job. This is not unusual,either in health care or in the world of commerce as a whole.For the purposes of this article, however, my concern is withhow we develop the “reasonable margin” piece. It becomesespecially important when our reimbursement is a function ofcharges, or we bill a payor out-of-network, or we balance billa patient.

Everyone knows why the law allows for what commonly areknown as “class action” lawsuits. When some anonymouscorporation cheats you out of $75 you may write to thepresident, the Better Business Bureau or your congressperson but it is unlikely that you will retain an attorney andsue for it. But if, in one lawsuit, one set of attorneys canrepresent 25,000 victims of the same fraudulent businesspractice then an important right is secured in an economicallyefficient manner. (I know, I know; you get two coupons andthe lawyers get $10 million in fees, but the public policy ofpunishing fraudulent business practices is advanced, to thetheoretical benefit of all of us.) What kind of a nightmarewould it be if an uninsured or underinsured patient who isbilled full charges when practically no one else (insurers,other third party payors) is billed the same way, is allowed touse the device of a class action to assert - on behalf of himselfand thousands of other patients similarly billed - that fullcharges are unreasonable, that billings based on full chargesconstitute an unfair billing practice, and that such billingsconstitute abuse, fraud, or whatever else he or she might labelthe practice? Instead of facing the prospect of having to writeoff hundreds (or maybe a few thousands) on an individualencounter you now are faced with having to refund millions!

This is precisely what’s happening in Indiana in the context ofa class action lawsuit entitled, Allen and Moore v. ClarianHealth Partners, Inc., now working its way through theappeals process. It seems that before either of these plaintiffsreceived medical care they signed the hospital’s usual“guarantee of payment” which read as follows: “. . . .theundersigned guarantees payment of the account, and agreesto pay the same upon discharge if such account is not paid bya private or governmental insurance carrier.” There was nomention of “regular rates,” “charges,” “usual and customarycharges” or any reference to a CDM or to just what theplaintiffs would be required to pay. Oh, did I mention that


these guys were uninsured (and presumably the hospital knewit going in)? Upon discharge the patients received bills for thefull actual charges maintained in the CDM. Rather thanpaying anything, they retained a lawyer to sue the hospital forwhat we call “declaratory relief” meaning a declaration of theparties’ respective legal rights in the context presented. The“declaration” the plaintiffs are seeking is that billing self paypatients at full CDM charges is unlawful because it has norelation to the “fair and reasonable value” of the servicesrendered.

Some of you will recall earlier articles in which I discussedthe concept of “fair and reasonable value”, or quantummeruit, in contexts in which no agreement to pay a fixedamount was reached between patient and provider in advanceof the services. The lesson there is that if a contract is silenton a price term - services are rendered in expectation ofpayment but no payment amount is agreed between theparties - then the law will apply a variety of fact specificcriteria to determine the fair and reasonable value of theservices in context - and that is all the performing party gets.Here, the attorney proposed to file the suit as a class actionseeking a declaration that every patient that ever was billedby this hospital on the same basis was entitled to the samedeclaration that the billing was unlawful. The consequencesof a successful suit, obviously, are that the hospital will haveto refund millions of dollars and write off millions more, tosay nothing of the thousands of work hours and hundreds ofthousands of dollars in administrative expenses related to thepaperwork involved.

The Indiana appeals court found that because the “guarantee”did not refer to any other documents or outside facts to whichthe patients could look to see what they would be required topay, the “guarantee” did not fix a price term and so the ruleabout “fair and reasonable value” would apply. According tothis Court, at least in Indiana, if the “guarantee” saidsomething like, “as set out in the hospital’s ChargeDescription Master, a copy of which is on file in theRegistration Office,” then the guarantee may have beenupheld. New York courts, however, have not been sogenerous; pointing a layperson with no medical or codingexperience in the general direction of the CDM before servicesare rendered and a chart is coded is like saying that you agreein advance of repairs to pay the mechanic whatever he or shedetermines based upon the application of some MechanicsMaster Pricing Guide when you yourself can’t even use anadjustable wrench. But I digress; the point is that the Courtholds that an independent inquiry must be made to determinewhat the fair and reasonable value of the services may beregardless of what is in the CDM.

Well, what about the idea of doing up an “estimate?” Leavingaside emergency situations (an entirely separate billingcomplication), is it possible to develop an accurate estimateto which the patient may be held accountable? It turns out

that this hospital made that argument. Specifically, it arguedthat the peculiar circumstances of acute care hospitalfinancing are so complicated that courts are incapable ofdetermining what medical costs and expenses are“reasonable.” After all, haven’t federal and state regulators,the presumed experts, been grappling with these issues foryears without any real consensus or measurable success? No,the Court said, courts and juries are as capable of makingdeterminations of reasonableness in this context as in therealm of personal injury, defamation or any area in whichdamages need to be ascertained.

“ . . . .[T]hat medical billing is complicated does not changethe fact that this is a basic breach of contract case guided bywell-established Indiana law.”

