CMS-10079 comments #7 thru #9

American Hospital
Association

325 Seventh Street. NW
Washington, DC 20004-2802
(202) 638-1 100 Phone
www.aha.org

April 3,2007

Bonnie L. Harkless
Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development-C
7500 Security Boulevard, Room C4-26-05
Baltimore. MD 2 1244 - 1850

RE: CMS-I0079 (OMB#: 0938-0907); Hospital Wage Index Occupational Mix Survey and
Supporting Regulations in 42 CFR 412.64, February 2,2007
Dear Ms. Harkless:
On behalf of our nearly 5,000 member hospitals, health systems and other health care
organizations, and our 37,000 individual members, the American Hospital Association (AHA)
appreciates this opportunity to comment on the Centers for Medicare & Medicaid Services'
(CMS) proposed revision of the occupational mix survey, published in the February 2 Federal
Register.
The Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
requires the Secretary to collect data every three years on the occupational mix of hospital
employees for each short-term, acute-care hospital participating in the Medicare program in
order to construct an occupational mix adjustment to the inpatient area wage index. This
adjustment controls for the effect of hospitals' employment choices - such as the use of
registered nurses (RNs) versus licensed practical nurses (LPNs) - rather than geographic
differences in the costs of labor.
We appreciate CMS' efforts to further streamline and refine the survey and its instructions. Our
detailed comments are provided below.

NEW2007 COLLECTION
PERIOD
The proposal would extend the collection period from six months to one year and would cover
pay periods ending between July 1, 2007 and June 30,2008. Data would be due 60 days later on
September 1, 2008.

Bonnie L. Harkless
April 3,2007
Page 2 of 5
The AHA appreciates the change to include pay periods ending within a date range rather than
pay periods beginning and ending within a date range, which will be less confusing for hospitals.
We also are fully supportive of a one-year collection period to ensure that the data is not skewed
as a result of seasonal fluctuations in patient volume and employment.
In addition, we support the chosen time frame. While we believe that 90 days would be a more
appropriate time frame in which to compile the data, we understand that CMS only can afford 60
days in order to integrate the data for this collection into the wage index review process.
However, we urge CMS to undertake the next data collection early enough to allow hospitals 90
days in the future.

CATEGORIES
FOR 2007 COLLECTION
CMS proposes eliminating the collection of the management personnel and staff nurselclinician
subcategories from the RN category. The AHA believes that this change is appropriate because
the subcategories had a very minor affect on the adjustment and added additional work for
hospitals.
CMS also would add surgical technologists to the LPN category, as they perform similar
functions and sometimes substitute for nurses. We believe that this addition is warranted
because there was substantial confusion regarding the placement of surgical technologists during
the last collection. Surgical technologists represent 1.21 percent of hospitals employees, per the
Bureau of Labor Statistics (BLS) data for General Medical and Surgical Hospitals as of May
2005, and 4.25 percent according to data from 20 of our member hospitals.' In addition, the BLS
data show that the mean hourly wage rate for surgical technologists is $16.96 versus $16.65 for
LPNs. Thus, we believe combining the two categories is reasonable given their prevalence,
similar functions and wages.
Finally, CMS would clarify that paramedics who are employed by the hospital and work in the
emergency department, and unit secretaries, or "ward clerks," should be included in the "all
other" category since they do not appropriately fit under the other existing definitions associated
with this collection. While the AHA agrees that paramedics should be included in the "all other"
category, we believe that it is more appropriate to include unit secretaries in the nursing
category. Even though unit secretaries do not directly provide clinical care, they serve a function
that frees up the nursing staff to do other duties, just as medical assistants (MAS) do in clinics.
Unit secretaries are not simply office staff; they work on the floor with nurses and complete tasks
such as charting, transporting patients, completing laboratoryldietary slips, stocking patient
supplies, census taking, etc. A job description can be found on the Dictionary of Occupational
The DOT listings are
Titles (DOT) Web site at www.occupationalinfo.or~241245362014.html.

'

This sample includes hospitals fiom four states and only includes staff fiom the cost centers specified by CMS in
the 2006 collection instructions.

