Industry Insights

Industry Insights

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December is usually a good time to take stock of where we are and what lies ahead. There are the year-in-review shows, the pieces on famous celebrities who passed during the year; and then there are articles and programs that attempt to presage the upcoming year. What will be the
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“Quality is job 1” was a famous tag line, beginning decades ago, for one of America’s major automakers. It did not escape the company’s attention that attention to detail would help propel their brand in the minds of millions of car buyers and advance sales in the process. Today, quality
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The Centers for Medicare and Medicaid Services (CMS) has finalized its Medicare Hospital Outpatient Prospective Payment System (OPPS) for 2023. The final rule (FR) will affect roughly 3,500 hospitals, as well as approximately 6,000 ambulatory surgical centers (ASCs). Based on a fact sheet published by CMS, it appears there will
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During the days of the American Civil War, some commodities were hard to come by, such as material to make hundreds of thousands of military uniforms. To keep expenses low, Northern quartermasters ordered a material known as “shoddy.” It was a mishmash of discarded woolen rags mixed with new wool
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 Thursday, 10 November 2022 Whether it’s Merle Haggard’s “Working Man’s Blues” or Dolly Parton’s “Working 9 to 5” or the Beatles’ “Hard Day’s Night,” humans have historically set their workforce woes to music. There’s something comforting in sounding out one’s complaints about his or her job, especially if that job
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There are no two ways about it. Stuff happens. In the midst of our own personal and societal crises, hope tends to ebb away. Fear and pessimism easily set in. In such times, however, we should recall the old saying: “every cloud has a silver lining.” Hospital leaders will need
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Change happens; and sometimes it comes at you fast. In 2008, the telephone manufacturing industry was running at full steam. Wired and cordless phones, as well as answering machines, were in high demand. But since that time, employment in the telephone apparatus manufacturing industry has steadily declined by more than
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“Gloom, despair and agony on me. Deep dark depression, excessive misery.” The renowned refrain from the old Hee Haw television series exemplifies the mood of many as they assess the status of their hospital’s emergency department. It’s bad enough to have to hear the wails and weeping coming from these
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“Eternal vigilance is the price of liberty.” This phrase, or the inversion of it, has been attributed to different Americans of notable status since at least 1809. The famous aphorism, in its original context, was meant as a warning against would-be tyrants within government circles; but it can also be
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It’s the prototypical nightmare. You’re back in high school, and it’s your turn to get up before the class and deliver a speech on Jurassic-era dinosaurs or the causes of WWI or whatever topic had been assigned to you weeks before. It is only then that you realize to your
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As of this writing, a hurricane is brewing in the Caribbean and is threatening to hit a highly populated section of western Florida later this week. Ian is currently tracking toward Tampa and is strengthening in intensity. People there are already undertaking preparations: boarding up windows, filling up gas tanks
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It was over a hundred years ago. What was then deemed as perhaps the most widespread pestilence the world had ever witnessed was finally coming to an end. The Spanish flu, whose proliferation was certainly assisted by theater-wide troop movements during World War One, had wreaked havoc across the planet.