Patients and their lawyers pushing back on billed charges isnothing new; what is so frightening here is the prospect thatcourts will start authorizing several aggrieved patients torepresent large groups of unnamed patients in major classaction lawsuits, exposing hospital systems to millions ofdollars in damages and losses. The moral of the story is thatyour CDM has to pass the “smell” test and that when anybillings or payment demands are based in whole or in part onactual charges those charges must be “reasonable.” Try this:look in the mirror and pretend that the face looking back atyou is the judge. Can you truthfully say, “Sure our chargesare reasonable, your Honor. These documents show howcosts are derived in each cost center and our people willtestify about the different costs related to acquisition,inventory maintenance, administration, delivery, followupcare, and the amortization of capital and labor expenses overthe entire structure of the organization. We can establish bydocumentary evidence that our markup margin is in theaverage for medical centers of our size, geographic location,payor mix and case mix. More importantly we can show thatthe charges demanded of Mr. Smith were within the mid-rangeof charges billed to self pay patients by all hospitals in ourarea that perform the same procedure.” I hope you can,because one day you may have to.

James Fouassier, Esq. is the Associate Administrator ofthe Department of Managed Care at Stony BrookUniversity Hospital, Stony Brook, New York. His opinionsare his own and may not reflect those of Stony BrookUniversity Hospital. He may be reached at:[email protected]

ANNUAL HFMA REGION 2 FALL INSTITUTE

“BUILDING TOMORROW'S HEALTHCARE TODAY”

October 15-17, 2012

Saratoga Hilton and City Center

Saratoga, NY

Central New York Chapter • Hudson Valley NY Chapter

Metropolitan New York Chapter • Northeastern New York Chapter

Puerto Rico Chapter • Rochester Regional Chapter

Western New York Chapter

Who Should Attend:CFOs, VPs of Finance, Controllers, Department Heads, Administrators, Revenue Cycle Leaders,

Chargemaster Coordinators, Directors of Finance, Budget Analysts, Managed Care Contractors, Reimbursement Managers, Denial Management Specialists, Patient Financial Service Managers and Supervisors, Accountants and Compliance Staff

Session Levels:Strategic General Assembly sessions and breakout sessions with operational nuts and bolts to help solve specific problems to improve the bottom line.

13 CPE Credits






Q&A: Communicating Difficult Changes

Reprinted with permission from HFMA Leadership Series


Few healthcare leaders enjoy the intricate work oftransitioning an organization through major upheavals,such as mergers, consolidations, or layoffs. But difficultchange has become par for the course as providersposition themselves for a leaner, performance-orientedfuture. Two communication strategies—honesty andtransparency—can help ensure a successful outcome.

In 2009, Connecticut’s New Milford Hospital was facingsignificant operating losses and questions about its futureviability as a stand-alone hospital. “The organization waslosing patient volume, which affected the organization’s abilityto expand its clinical offerings, access capital, and recruitphysicians,” says Richard J. Henley, FACHE, FHFMA,president & CEO, Healthcare Strategic Solutions, LLC. “Theboard knew it was likely that the hospital would need toconsolidate with another healthcare provider.”

Brought in as interim CEO, Henley transitioned the 85-bedNew Milford Hospital through a merger with DanburyHospital, a larger teaching hospital about 15 miles away. Thedeal between the two not-for-profits was successfullycompleted in a year’s time, and the two hospitals have sinceexpanded and also consolidated a number of services.

Despite the speed of the transaction, the merger was anythingbut routine in the town of New Milford, which has a populationof about 30,000. Employees had worked their entire careersat the hospital, and many had parents or siblings who hadworked there, says Henley. Residents worried that they wouldlose community medical services, and many of the medicalstaff practiced only at New Milford, and felt like theirlivelihoods might be threatened by the merger.

“It was clear from the start that we needed to approach thiswith a strong sense of openness and transparency,” saysHenley. “The most important way of dealing with monumentalchange—whether mergers, employee benefit conversions, orother changes—is to have frequent, timely, and transparentcommunications.”

How did you go about communicating the merger toemployees, physicians, and other stakeholders?

Henley: It was clear that we needed a multiprongedcommunication effort that included all of the hospital’sconstituencies: employees, physicians, the board, unionleaders, community members, donors, major suppliers, andthe media. If you communicate to one group and not another,then people start talking in the cafeteria and parking lot—andthat’s how falsehoods start multiplying.

For staff, we held town meetings at every juncture of our

financial turnaround plan. Every employee was invited, andafter I gave a presentation that summed up our progress, Iopened up the floor for questions. Employees would often getup and say, “I heard such and such,” which gave me theopportunity to clarify issues, address concerns, and dispelrumors.

To communicate to physicians, we spent a lot of timeattending medical staff meetings and meetings of majorclinical departments. At the end of the agenda, I would give anupdate on the financial turnaround and the mergerdiscussions. It’s very important to keep physicians informedbecause medical staff can often make or break a merger.

Knowing this, we added a very well-respected physician to theboard committee that was negotiating the merger between thetwo hospitals. The physician was not then a regular boardmember, but he was very well regarded by his medical staffcolleagues, his patients, and members of the community. Bysitting on the board committee, he was able to provide regularreports to other physicians, build support, and dispel rumors.

How were you able to prove to stakeholders that youwere sincere in your message?

Henley: Here’s a mistake that many healthcare organizationsmake after merger negotiations commence. Typically, leadersput everything on hold. For example, there are no clinicaladvancements or new equipment purchases. The physiciansand employees see that leaders are not trying to advance ordevelop the organization, which can really destroy morale.More important, if the merger ends up not taking place, theorganization is now one year behind.