Bonnie L. Harkless
April 3,2007
Page 3 of 5
used by several federal agencies, large companies, universities and hospitals, as described on the
DOT main Web page. Attachment I contains a description of the training that unit secretaries go
through under the MT. Hood curriculum. Notice that it is not all administrative - they also must
take classes on anatomy and physiology, psychology, medical terminology, disease processes,
etc. In addition, the cost center limitations should limit these positions to clerical support in the
actual nursing departments and not general administrative staff.
This type of personnel is common in hospitals nationwide. The listing on the job Web site
http://~~~.indeed.corn/q-Unit-Secretary-jobs.html
shows the prevalence of unit secretaries.
In our sample of 20 hospitals, unit secretaries represent 5.1 percent of nursing staff, and all
hospitals had hours in this category. We also looked at the summary information from BLS,
which shows that the "Healthcare Support Workers, All Other" category - which we believe
likely captures unit secretaries - has one-and-a-half times as many hours as MAS. See the table
below.
SOC
Code
Number

Category

Hours

% of
Entire
Hospital

% of
Nursing

29-11 11

RN

1,354,020

28.05%

65.13%

29-206 1

LPN

171,270

3.55%

8.24%

31-1012

Nursing Aides, Orderlies, and Attendants

377,080

7.81%

18.14%

3 1-9092

Medical Assistants

0.98%

2.29%

29-2055

Surgical Technologists

1.21%

2.80%

3 1-9099

Healthcare Support Workers, All Other

1.47%

3.40%

Total Nursing with New Categories

I

Total All Employees

4,826,410

MAS are more common in physician offices and clinics, where they are more likely to be crosstrained in other areas like phlebotomy. Unit secretaries do less clinical work than MAS because
of their location. However, their function is generally the same: to relieve the nursing staff of
simpler and more administrative tasks. We believe that unit secretaries should be included in the
same category as MAS, as they are more prevalent, paid similarly and serve a similar function.
Ultimately, using unit secretaries to free up RNs and other staff lowers the overall hospital
average hourly rate, just like using more nursing aides. We provide an example in Attachment

I

Bonnie L. Harkless
April 3,2007
Page 4 of 5
11, which demonstrates that the exclusion of even a relatively small number of unit secretaries
would have a significant impact on a hospital's occupational mix adjustment. The example,
based on our 20 hospital survey, shows that counting unit secretaries in the "all other" category
would lower a hospital's occupational mix adjusted salaries by 1.1 percent. Hospitals that use
this type of staff to lower costs and be more efficient will be penalized.

EMPLOYEES
TO INCLUDE IN THE COLLECTION
CMS would further clarify which nursing personnel to include in the "all other" category. In
particular, we appreciate the alteration of the wording on the survey instructions in the second
paragraph that previously suggested that the cost centers were only a "general rule," but now
clearly restricts the collection to "only7' these cost centers. The AHA also is supportive of the
inclusion of the following cost centers: 53 (Electrocardiology), 58 (Ambulatory Surgical Center
(Non-Distinct Part)) and 59 (Other Ancillary). However, we have some additional suggestions.
We surveyed the 20 hospitals previously noted to measure how well the existing cost center
definitions captured traditional nursing personnel. An internal skill mix indicator for "Registered
Nurses-Direct Patient Care" served as a proxy for this review. For the 20 combined hospitals,
the existing categories accounted for 93.6 percent of traditional nursing personnel, ranging from
83.7 percent to 98.9 percent from hospital to hospital. Only one hospital's percentage was below
89.1 percent.
If the four cost centers mentioned above are added to the survey, the categories would then
account for at least 96.9 percent of traditional nursing personnel in the sample hospitals. The
percentages by hospital would range from 93.9 percent to 99.6 percent. This demonstrates that
the cost centers chosen by CMS for the previous survey captured the vast majority of nursing
personnel. Any additions should be restricted to areas of the hospital with a high percentage of
nursing personnel, whose exclusion may unfairly advantage some hospitals.
Line 53 Electrocardiolo~- Based on a review of a sample of hospitals, the largest single
concentration of direct patient care RNs that were not included in the survey was in cardiac
catheterization laboratories. These laboratories can be subscripted under Line 53 or 59. Because
of the typically high percentage of traditional nursing staff working in these laboratories, we
believe that this cost center should be captured in the survey.
Line 58 ASC (Non-Distinct Part) - This cost center includes the cost and staffing information for
outpatient surgeries paid under the outpatient prospective payment system and is included in
Worksheet S-3 on the cost report that is utilized to calculate the wage index. These are not the
ambulatory surgical centers, which are paid under their own fee schedule (please note: cost
center 92, Ambulatory Surgery Center (Distinct Part), should not be included since it is excluded
from the S-3 wage index information utilized to calculate the wage index). Since the operating