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Not all hospitals are created equally. There are those that service medium-sized cities and those found in rural communities. There are major metropolis medical centers and there are hospitals that are a part of a greater health system. Today’s article deals with a medical facility category called “Disproportionate Share Hospitals,”
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September 7, 2022 The earth continues to turn as it has for uncounted eons.  Except for a microsecond here or there, our planet spins at essentially the same rate each day with precision and predictability.  But, while Earth is unchanging in its rotational cadence, the world of human endeavor and
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August 31, 2022 In this final installment of our review of the 2023 Medicare Inpatient Prospective Payment System (IPPS) Final Rule (FR), we will be focusing on the various quality programs outlined in the rule.  The key quality provisions that will be deemed important to hospital decision-makers are provided in
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August 24, 2022 Reduction is not always a negative concept. One need only visit the local health spa and espy those working to reduce their weight and waistlines to draw that reasonable conclusion. Reducing dependence on harmful substances and hurtful habits is considered a positive thing, as well. Reducing one’s
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August 17, 2022 There are few things more certain than the prospect of progress.  It’s all around us, in our homes and in our hands.  Just a few days ago, physicists at the Lawrence Livermore National Laboratory officially confirmed a major breakthrough in the decades-long dream of nuclear fusion.  The
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August 10, 2022 On August 1, 2022, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Hospital Inpatient Prospective Payment System (IPPS) Final Rule (FR) for fiscal year (FY) 2023, which begins October 1, 2022.  Along with the publication of the FR, CMS also issued a fact sheet
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August 3, 2022 In our last two alerts, we provided our readers with some of the key highlights arising from 2023 Outpatient Prospective Payment System (OPPS) Proposed Rule (PR) released a few weeks ago by the Centers for Medicare and Medicaid Services (CMS).  Today’s alert will conclude our summation of
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July 27, 2022 As stated in last week’s alert, we will be providing further details arising from the 2023 OPPS Proposed Rule (PR) that was recently released to the public.  In this week’s alert, the focus will be on proposals applicable to rural and critical access hospitals.  The following represents
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July 13, 2022 On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) issued its Medicare Physician Fee Schedule (PFS) proposed rule (PR) for calendar year 2023.  Though the PR primarily addresses Medicare Part B conditions and claims, there may be some provisions found therein that will have
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July 20, 2022 On July 15, 2022, the Centers for Medicare & Medicaid Services (CMS) issued its 2023 Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule (PR).  There will be a 60-day comment period, ending on September 13.  A final rule is expected to be issued in early November and
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July 6, 2022 “Country roads, take me home to the place I belong.  West Virginia, mountain mama, take me home, country roads.”  There is an allure to the idyllic lands that lie outside of our nation’s cities and suburbs.  A slow-paced spot where sweeping landscapes and peaceful pastures create a
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June 29, 2022 Enjoy life’s triumphs while you can, because they are often fleeting.  The greatest comedian occasionally bombs.  The major leagues’ top slugger will sometimes strike out.  In other words, even those individuals and entities that have obtained recent success—even a string of successes—will eventually experience a loss.  That
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June 22, 2022 Opinions are like grandma’s holiday fruitcake: they typically contain questionable ingredients and rarely receive universal approval.  Let’s face it, we all come from different backgrounds, with different perspectives, and we are not going to always agree on every issue.  Given these individual differences, it is exceedingly difficult
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June 15, 2022 “He keeps his cards close to the vest.”  The familiar adage describes a person who is, by his very nature, not normally disposed to trumpeting his business through the streets.  All of us, to one degree or another, are prone to privacy; and, while we prefer complete
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June 8, 2022 As promised in last week’s article, we want to conclude our two-part examination of hospital expenses by looking specifically at labor costs in today’s alert.  According to the extensive article published by the American Hospital Association (AHA) last month, which we referenced last week, labor costs are
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June 1, 2022 We’re all aware of the increasing prices at the gas pump and the grocery store.  It’s a wonder how most Americans are currently able to make ends meet.  The financial strain that many in our society are facing right now is concerning, and many in the halls
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May 25, 2022 There are few things more frustrating than having insurance that doesn’t cover you in a crunch. It’s like paying for an exorbitant house warranty only to discover in the dead of winter that it didn’t pay to replace your non-functional furnace. That can be a shattering (and,
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May 18, 2022 Last week, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register a final rule (FR) relating to Medicare Part C, also known as Medicare Advantage (MA), and Medicare Part D, relating to drugs.  The agency also released a fact sheet that provides an overview of
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May 11, 2022 As the Russian ambassador and a U.S general lunge into a physical altercation with one another in a secure area of the Pentagon, the president scolds them both with the admonition: “Gentlemen, you can’t fight in here.  This is the War Room!”  The iconic line from Stanley
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May 4, 2022 In last week’s alert, we provided some of the key highlights found in the federal government’s Hospital Inpatient Prospective Payment Systems (IPPS) Proposed Rule (PR) for fiscal year (FY) 2023 (beginning October 1, 2022).  Today’s alert will flesh out some of the proposed changes in hospital-related quality