As the veteran of numerous mergers, I took the oppositeapproach. We did everything possible to strengthen the NewMilford Hospital during the year leading up to the merger. Forexample, we acquired major capital equipment, including abrand new MRI and a high-speed, low-dose CT scanner, aswell as a new linear accelerator for our cancer center. Theseinvestments showed the community that, even if we do merge,no one is going to close us down. I was honest with communitymembers. I told them that some services would likely berelocated or consolidated. But I also stressed that the goalwas to use the footprint of their community hospital—thebuildings, the staff, the equipment—to continue to offerneeded services.

In addition, by continuing to invest to become clinicallystronger, we showed our medical staff, nurses, and otherclinicians that we’re making a strong commitment toimproving services for our patients and staff. This helpedminimize the defection of physicians, employees, managers,donors, and others.


What if a leader is not a good communicator by nature?

Henley: Some leaders are good at one-on-one communication,but freeze up in front of large groups. In those cases, it’s betterto ask another leader on the executive team to handle grouppresentations than to not do them at all. Each presenter needsto come across as credible, open, and transparent for themessage to have true value and meaning.

What communication mediums did you find effective?

Henley: To work through and accept change of thismagnitude, people need to see your message, hear it, andtouch it in a variety of mediums. This communication is not aletter that you write to a group of people. You need amultipronged strategy and approach.

We worked with our marketing people to develop a well-rounded communications plan. In addition to all the variousmeetings I mentioned earlier, we had a monthly column aboutthe merger in the employee newsletter. Employees could alsosubmit questions (anonymously, if they wanted) via ourintranet site. We also posted news about the merger on thehospital’s website for everyone in the community. Somaintaining an online presence also proved helpful.

However, when communicating major changes, you have tobe very visible—you need to get out and about on thedepartments and units, make presentations in front of groups,and talk one-on-one to major donors, physician leaders,community leaders, etc.

What can healthcare leaders do to prepare before theyhave to deliver major news to a particular group?Henley: You want to know your facts. I always ask myself,“What is this group’s likely issues and concerns?” Theseshould not be canned speeches. You need to tailor yourmessage to the audience. For example, if you are meeting withmembers of the obstetrics department, put yourself in theirshoes. As you think about the audience’s perspective on theissues discussed, always be guided by, “What is the impacton them?”

What if someone asks you a question that you aren’tprepared to answer?

Henley: Be careful not to get defensive. Be factual. If you don’tknow the answer, don’t speculate. Say something like, “Thathas not yet been discussed, but I will certainly share theinformation with you as it becomes available.”

Also it’s important to always be honest and forthright. Ifsomeone says, “I was told by so and so that the ITdepartments would be consolidated and relocated off site …”If that has been decided and is true, and you had just deniedit, then you would lose all credibility.

In some cases, you may not be able to share certaininformation with employees, the press, or others. But you canstill be honest. For instance, you might say something like,“Those discussions are being held at the committee level, andI’m not at liberty to discuss that at this time.” Or you mightsay, “Here’s what I can share with you at this juncture. Otherspecifics are at a confidential juncture, and I can’t discussthem yet but will do so as soon as we can share them withyou.”

What do leaders sometimes do wrong when deliveringdifficult news?

Henley: Some leaders downplay the situation and saysomething like, “Nothing will likely change. It will be businessas usual.” But in the case of something as monumental as amerger, everyone knows that is not true. I’ve seen leaders usethis sugarcoated approach as their communications style. Butthese leaders will, ultimately, lose trust and respect amongsttheir stakeholders.

One phrase resonates in my mind: It takes a long time to buildtrust, but it is very easy to lose. You can spend a lot of timecommunicating with physicians, employees, the board, thecommunity, and the media. But if they feel that you are nothonest and transparent, then all that goodwill you are tryingto foster will be for naught.

Richard J. Henley, FACHE, FHFMA, is president & CEO,Healthcare Strategic Solutions, LLC, Easton, Conn., andformer senior executive in a variety of healthcaresettings ([email protected]).

Rich is a former National Chairman and Metro NYChapter President of HFMA.





Using Business Intelligence IntelligentlyBy Lola Butcher


Data-savvy providers are using business intelligence toimprove care at the bedside, coach physicians to useresources more wisely, manage populations of patients, andimprove financial performance.

Key TakeawaysProviders at the forefront of business intelligence share a number oflessons learned:• Identify the best data storage approach for your organization: Someproviders are using physical data warehouses; others are employingvirtual approaches

• Enlist the help of clinicians and other frontline staff in identifyingthe right data to capture, the right performance targets, etc.

• Employ straightforward performance dashboards that use visualcues to help leaders and staff quickly identify when they need totake action

• Institute a process improvement process for addressing issuesidentified through business intelligence

Across the country, health systems are turning data into usefulinformation in surprising new ways. By combining data from a myriadof sources, analyzing it to inform specific processes, and presenting itin easy-to-understand formats, they are improving efficiency, loweringcosts, and saving lives.

For example, Denver Health is using business intelligence to identifypatients who are likely to have a heart attack or other serious cardiacevent. A programmed “workflow” continually scans the hospital’s datawarehouse in search of patients who are deteriorating. If certainfactors—for example, oxygen levels or systolic pressure—hitpredetermined thresholds, clinicians are notified so they can intervene.

