Heather Paulsen--CA

While I appreciate the intent behind the proposed rule changes to improve patient care and safety, I find that many of the proposals will have unintended consequences that will actually hinder the effectiveness of RHCs in the long run. My comments: 1. The proposed requirements per Section 491.10(a)(3)(v), requiring that all entries in the health record be dated and timed and authenticated, are in many ways impractical. We are a clinic still utilizing paper charts (cost is the barrier to implementation of an electronic medical record). We already strive to maintain complete, legible and signed entries in the charts; it is unclear how requiring dating and timing of every entry will improve patient safety and care. The wording of the proposal is also unclear as to who needs to authenticate each entry. Two examples: · After a physician gives a nurse an order for an injection, and the nurse fully documents the injection (including date and time, as that is pertinent should there be an adverse reaction), does the physician then need to “authenticate” the nurse’s chart entry, as the ordering health care provider? This multiple handling of the chart would be a remarkable exercise in inefficiency, adding to the physician’s already staggering piles of uncompensated paperwork, without adding anything to improve the quality or safety of the care provided to the patient. · Nurses often handle patient inquiries by telephone, or report lab results to the patient by telephone, per the physician’s request. Would the physician then need to “authenticate” the nurse’s already thorough documentation of the discussion in the patient chart? If each of these charts has to pass through the hands of the nurse AND the physician, again, the inefficiency and sheer volume of uncompensated work on the part of the physician will drive many away from practicing medicine. Our physicians already feel overwhelmed and discouraged by the mountains of (uncompensated) paperwork required of them. By requiring them to arbitrarily date and time every entry in the chart (they already initial every piece of paper they review), we will be adding to the hours they spend without any evidence that dating and timing every entry adds to the quality or safety of patient care. This requirement needs to be limited to those documents on which date and time actually matter in terms of patient care. It seems a simple step to add to all entries, but in every day clinic operations it is not feasible nor practical nor substantively valuable. 2. Regarding the proposed changes to the payment methodology: The proposed rule will reduce the reimbursement to clinics already struggling to make ends meet. CMS approves and establishes a per-diem rate for RHCs, yet the current payment methodology ensures that we receive less than this cost-per-visit. The proposed rule cuts into this payment even further. Every dollar received is critical to keeping our doors open, and cutting payments further will jeopardize our very existence. Closure would devastate our community and would be a virtual death sentence for our local hospital (the next nearest hospital is more than an hour away). I advocate for change in the exact opposite direction from the proposed rule: Medicare payments should complement the patient payment to equal the per diem rate. 3. Regarding the QAPI requirement: As a provider-based RHC, we are already accountable for continuous quality/performance improvement programs per the hospital’s policies and JCAHO accreditation requirements. We are already doing this work. Having to call it something else and report our results to yet another entity will pull valuable resources away from actually implementing the improvement programs. I see this proposal as increasing our costs without adding value to our ongoing quality assurance efforts. 4. Similarly, as a provider-based RHC, we are already following the hospital’s and JCAHO’s policies and requirements for infection control. Additional burdensome reporting requirements, per this proposed rule, would pull limited resources away from activities that would actually enhance quality of care and patient safety. 5. My understanding is that the location requirement proposed rule has been pulled from the table as of yesterday. I am glad, as I had many comments to share regarding its confusing, difficult-to-manage nature. Thank you for considering my comments.