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April 27, 2022 Last week, the Centers for Medicare and Medicaid Services (CMS) released a preliminary version of the Hospital Inpatient Prospective Payment Systems (IPPS) Proposed Rule (PR) for fiscal year (FY) 2023 (beginning October 1, 2022).  The following will act to summarize some of the key proposals that would
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April 20, 2022 The Centers for Medicare and Medicaid Services (CMS) released this month an announcement regarding Medicare Part C (Medicare Advantage program) and Medicare Part D (Medicare drug program).  The Announcement addresses changes for the two programs beginning in January of 2023.  The following will summarize the key points
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April 13, 2022 There is safety in numbers, according to the well-worn adage.  However, should the numbers continue to grow, we might rightly assert that there is not only safety; there is substantial power.  This principle is no doubt behind humanity’s historic trend toward cooperation and incorporation: tribal clans transitioning
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April 6, 2022 It never ceases to amaze—the annual rise in NFL player salaries.  Each year, there is a new all-time high contact paid to the star quarterback or flashy wide receiver or dominating defensive tackle, and this trend has just reached astronomical levels.  Late last month, the Cleveland Browns
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March 30, 2022 No one said life would be easy.  Look no farther than Sunday’s Academy Awards, when comedian Chris Rock was suddenly smacked upside the head on live TV by actor Will Smith (who went on to win the Oscar for best actor that same evening).  Fortunately for Rock,
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March 23, 2022 It’s not exactly breaking news to report that hospitals across the American landscape are facing a shortage of clinical workers.  From the rocky coasts of Maine to the sun-drenched beaches of California, there is a staffing crisis that is continuing and, in some cases, intensifying.  Over the
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March 16, 2022 Can’t we all just get along?  Those words famously spoken by Rodney King during the 1992 Los Angeles riots ring out, even today, as a call to our better nature.  It’s the idea that humankind has the capacity to come together even in the midst of mistrust
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March 9, 2022 In a highly touted mini-series based on Herman Wouk’s The Winds of War, there is a poignant moment in which a pensive President Franklin Roosevelt says somberly—almost sorrowfully: “It’s a bad thing to go to war.”  It is indeed a sad state of affairs when those in the
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March 2, 2022 How quickly things can turn on a dime.  Years of continental peace can suddenly break forth in major hostilities, as we are currently witnessing in eastern Europe.  Perennial underachievers in sports can surprisingly find themselves in a Super Bowl; look no farther than this year’s Cincinnati Bengals. 
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February 23, 2022 When it comes to matters of the heart, there are few that are more important than the promotion of cardiovascular health.  American hospitals are world renown for their excellence and innovation in the treatment of heart disease.  To support this assertion, a recent post in Becker’s Hospital Review outlined
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February 16, 2022 Earlier this month, the Centers for Medicare and Medicaid Services (CMS) released its 2023 Medicare Advantage (MA) and Part D Advance Notice.  The 159-page document is meant to provide the medical community with a head’s up on potential provisions that will be included in the 2023 Final
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February 9, 2022 With the recent surge of inpatients that many hospitals have been facing, whether due to COVID or those who have finally elected to have surgeries that they had previously put off, there is now a current premium on bed space.  We recently talked to a clinician at
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February 2, 2022 In follow-up to our article of last week, we thought it might be helpful to share a summary of a report on the most recent findings relative to hospital finances that was just published by financial consulting firm Kaufman Hall (KH).  The 31-page report makes it clear
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January 26, 2022 As curious beings, we humans have an affinity for the future. We wonder how it will unfold and what we will find once we get there. This natural desire to know what will be becomes even more acute as we contemplate our own individual outcomes. How will
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January 19, 2022 When the founders of this republic wanted to “form a more perfect union,” they dispensed with the fairly feckless Articles of Confederation and instead crafted a document considered by legal and political scholars the world over as unparalleled in its wisdom and framework.  One of the keys
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January 12, 2022 For years, the healthcare industry has struggled through an increasing shortage of clinical practitioners.  It seemed that every long-term forecast of the situation pointed to a dire drop-off in the number of healthcare providers in the decade ahead.  This was due, in part, to a dramatic downturn
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January 5, 2022 Beginning with the first day of 2022, out-of-network (OON) providers are no longer allowed to engage in what is known as balance billing when providing services in an in-network facility.  Balance billing for emergency services is now prohibited in both in-network and OON facilities.  As you will
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December 29, 2021 One of the current thought leaders in the world of high-tech innovation is Elon Musk.  The visionary Tesla developer and rocket designer has much to say about the future of technology, including a few warnings about the potential pitfalls of artificial intelligence (AI).  In multiple interviews, Musk
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December 15, 2021 It seems to happen every year: the plunging sword of Damocles is avoided at the last minute.  In the present context, the threat that had been hanging over the head of every Medicare provider was a set of substantial cuts in payment tied to patient services.  Sequestration