“We can now predict hours ahead of a cardiac event that a patient islikely to code,” says Gregory Veltri, the system’s CIO. “As a result, inour non-ICU areas, we have experienced zero cardiac resuscitationevents for some quarters.”

While quick to praise the noteworthy improvements attainable withbusiness intelligence, those in the trenches warn that these efforts aretime-consuming and often frustrating. As the industry adopts value-based performance approaches, many healthcare leaders—fromphysicians and nurses to administrators and IT—will likely see theirresponsibilities for data collection, analysis, and monitoring increasein future years.

“The most important thing to know is that business intelligence is awork in progress,” says Michael C. Lindberg, MD, chair of the medicinedepartment, Hartford Hospital. “You can’t just say, ‘This is it,’ and leaveit alone. You have to be looking at the data all the time and makingadjustments.”

Collecting and Mining DataOne key upfront decision that healthcare organizations have to makeabout their business intelligence strategy is where to house all the data.Denver Health and Northeast Georgia chose different approaches.

Creating a single data warehouse. Denver Health built a datawarehouse for financial data in the mid-1990s and began adding clinicaldata in 2005. Since then, the data warehouse has grown to supportregistries that help manage chronically ill patients, inform qualityreporting and benchmarking, and develop patient management reports—not to mention dashboards, or the easy-to-read interfaces that allowclinicians and executives to quickly assess progress on key measures.

“We have produced CFO dashboards, CEO dashboards, core measuredashboards, and ambulatory indicator dashboards,” says Veltri. “Andwe’re now actually producing a hospital dashboard that tracks all of ourmeaningful use indicators, plus all of our core measure and regulatoryindicators.”

Veltri calls the warehouse “the single source of truth” for Denver Health,and access to that truth is disseminated throughout the organization.

“We wanted analytical tools that were easy to use with the idea thatdepartmental super users or physicians would eventually mine thedata,” he says. “Today we have approximately 50 physicians anddepartmental users plus 12 IT staff who leverage the data warehouse,enabling improved quality, safety, and patient outcomes.”

Building a data warehouse is a huge IT project that can cost millions ofdollars, depending on the size and scope of such a project. Costs includenot only the tools for development, but hardware, storage, training, andresource costs. For an organization the size of Denver Health that wantsto centralize organizational reporting as much as possible, the cost ofa data warehouse is an ongoing expense, says Veltri.

“A lot of organizations are not willing to invest millions in a projectwithout an upfront definable ROI, but there’s no return in building a datawarehouse until the foundation is built and data integration in someform is completed,” says Veltri. “And the return received is based onhow the platform is leveraged by organizational leadership. If you’re notwilling to take some risks, then just don’t start.”

Pulling data from multiple sources. At Northeast Georgia HealthSystem in Gainesville, Ga., the business intelligence journey began twoyears ago. Instead of a traditional, physical data warehouse, NortheastGeorgia employs a so-called “virtual” data warehouse strategy, usingtechnology that allows data to be pulled from multiple sources withoutfirst being aggregated inside a warehouse.

“Knowing how fast health care is continuing to change, we believe wecan accomplish our virtual enterprise intelligence strategy with thisnewer technology rather than having everything in a traditional datawarehouse,” says CIO Allana Cummings.


Northeast Georgia’s business intelligence tool uses “in memory”computing, an approach that is less expensive than building a datawarehouse because there are no costs for the warehouse hardware,software, implementation, or support. Cummings says it allows for datato be analyzed more quickly. However, because data is pulled fromdisparate sources, there is no central point of control that ensures thatall data is “normalized” for analytical purposes.

In Cummings’ view, that does not present a problem as data can benormalized on an as-needed basis, which is required in a smallpercentage of analyses. Northeast Georgia’s business intelligence workis overseen by a data quality council that is chaired by the system’s chiefdata architect and includes representatives from clinical, ancillary,quality improvement, revenue cycle, and other areas of the healthsystem. “The council’s goal is to help us ensure the integrity of databeing reported in the organization, and that starts at the point of actualdata collection,” says Cummings. “We’re looking at standardizingdefinitions, how the information is entered, how it is pulled, and how itis used.”

From left, Northeast Georgia’s Zan Miller, chief data architect, andJames M. Bailey, MD, chief medical information officer and chief qualityofficer, serve on the health system’s Data Quality Council that overseesbusiness intelligence work.

Transforming Data into Useful InformationConnecticut’s Hartford Hospital, an 867-bed regional referral center, isgaining market share as its ability to move patients through the hospitalimproves. As a result of monitoring pertinent data and taking neededactions, the hospital is now discharging patients in a more efficientmanner. Every Sunday night, inpatient data from several systems—patient billing, bed management, and transport—is compiled and loadedinto the hospital’s patient throughput dashboard. “Come Mondaymorning, we can pull up the latest data from the last week,” saysMichael C. Lindberg, MD, chair of the medicine department.

The dashboard includes three subsections:• Discharge metrics, including the following:

• The percentage of patients discharged by 11 a.m.• The percentage of orders for discharge that are in by 10 a.m.• Average length of stay• The number of opportunity days (the days that patients staybeyond their predicted length of stay)

• Bed management measures, including the length of time betweenwhen a bed is requested and is assigned

• Capacity metrics, including average daily census, the number ofbeds that are closed, and the readmission rate for the previous 30days

Since the dashboard came online in 2009, the percentage of patientsmeeting the hospital’s early discharge target of 11 a.m. tripled—increasing from 9.5 percent to 30 percent.