Bonnie L. Harkless
April 3,2007
Page 5 of 5
room and recovery room cost centers are already included in the cost center listing, it would be
inconsistent to exclude this cost center.
Line 59 Other Ancillary - This cost center should be included since many areas within it are
subscripted cost centers with high use of nursing staff, such as cardiac catheterization
laboratories, cardiac rehabilitation and endoscopy. However, CMS should consider specifying
only these two subscripted lines within this cost center to avoid collection of other scattered
outpatient ancillary services that are not necessarily provided broadly across hospitals and do not
necessarily have high nursing usage.
Line 57 Renal Dialysis - While this cost center was not recommended by CMS, we believe it
should be considered given the high utilization of traditional nursing staff in this area.
Other lines considered - The AHA does not support the inclusion of X-Ray line 41 because
imaging has a fairly low percentage of RNs compared to the overall cost centers (6 percent in our
sample), and because adding line 41 would likely require lines 42 and 43 as well. Nor, do we
recommend that Social Services be added to the survey unless a new Social Worker category is
added. Much of the staffing in this area can be accomplished with either RNs or Social Workers.
Therefore, reporting only RN staffing would overstate hospitals' RN percentages, which could
result in adverse occupational mix adjustments in areas where Social Services are staffed by a
higher percentage of RNs. Our sample indicated that greater than 5 1 percent of staffing in these
areas are not RNs. Seven of the sample hospitals showed no RN staffing, while five hospitals
showed 100 percent RN staffing.

If you have any questions, please contact me or Danielle Lloyd, senior associate director for
policy, at (202) 626-2340 or [email protected].

k Pollack
~f ecutive Vice President
Attachments

Attachment I

Catalog Year 2006-07
MHCC Faculty Advisor:
Carole Wickham: 503-49 1-7195 - Room AC 2772 [email protected]
A Medical Office Specialist as a Unit Secretary finctions as the center of the communications
hub found in a hospital unit. S h e works in a dynamic medical setting with physicians, nurses,
and other healthcare professionals. Desirable traits of a Unit Secretary include strong
communication skills, flexibility, professionalism, and responsibility. Students should have
typing competency and basic formatting knowledge before enrolling in classes in this program.
Upon graduation, students may be hired to work in physicians' offices, public and private
hospitals, teaching hospitals, clinics, laboratories, insurance companies, and governmental
facilities.
Please check the MHCC website for any curricular changes that have occurred since the catalog
was published.

I

1 First Quarter (Fall)
Powerful Strategies for the Office Team
Medical Terminology I

/ Survey of Body Systems

!BI~OO

-,

rgffi

I-- ... ...
1 ~

Business Tools and Techniques
.

,,

~

..

~

-.-

...-.-

.-

6I1 Beginning
5
Algebra I1 (or

Second Quarter (Winter)

~ 0 2 5

1 Medical Terminology I1
1 Introduction to Medical Transcription
1 Medical Office Procedures

hi1

( Introduction to Business Computing

1~015

.

1~024

-I

Cr

-4

3
I
4
7
3

r
1
I

I
7
7
'

17

3

T
4

-r?

1-1

English Composition1

r

3

I Third Quarter (Spring)
Diversity and Healthcare
I

1-i ~ 0 2 7

( Hospital Administrative Procedures
Medical Transcription I

1~034

Health and Fitness for Life

I

4

7
3

Introduction to Intercultural Communication
or SP 100 Basic Speech Communication

kourth Quarter (Fall)

I

r---

Medical Coding I - ICD-9-CM
Medical Transcription I1

I

3

I

3

Business Communications
Essentials of Human Anatomy and
Physiology I'
BTllO

Business Editing

1 Fifth Quarter (Winter)
1I- ~

~

2

IMedical
4
Law and Ethics
1 Medical Coding I1 - Procedural Coding

--- -

r

4

Essentials of Human Anatomy and
Physiology I1
Records Management with Microsoft Access
Electronic Calculator and 10-Key Operations

) Sixth Quarter (Spring)

T

I

3

1

I

Pharmacology for Medical Office
Occupations

/~

~

2

/ Disease
5
Processes

I r - / Building a Professional Portfolio

I

3

m

I
I -B- I

PSY201

General Psychology or PSY 101 Psychology
of Human Relations
Cooperative Education Internship

3

4

1 Prerequisite. See course description in back of catalog.
2 Students may not use demonstrated proficiency on the College Placement Test (CPT) to satisfy
this requirement.

$ See pages 7-1 0 of the printed catalog.
The student must document initiation of the three dose Hepatitis B vaccine series, the second
dose of measles immunization, and current Tuberculin skin test (PPD) by the first week of
classes.
Note: A minimum grade of "C" grade is required in all courses.