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December 8, 2021 For those hospitals hemorrhaging clinical workers and clerical staff due to the Biden administration’s COVID-19 vaccine mandate, there have been some recent developments that may have an impact on your facility.  By way of background, an interim final rule (IFR) promulgated last month laid down COVID vaccine
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December 1, 2021 Last month, the U.S. House of Representatives narrowly approved the Build Back Better (BBB) legislative package submitted by the Biden Administration.  The term, “build back better,” has been used multiple times by Mr. Biden since the 2020 campaign.  He, in turn, got the phrase from World Economic
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November 24, 2021 Americans gravitate toward the cutting edge.  We like checking out the latest gadgets and getting our hands on the trendiest gizmos.  New technology brings wonderment to the observer and is subconsciously seen as a form of modern-age magic.  But high-tech wizardry is not just for awing and
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November 17, 2021 At the direction of the Biden Administration, the Centers for Medicare and Medicaid Services (CMS) issued, this month, an interim final rule (IFR) that will require hospital personnel to receive one of the federally approved COVID-19 injections, unless they obtain an approved exemption.  The agency issued a
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November 3, 2021 There’s no doubt about it: Nicholas Cage is one of America’s finest actors. In fact, he is so good at his craft that he has been among Hollywood’s highest-paid personalities, amassing at one point $150 million in acting fees. That’s quite a chunk of change. However, the
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Summary The federal government has just released new regulations that provide details for implementing provisions of the No Surprise Act. How will this affect anesthesia providers? Today’s alert takes a look. October 6, 2021 On September 30, 2021, the U.S. Department of Health and Human Services (HHS), along with other
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September 29, 2021 There’s equity and then there’s equity. Not all equities are, well, equal! You might have equity built up in your home or business. That is, your property may have accrued certain monetary value that exceeds the amount owed. The term is also used relative to other financial
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September 22, 2021 “The best laid plans of mice and men often go awry.” The original quote from poet Robert Burns is a bit different with its Gaelic inflections, but this approximate version of the maxim has become the standard rendering for modern ears. However the statement is styled, its
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September 8, 2021 Friends in high places: it certainly doesn’t hurt; and, more often than not, that advantage can greatly help. Having the right connections can make all the difference in pushing your agenda through and realizing ultimate success. There is perhaps no greater example of this than those who
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September 1, 2021 Over the last two weeks, we have brought you our summation of the recently released 2022 Inpatient Prospective Payment System (IPPS) Final Rule (FR). Today’s alert will be our last installment of the FR and is based, in part, on summaries provided by both the Centers for
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August 25, 2021 Today’s alert will act to continue our summarization of the 2022 Inpatient Prospective Payment System (IPPS) Final Rule (FR), which we began last week. The current summary will focus primarily on the new quality reporting requirements and is based in large measure on a synopsis of the
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August 18, 2021 Earlier this month, the Centers for Medicare and Medicaid Services (CMS) released the 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) Final Rule (FR). The agency also released a multi-page fact sheet that provides a snapshot of some of FR’s key provisions. Based on our gleaning of
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August 11, 2021 Last week, we provided highlights from the Medicare Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule (PR) for 2022. Due to the enormity of the PR, we were forced to provide our summary in multiple parts. This article will provide additional details on what the government has
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August 4, 2021 Last month, the Centers for Medicare and Medicaid Services (CMS) released its 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System Proposed Rule (PR). To help explain the PR, the agency also released an extensive fact sheet summarizing the massive set of
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July 28, 2021 Last week, we published an alert that outlined some of the key provisions of the Medicare Physician Fee Schedule (PFS) Proposed Rule (PR) for 2022 that may affect hospitals. As promised in that alert, this week’s article will provide additional details arising from the 2022 PR. Again,
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July 21, 2021 It’s that time of year again. Last week, the government released the 2022 Medicare Physician Fee Schedule (PFS) Proposed Rule (PR), and there are some interesting changes that may be in store for hospitals. The following treatment is based on what we’ve gleaned from summaries of the
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July 14, 2021 One of the leading theories meant to explain the formation of celestial bodies, such as stars, planets and moons, postulates that particles of mass and dust created by a primordial explosion, i.e., “Big Bang,” were forced to eventually coalesce at random points in the universe due to
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July 7, 2021 On July 1, 2021, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury released an interim final rule (IFR) that acted to flesh out some of the provisions of the No Surprises Act (NSA), scheduled to go into
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June 30, 2021 Down in Louisiana, where the bayous slowly snake their way past moss-laden cypress and where 300-year-old live oaks stand witness to a colorful and mystical past, the state’s residents are readying themselves for another hurricane season. It seems to be an annual rite of endurance for this
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June 23, 2021 Summers remembered—in a time before smart phones and social media. The car is packed and the kids have climbed into their designated seats. Mom and Dad are in the front, excited to get this vacation on the road. They have all mentally readied themselves for the ride.