Lindberg keeps his eye on the weekly updates to ensure no one isbacksliding. “If I see a physician who is starting to drift—for instance,if three data points show him missing our patient throughput goals—Iwill pull him into my office,” he says. “I pull up the graph and show him,‘This is you. Here’s how you compare with everyone else. Let’s take alook at this right on the screen. Why are you having trouble?’”

A multidisciplinary group including pharmacists, hospitalists, nurses,midlevel practitioners, and representatives from various clerical areasare tasked with combing the patient throughput dashboard forinformation that can be immediately put to use. “All of us go over thisstuff on a weekly basis to see what the trends are,” says Lindberg. “Wego to individual patient floors to give them feedback. We reward thefloors that are doing great, and we use the lessons learned from thegreat floors to help the floors that are having trouble.”

For example, the dashboard revealed that a medical floor consistentlyhad an extremely long length of stay for its patients and a lot ofopportunity days. Both results contributed to a backlog in the emergencydepartment (ED). “We slightly restructured our hospital medicineservice to put two dedicated hospitalists on that floor,” says Lindberg.“That floor was then able to reduce its length of stay to below thehospitalwide mean by simply redistributing resources.”

In another case, dashboard data showed that the length of stay wasunnecessarily high for medical patients who were placed on a floor thatis usually reserved for surgery patients. “By getting surgical midlevels—physician assistants and nurse practitioners who were working on thatfloor—to not only take care of their surgical patients, but to help withmedical patients, they improved throughput and helped get the patientsout earlier in the day with a shorter length of stay,” he says.

Having met its early discharge target, Hartford is currently focusing onreadmissions: Its overall readmission rate is currently about 10percent—which is below the hospital’s 2012 target of 12.3 percent. Itsheart failure readmission rate has fallen from 24.7 percent in early 2011to 21.4 percent this year. “We think we can get our heart failurereadmissions down to 15 percent or lower,” says Lindberg.

Using Data to Save LivesMercy Hospital St. Louis, the flagship hospital of the Sisters of Mercyhealth system, is reducing sepsis mortality with a business intelligenceapproach. Data pulled from electronic health records (EHRs) is beingused to monitor—and improve—the hospital’s handling of severe sepsisand septic shock.

Shortly after the 31-hospital Sisters of Mercy Health System installed itsEHR system, hospital leaders engaged a vendor to start mining datathat could be used to improve clinical performance. The upshot: newcare protocols for patients who develop one of the deadliest hospital-acquired conditions.

Severe sepsis strikes about 750,000 Americans each year, and it isestimated that between 28 percent and 50 percent of these people die—more than the number of U.S. deaths from prostate cancer, breast cancer,and AIDS combined (National Institute of General Medical Sciences,2009). Researchers estimate that about half of sepsis cases may behospital-acquired (Eber, M.R., et al, “Clinical and Economic OutcomesAttributable to Health Care–Associated Sepsis and Pneumonia,” Archivesof Internal Medicine, Feb. 22, 2010, vol. 170, no. 4).

Timely diagnosis and treatment are essential for survival, says RobertTaylor, MD, a critical care physician, Mercy St. Louis. Evidence-basedguidelines call for a “resuscitation bundle” of treatments to be deliveredwithin six hours of diagnosis and a “management bundle” to beadministered within 24 hours.


Like most hospitals, Mercy Hospital St. Louis did not know how well itwas complying with those guidelines until EHR data was available.

An analytics vendor extracted data from 27,000 de-identified patientrecords at four hospitals in the Mercy system and created a databasethat could be analyzed to reveal the facts: Overall, the four hospitalswere less than 3 percent compliant with the entire six-hour bundle andless than 20 percent compliant with any of the individual elements.

That was just the information Taylor needed to start an improvementinitiative. The “change elements” of that initiative include the following:• Expediting admissions from the ED to the ICU so treatment canbegin

• Integrating a sepsis response team with the hospital’s rapid-response team

• Developing sepsis care pathways• Embedding sepsis order sets in the EHR• Arranging a stat order with the pharmacy so that antibiotics will bedelivered in less than an hour after they are ordered

Mercy St. Louis began tracking several measures on a daily report card:time from sepsis diagnosis to ICU admission, time to placement of acentral-venous catheter, time to achievement of the volumeresuscitation goals of the sepsis care bundle, and time to administrationof antibiotics.

The results are astounding: In the first months of 2012, the mortalityrate for severe sepsis at Mercy St. Louis was 5.5 percent—down from22 percent in early 2011. At the same time, the ICU length of stay forsepsis patients has fallen from eight days to three, and the overall lengthof stay for the sepsis diagnosis has decreased from 10.6 days to 8.7.

“We are talking about a disease process that will kill one in fourpatients, and our survival rate has improved remarkably in just sixmonths,” says Taylor. “Our ICU and total hospital lengths of stay havealso decreased. Those are important, fundamental markers that suggestthat we are already making a difference.”