Attachment I1

lmpact of Unit Secretaries on the Occupational Mix Adjusted Average Hourly Rate
Average Hourly Rate 5% Unit Secretaries included in the Medical Assistant Category
Average Hourly Rate Unit Secretaries included in the All Other Category
Impact
% Impact

Spreadsheet for Proposed FY 2007 Calculation of Provider Occupational Mix AHW
Fields in
are filled in by the provider f r m the prov~detsoccupational mix spreadsheet
FielQ in BLUE are filled in from IPPS wage index Web Site or Federal Registers (these are the same in the proposed and final rules)
Fields in BOLD are calculatedfields--DO NOT ENTER any information here

Name
X Change

Total Nurse Hours
ALLOTHER (Including Unit Secretaries)
TOTAL

m , ~$MI@
3%?@
Based on final 2007 wage data

Hours (From S3, Parts II and Ill)
Unadjusted AHW
Nurse Occ Mix Wages
All Other unadjusted Occ Mix Wages
Total Occ Mix Wages

%2w@
$31.88
$19,088,730)step 7
$20,868,671 ste 7
$39,957,401 step 8

Final Occ Mix Adjusted AHW
(1) Per page 59887 of the October 11,2006 Federal Registel

i-t

I

-0.10%

$32.20
$0.35

1.1%

Provider Number
Flt
Occ Mix Besin Date
Occ Mlx ~ n Date
d

Name
% Change

RN Mngt
RN Staff
LPNs
Nurse Aides
Medical Assistants (t Unit Secretaries)
Total Nurse Hours

149.071

0.98%

2.07%
69.77%
0.58%
16.97%
10.61%
100.00%

4,672,352

ALLOTHER
TOTAL

Wages (From S3, Parts IIand Ill)
Hours (From S3, Parts IIand Ill)
UnadjustedAHW

$39,99&$4$ Based on initial 2008 PLlF dated 1 W 0 6

Nurse Occ Mix Wages
All Other unadjusted Occ Mix Wages
Total Occ Mix Wages

$19,961,465 step 7
$20,429,745 step 7
$40,391,210 step 8

Final Occ Mix Adjusted AHW

,=wt

1

$31.88

R

$32.201steP 8

I

$38.59080
$33.37390
$19.27210
$13.69060
$15.63040

$0.80
$23.28
$0.11
$2.32
$1.66
$28.1 8

+

$28.7431

1.M01

48.92%

Federation of

PROVEN LEADERSHIP
1 9 6 6

-

April 2,2007

Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development-C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Boulevard
Baltimore, MD 2 1244 - 1850
RE: CMS-10079 (OMB#: 0938-0907); Hospital Wage Index Occupational Mix Survey
and Supporting Regulations

Dear Ms. Harkless:
Enclosed is an amended version of the comments on the occupational mix survey that we
sent to you on Friday, March 3oth. This amended version includes an attachment that is
referenced on page 2 of the comments, but which was inadvertently omitted from the
comment letter filed on March 3oth.
Thank you for your consideration. If you have any question, I can be reached at 202-6241529 or sspeil(i3fah.org.
Sincerely,

Steven Speil
Senior Vice President, Health, Finance
and Policy
Enclosure

80 I Pennsylvania Ave., NW, Suite 245 Washington, DC 20004-2604 202-624- 1500 Fax: 202-737-6832
-

2 0 0 6

Detailed Occupational Mix Calcs

lmpact of Unit Secretaries on the Occupational Mix Adjusted Average Hourly Rate
Average Hourly Rate 5% Unit Secretaries included in the Medical Assistant Category
Average Hourly Rate Unit Secretaries included in the All Other Category
Impact
% Impact

Page 1

$32.20
$31.85
$0.35

1.1%

MHV P a l s n ! ~x!R
~ 330 leu!3

ZOP 186866'0
1

S

8

~

L

C

$

MHV papn!~eun
(II pue 11 sued 'E-s~ 0 ~~ 3J )~ O H
(111pue IIsued 'E-s~ 0 ~s 3a s) e ~
FOdW W W

88'LE$

elep a6em LOOZ leu!j uo pesea

%C8'LP

L8L66.0

&w@a

~~

L dals u!