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June 9, 2021 There is a film shot off the shores of Ireland involving a hapless fisherman played by the well-known Irish actor, Colin Farrell. He’s out trawling one day, having little luck, when suddenly his nets haul in an unexpected catch: an unconscious woman. He performs CPR and, to
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June 2, 2021 One of Sylvester Stallone’s early movie roles was as a union organizer for FIST—a clever acronym for the fictitious Federation of Interstate Truckers. Meant as a rough allusion to the real-life Teamsters, the film portrays the early years of unionization in America, including all that went with
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May 26, 2021 Taking on the giant—that’s the spectacle that many of us will pay to see; and, typically, we’re rooting for the underdog. Classic stories abound with such clashes: David and Goliath, Jack and the Beanstalk, Honey, I Shrunk the Kids . . . okay, maybe that last one
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May 19, 2021 Today’s article will conclude our look at the massive 2022 IPPS Proposed Rule (PR). So far, we’ve summarized how the PR treats topics such as payment rates, quality measures, negotiated payment disclosure, residency programs and efforts to reduce hospital readmissions. Based on a summary of the PR
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May 12, 2021 Today’s article is a continuation of last week’s treatment of Medicare’s 2022 Inpatient Prospective Payment System Proposed Rule (PR), released in late April. As we pointed out previously, the PR contains over 1,900 pages of proposals. Consequently, we have found it necessary to break down the proposed
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May 7, 2021 India is struggling to fight off a second crushing wave of COVID-19 cases. Please join MiraMed Global Services, part of the MiraMed Family of Companies, in helping to raise money to help India amid a surging second wave of COVID-19 through donations to MiraMed Helping Hands for
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May 5, 2021 Last week, the Centers for Medicare and Medicaid Services (CMS) released its Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Rates Proposed Rule, along with a fact sheet that acts to summarize the critical parts of the proposals. The
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April 28, 2021 There is a movie comedy set in rural Louisiana where a woman goes into the hospital, and her son—wanting to make her as comfortable as possible—fills her oversized suite with the rustic reminders of home, including the family’s live-in mule. Though silly and over the top, the
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April 21, 2021 For millennia, trumpet-type instruments have played an important part in military history. In ancient times, a ram’s horn was used. In more recent centuries, the bugle was deployed. Such an instrument was used in the famed Charge of the Light Brigade. It was used throughout the Civil
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SPECIAL ALERT: Sequestration Cuts Postponed to 2022 April 19, 2021 On Friday, April 16, 2021, the Centers for Medicare and Medicaid Services (CMS) announced that the two-percent sequestration cut in Medicare fee for service (FFS) payments to providers, scheduled to commence April 1, 2021, has officially been pushed back to
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April 14, 2021 No pandemic lasts forever. I’m sure those in the Middle Ages must have thought that there would never be an end to the Black Death, but it eventually subsided after seven years. Many in the early twentieth century no doubt believed that the Spanish flu would keep
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April 7, 2021 In his book, Why Not the Best, Georgia governor and presidential candidate James Earl (“Jimmy”) Carter, Jr. described an incident involving “the father of the nuclear navy”—Captain Hyman Rickover—who would later become a four-star admiral and the longest serving member of the U.S. armed forces in history.