The sepsis treatment protocols that Taylor is developing will bedisseminated throughout the Mercy system. Meanwhile, Mercy leadersare returning to the database to find other opportunities for improvingperformance.

Addressing the Challenges“We’re really excited about what we are already able to do, and what weare going to be able to do,” says Tim Smith, MD, vice president ofresearch at Mercy’s Center for Innovative Care. That said, using EHRdata in this way presents many challenges.

Capturing the right data. The first is ensuring the EHR captures theright data in the right format so it can be analyzed to produce actionableinformation. “It takes teams of people to be able to do that, and evenwith the help of an outside analytics firm, it takes a lot of resources,”says Smith.

Contracting with an outside vendor that will work with patient data istime-consuming because the health system must ensure that it iscomplying with the Health Insurance Portability and Accountability Act.“There’s a lot of work that goes into that before you can even push thefirst button,” he says.

Overcoming those data challenges—not to mention the processimprovement challenges that follow—is worth the work when lives arebeing saved, says Smith: “When this whole story unfolds in the next yearor two, we are going to be able to point to some pretty phenomenalsuccess rates in sepsis management.”

Identifying the right targets.While the technical aspects of businessintelligence have been worked out in other industries, the conceptualquestions specific to health care are just now emerging. For example,when administrators and clinicians have the opportunity to getinformation they have never had before, it is not always clear whatinformation they need or how it should be used.

Veltri discovered this when Denver Health created a registry forhypertension patients. Clinicians could—for the first time—see thatabout 30 percent of patients had blood pressure under control. Veltriassumed the visual target to be used on the registry dashboard was 100percent of patients, but clinicians pushed back: “They said, ‘Is it possibleto get to 100 percent?’”

After a debate on whether targets should be achievable or aspirational,physicians agreed to set the target at 70 percent. In the three yearssince the registry was established, blood pressure is under control for71 percent of Denver Health’s hypertensive patients, compared toapproximately 50 percent nationally.

The achievable-versus-aspirational target is just one of many issues thatmust be considered when presenting data that is used for decisionmaking. Veltri recommends that all business intelligence requests beevaluated on six questions:• Is there agreement on what to measure?• Can anything be done to affect the measure?• Are there specific goals or targets?• Are there defined critical thresholds?• Is an upward or downward trend “better?”• Is there such a thing as “too good?”

“Learning to create the right metrics is a journey, and these guidelinescan help an organization measure metrics that matter,” says Veltri.“Understanding what is being measured, and why, is as important asthe measurement itself.”

Helping users interpret the data. Electronic dashboards must be builtwith the audience in mind, an understanding of how the information willbe used, and a clear indication of how frequently the data is refreshed.“Everybody assumes that the data that they are looking at is current asof the time they are looking at it, and that’s not necessarily true. Somedata is one-day old, some data is real time,” says Veltri. “But the usershave to know that.”

Most business intelligence dashboards use visual cues—such as redflags or green arrows—to help users quickly interpret the information.Denver Health embeds another layer of information. “When you mouseover an indicator, it tells you what value is good and what the target is,”says Veltri. “If national benchmarks or research is available, thatinformation is provided to help the user interpret what is beingdisplayed.”


Getting StartedThe business intelligence pioneers profiled in this article share otherlessons they have discovered in their journey:

Do not try to engage physicians in the start-up phase. “During thattime, there’s really nothing for anybody to decide. You’re just buildingdata maps and dictionaries and the basic foundational elements of thewarehouse,” says Veltri. “If you put organizational leaders or physiciansinto this upfront process, they get bored because there is little progresstoward the things they want, such as dashboards or reports.”

Appoint the right group of people to set priorities, depending onyour organization’s needs. At Northeast Georgia, an EnterprisePriority Council is made up of the system’s vice presidents and medicalstaff members. “Based on what we are trying to accomplishstrategically, they help prioritize the next opportunity, whether that isdeveloping a new dashboard tool or taking on an improvement projectwith some technology need,” says Cummings.

In Denver, clinicians and revenue cycle leaders serve on the WarehouseAdvisory Council that sets priorities. “They prioritized colorectal cancerscreening as the first registry that we would build—even over diabetes,”says Veltri. “The primary reason was that a key stakeholder had receiveda grant to support a colorectal cancer screening project, which paid forsome of the development. Without such a council, IT never would haveknown that this direction was acceptable to the physicians.”

Share dashboard data broadly. At Hartford Hospital, the chiefphysicians of every department and every division have access to all thedata—as do the nurse managers. “Any nurse who is managing a floorcan go in and look at my physicians and I can go in and look at her floor,”says Lindberg. “That allows us to have a conversation on how thedifferent things are impacting one another. We can brainstorm togetherand come up with good solutions, working as a collaborativemanagement team.”

Document how EHR data can be used to drive clinicalimprovement. Because this capability is so new, everyone is atrailblazer, making mistakes as they gain experience. “I wouldencourage others that want to embrace a program like this to documentthe processes and the failures and successes and how we can improvethis,” says Smith. “We can all learn from one another as we go forward.”Veltri believes business intelligence answers the question: Can hospitalsimprove quality and charge less for that quality? “The answer is: ‘Yes,Denver Health has proven this can be accomplished,’” says Veltri. “Butthe organization must manage the use of quality data, and use this datato make informed decisions based on data.”

Lola Butcher is a freelance writer and editor based in Missouri.Interviewed for this article (in order of appearance): GregoryVeltri is CIO, Denver Health, Denver ([email protected]).Michael Lindberg, MD, is chairman, department of medicine,Hartford Hospital, Hartford, Conn. ([email protected]).Allana Cummings is CIO, Northeast Georgia Health System,Gainesville, Ga. ([email protected]). Robert Taylor, MD,is a critical care and internal medicine physician, Mercy HospitalSt. Louis, St. Louis. Tim Smith, MD, is vice president of research,Mercy Center for Innovative Care, St. Louis.([email protected]).

Reprinted with permission from HFMA’s Leadership series







Do What You Got To DoBy Kent Radler


Our daughter, Maggie, just finished her first year performingwith The Cincinnati Shakespeare Company (http://www.cincyshakes.com), so I am eating my words of thejoke about her being a Shakespearian actress and having torecite the line, “Would thou likest a hot apple pie with that?”

We’ve watched Maggie die as Shelby in Steel Magnolias, seenher killed playing both Desdemona and Emilia in Othello, sawher go mad as Lady Macbeth, and now, this past weekend,listened to her screaming from child birth portraying Rose ofSharon in The Grapes of Wrath. And people wonder why I wantto make them laugh?

Walking away from The Grapes of Wrath I found the strengthof the mother, Ma Joad, amazing. While the men werefaltering, she was pushing on. She said, “We do what we gotto do.”

If you read my article last Mother’s Day titled She’s No JuneCleaver, you know my mom is a strong, independent womanand it seems I have surrounded myself with these women myentire life.

During my days as a hospital CFO and CEO, my favoriteDirector of Nurses was Sue Kinder in Frederick, Oklahoma.Sue is smart, tough, and an extraordinary person.

Sue trained all of the charge nurses to deliver babies. Onenurse, however, was resistant to this change and would justcall Sue in whenever a mom presented at the hospital.

One night I’m leaving work, I meet Sue returning to deliver yetanother baby. Sue has red hair and when she gets angry, herneck begins to get red and it works itself up to her face. Thatnight she looks like she has a big pimple on her shoulders.Sue hands me $42, saying, “That is how much it cost to bailsomeone out for battery. You’ll be getting a call tonight.”

The following morning I call Sue into my office, saying, “Itdoesn’t bother me you get so angry with this nurse. Whatbothers me is you know how much it costs to bail someone outfor battery.”

Sue says, “Yea, well as long as ‘her highness’ works here youbetter keep that $42 because someday you’ll need it.”

One of the strongest women I ever knew was my mother-in-law, Emma Lou Griffith.

I know it’s fashionable, especially for a man, to make fun ofyour mother-in-law, but mine was a saint. Emma Lou and Iinstantly bonded because we shared a love for Twyla and, eventhough Emma Lou has been gone longer than the time I hadwith her, I miss her every day, especially hearing her laugh.

Over the 44 years I have run, it has been a source of both joyand pain, but today one of my most pleasurable experiences isexploring a new city during my travels on my run.

Running is also a great way to meet people and make newfriends.

A few years ago I’m running in Tulsa when two guys drive byyelling obscenities at me. I’m filled with endorphins, thinking,“We all ought to live in peace and harmony on such a gloriousmorning.” So to communicate this to these two hayseeds, Iraise a finger to the sky.

Who knew the good people of Tulsa find that finger offensive?We’re on the side of the road yelling at each other when apoliceman pulls up saying, “Okay, break it up and move along.”

I go, “You heard him, girls, the man said move along.”

The cop snaps. “Sir, I’m fixin’ to take you to the station and Idon’t mean the bus station.”

When I tell Twyla and her mom this, Twyla says, “Don’t call meto bail you out of jail.”

I go, “I hadn’t planned on it, I was calling your mom.”

Emma Lou says, “Yea, and I’d do it just to hear the story.”

I had to confess, “Emma Lou, actually, a night in jail might dome a world of good.”


Maybe Emma Lou’s best quality was her perseverance, whichis a nice way of saying she was both stubborn and creative.Twyla’s dad once confessed the children got all theirstubbornness from him because Emma Lou had not lost any ofher’s.

Emma Lou was so stubborn death could not curb it.

When Twyla started teaching, I was the CEO of a hospital, sowe needed someone to watch the children after school. Weasked Emma Lou if she would do it, but insisted we pay her.She resisted for a minute, then relented. I remember thinkingat the time, “That was easier than I thought it would be.”

Seven years after Emma Lou died, I get a call from the banksaying Emma Lou had opened a savings account with Twyla’sname on it. In it was the money we paid her for watching thekids those many years ago.

But her stubbornness, combined with her creativity meantwhen Emma Lou decided to do something, you knew, come hellor high water, she’d do it. She sheet rocked her entire livingroom, including the ceiling, by herself. If you told me to dothis, I’d still be standing there with a stupid look on my face.Not Emma Lou. When she did the ceiling, she constructed Tsmade out of 2-x-4s that she could wedge under the sheet rock,holding them in place while she screwed them in.

The recession has been difficult for most of us, but when I’mstruggling, I’m reminded of Emma Lou sheet rocking that roomand I do what I got to do. In the words of Samuel Johnson.“Great works are performed not by strength, but byperseverance.” Ma Joad could not have said it better.