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April 2, 2021 The Centers for Medicare and Medicaid Services (CMS) released a Medicare Learning Network (MLN) article on April 1 concerning the Advanced and Accelerated Payment Program (AAPP). As our readers will recall, this was one of several programs the federal government made available to medical providers who were
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March 31, 2021 We’re being bombarded. The assault comes not in the form of laser-guided missiles or long-range howitzers, but rather in wave after wave of never-ending information. We can’t get away from it, and the reason is clear. It is our inability to disconnect from an array of electronic
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March 24, 2021 In a song released in 2009, celebrated lyricist Bob Dylan used the repeated refrain, “I feel a change comin’ on.” In an earlier era, the late great Sam Cooke assured us that “a change is gonna come.” These remarkable musicians knew that, despite the present situation and
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March 17, 2021 Safety first—that’s the mantra of many institutions and factories and organizations across the country. Wear your hardhat and your harness. Bend at the knees and put on your goggles. Follow the safety guidelines even if it creates a little inconvenience in the short term. After all, it’s
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March 10, 2021 Over the weekend, the United States Senate narrowly passed a revised version of the American Rescue Plan Act (ARPA) that had been previously passed by the House of Representatives. The measure, which provides some $1.9 trillion in federal funding, will now go back to the House for
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March 3, 2021 You’re taking a shortcut through the woods on your way home. All of a sudden you get that uneasy feeling that you’re being watched. Here’s another scenario: you’re sitting at your desk in relative seclusion, going busily about your work, when you get the sense that someone
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February 24, 2021 It’s been a little over a year since the first COVID-19 case was treated in an American hospital. Since that time, we have witnessed one of the most remarkable societal transformations to occur in peace time. Millions of people have masked up and thousands of businesses have
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February 16, 2021 MiraMed Global Services (MiraMed) is pleased to announce the release of the winter issue of Focus, MiraMed’s healthcare journal. We have assembled some of the best and brightest subject matter experts in the field of healthcare and hospitals within this issue. We are proud of this group
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February 18, 2021 While a few astrophysicists have calculated the near impossibility of intelligent life developing elsewhere in the galaxy, there is a growing number of scientists and astronomers who are nevertheless accelerating their search for extraterrestrials. From the efforts of SETI in the 60s to the Voyager missions that
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February 10, 2021 Imagine you had a time machine that allowed you to travel back to the days when knights actually wore armor and damsels were occasionally in distress. In this era, you might eventually happen across a massive fortress-like structure, fortified in stone and surrounded by water. You immediately
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February 3, 2021 Do you remember when rules were set in stone? No matter what the extenuating circumstances or the reasonable excuses, the rules were the rules and they were to be followed without exception. Well, that hardnosed notion has become a bit mushy as of late, what with all
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January 27, 2021 Back in the Carter administration, there was an attempt at arresting the growing cost of government by implementing a methodology known as “zero-based budgeting.” The idea was to prohibit the long-standing practice of simply adding a set percentage increase to the previous year’s budget to reflect the
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January 13, 2021 Have you ever tried to clean out a clothes closet? Depending on the number of shoes and sweaters and other unwanted wear lining the shelves, it can be a daunting task. Similarly, governments will occasionally attempt to tidy up their burgeoning law codes or over-stuffed sets of
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January 20, 2021 Think back to high school or college and the stresses you were under to complete an assigned report before the submission due date. A topic had to be selected, the research had to be performed, and then the actual writing process had to begin. The time and
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January 06, 2021 One of the first tasks of a clinician or healthcare facility when encountering a patient is to determine a diagnosis and course of treatment. Where and how will this determination be made, and by whom? With the recent promotion and extension of virtual medicine, including telehealth services,
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December 30, 2020 While millions of Americans have been stuffing wrapping paper and ribbons in the trash or heading to the store to return or exchange unwanted gifts, the federal government has delivered one more present to the American healthcare industry.  This package comes in the form of the Consolidated
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December 16, 2020 As we head toward the end of another year, there are the obligatory “year in review” offerings provided via television, print media and websites.  Some might argue that there are years we’d just as soon forget—2020 perhaps being one of them.  However, end-of-the-year stories aren’t always about