Though I’ve lost Emma Lou, I have added another strongwoman to my life. Maggie, following in the footsteps of hermother and grandmothers, has become a strong, independentwoman. I pity any man who tries to wrangle her because she’llsettle him down in a hurry.

Even though she can handle herself, I will always be her fatherand will stand up for her when appropriate.

And maybe when it isn’t.

I don’t care about your politics, Republican, Democrat, itmakes no difference to me, but, as a father, if Rush Limbaughcalled Maggie the misogynistic things he recently calledSandra Fluke, I’d kick his pasty white, chauvinistic butt all oversouth Florida. Then, instead of having to hear Rush’s vilecomments over and over again on the news, they would havebeen playing the video of me being arrested, hands cuffedbehind my back, my right shoe missing because it ispermanently implanted in Rush’s pudgy backside, confessing tothe world, “You’re darned tootin’ I did it. And if Rush, once heis able to speak, wants to say anything else nasty about mydaughter, I’ll do it again.”

The bad news is, with my unapologetic attitude, the Judge willhave no choice but to throw me in jail and without Emma Louaround, I am afraid I may be there for a while.

My only hope is Sue Kinder has that $42 in the pocket of herscrubs.

Do what you got to do and always remember laughter matters.

Known as the world’s cleanest comedian and speaker,Kent Rader helps people learn and experience howlaughter matters in reducing stress and improving theirbusiness A reformed accountant, Kent has written thestress reduction book titled Let It Go, Just Let It Goavailable at Amazon.com and has been seen onComcast’s Who’s Laughing Now. He is the winner ofthe Branson Comedy Festival and co-stars with JanMcInnis in the The Baby Boomer Comedy Show, CleanStand-Up Comedy For People Born Before Seatbelts.(www.babyboomercomedyshow.com) One conferenceparticipant said, “You are a wonderful reminder thatour human nature provides unlimited opportunities tolaugh, share, and defuse the stresses of our lives in away that is neither offensive nor exclusionary” Forinformation or a free DVD, please contact Kent at 405-209-3273 or email [email protected].


Photos by Marty Abschutz

Putting the Intelligence Back in BusinessBy Todd Nelson


Providers need to move from data-collecting organizations to data-driven organizations.Healthcare organizations are awash in data and reports. But a spreadsheet is not necessarily synonymous with business intelligence.HFMA’s Value Project defines business intelligence as the ability to collect, analyze, and connect accurate quality and financial data tosupport organizational decision making. The goal is to move beyond just generating reports and numbers—and turn data into actionableinformation that helps us move the dial on quality and cost.

Three ProngsTo get to true business intelligence, providers should adopt three strategies.

An enterprisewide data strategy. Providers need to ensure the accurate and consistent calculation and reporting of data acrossthe organization. For instance, Boston’s Partners HealthCare has ensured uniformity in reporting. The organization’s office of clinicalaffairs uses a three-color system—green, yellow, and red—for its quality dashboard to indicate whether the health system’s facilitiesare above, at, or below performance goals. Information is arranged to allow easy comparison between Partners’ facilities andagainst peer organizations.

A clear line of sight. The alignment of systemwide goals with department-level and individual performance metrics helps keep anentire organization on track. Bellin Health System balances its systemwide scorecard across five categories: effectiveness, efficiency,engaging others, growth, and teamwork. A cross-functional, interdisciplinary leadership team works with brand and unit leaders totranslate systemwide scorecard measures into metrics that cascade down to the individual goals of front-line staff.

Information availability. Information should be available to inform front-line decision making, as close to real time as possible.At HFMA’s recent Leadership Conference on Value, we heard several examples of how organizations are encouraging collaborationamong clinical, financial, and operational leaders to improve value. Critical to these collaborations is easy access to needed businessintelligence. For instance, financial and clinical leaders at Chicago’s Rush University Health System are collaborating to coordinatethe care of patients with specific clinical conditions or needs (e.g., patients needing bone marrow transplants). Using businessintelligence, Rush staff were able to identify variation in practices, and then improved outcomes and reduced costs throughstandardization.

An organization’s ability to deliver timely data will be driven largely by the degree to which data collection and analysis can be automated.For example, Rush was able to hardwire standardized practices into its electronic health record so staff could reference the guidelinesat the point of care. In addition, Rush is able to analyze the impact of the initiative from a clinical and financial perspective by trackingcost and quality metrics.

A Closing ThoughtAlthough following these strategies will get you a long way toward your destination, we must not lose focus. To create truly intelligenthospitals and health systems, we must do more than invest in technology. We also need to ensure that our staff are prepared to deliveron the service that our patients and their families expect. So let’s put the intelligence back in business intelligence. We must rememberthat templates and numbers and safety alerts are important, but at the end of the day, we are people serving people.

Todd Nelson is technical director for senior financial executives/accounting, HFMA, and a former hospital CFO([email protected]).

Reprinted with permission from HFMA’s Leadership series


Photos by Marty Abschutz

Documents

Volume 46 Issue 1 Summer 2012 OUR NEW LEADERS · Volume 46 Issue 1 Summer 2012 OUR NEW LEADERS President PALMIRA M. CATALIOTTI, FHFMA, CPA President-Elect DAVID EVANGELISTA Vice President