4

08.8Z$
96'09
wZ$
zL.0~
SP'PZ$
PSm0$

(bl M ~ R I

MHY
lbuOUoN, P@@W
r~d30~eun~
*wad

LW&

xq

LEPL'8Z$

-@If

I

9 dais

I

s dais

I

E dais

OPOE9'S C$
09069'E C$
0 CZLZ'6 C$
O6ELE'EW
0806S'8€$

%OOO
' OL
%PL'9
%ZO'LC
% C9'0
%9t'EL
%LL'Z

s ~ n awn^
o ~ leg01

6PG8L9S'P

s)uep!ssv l e a ! p a ~
Sap!v eSJnN
SNdl
~ e~ lt l ~
l6uR Ntl

bl

unowwy~300 MPWW

~
0 XQ AP % aePl
~ rrrO?ld ~
~ L ~ U O P P H

I

z dais

I

c dais

I

8

* '
::,+ggb;;:%-k,
" ~ 1 ;
:
~ $)
7 ~. ;
.
*$
&:@; p 5.p.

@%re

,.&&

3-

ales pu3 X!HI 330
ales u!6ag x ! mo
~
# I3
JeqUJnNJap!AOJd

.
,

U~Yl,rWRW&

rOo6ala3 l a q l o 1 1 a~q l lapun papnlau! sayela~aagl!un %p ~ J ! Maldurexa
a w uo!leu~o4u!Aue ~ 3 1 IO~
N 3o a - s ~ l a upaleln3lm aJe a108 u! sPla!j
(salru leu4 pue pasodo~daql u! aues aq) aJe asaq)) aa)s!6at) IeJapaj JO aI!S qaM xapu! a6em sddl UOJJ u! pall4 aJe 3 n i g u! spla!j
~aaqspea~ds
x!u leuo!)ednm S J ~ P ! A aq)
W ~UOJJ ~ a p ! ~ o
aq)
~A
dq u! pallu aJe
u! spla!j

MHV x!w leuo!jedn390 Jep!AoJd j o uo!jelnsle3 LOOZ AJ pasodold ~ ojaaqspea~dg
j

Detailed Occupational Mix Calcs

Spreadsheet for Proposed FY 2007 Calculation of Provider Occupational Mix AHW
are filled in by the provider from the provider's occupational mix spreadsheet
Fields in
Fields in BLUE are filled in from IPPS wage index Web Site or Federal Registers (these are the same in the proposed and final rules)
Fields in BOLD are calculated fields-DO NOT ENTER any information here

Examnle with 5% Unit Secretaries included under the Medical Assistant Cateaow
,
,.
Provider Number
FI #
Occ Mix Begin Date
Occ Mix End Date

'

Name
% Change

I
.

Provlder Occ

. ,.
'

I

step I

step 2

..

I

. .
i

..

~bHoun

Salaries

RN Mngt
RN Staff
LPNs
Nurse Aides
Medical Assistants (+ Unit Secretaries)
Total Nurse Hours

149.071

4,672,352

Wages (From S-3, Parts IIand Ill)
Hours (From S-3, Parts IIand Ill)
Unadjusted AHW

,

_- ,

2.07%
69.77%
0.58%
16.97%
10.61%
100.00%

Based on initial 2008 PUF dated 1016106

%3wms

:

$31.88

Nurse Occ Mix Wages
All Other unadjusted Occ Mix Wages
Total Occ Mix Wages
Final Occ Mix Adjusted AHW

$32.201step 8

.. .

..
.
.,

I

,'

step 3
.,

Pri,vlUai% b i ~atlonll
v l ~ e '
8ubmtegory by 8ubollteggry

ALLOTHER
TOTAL

W$ga Data fmm Colt Report

I

0.98%

1

Page 3

$38.59080
$33.37390
$19.27210
$1 3.69060
$1 5.63040

.,

> .. .,

.,:,.i

1
., -,

-

step 5

I

$0.80
$23.28
$0.1 I
$2.32
$1.66
$28.1 8

t

I

in step 7
:

'<~dl~
Nu
#m
il
,,

step 6

,

AHW

$28.7431

Uun,~Anlx
MJUrtmeirt
Factor

1.0201

s .

PfwldotYby
Total

48.92%

1

I PROVEN LEADERSHIP

Federation of

American
Hospitalsa
Charles N. Kahn I11
President

March 30,2007

Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development--C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Boulevard
Baltimore, MD 2 1244 - 1850

RE: CMS-10079 (OMB#: 0938-0907); Hospital Wage Index Occupational Mix Survey
and Supporting Regulations
Dear Ms. Harkless:
The Federation of American Hospitals ("FAH") is the national representative of
investor-owned or managed community hospitals and health systems throughout the
United States. Ow members include teaching and non-teaching hospitals in urban and
rural parts of the United States. We appreciate the opportunity to comment on the
Centers for Medicare and Medicaid Services' ("CMS") Occupational Mix Survey.
The FAH wishes to express its appreciation to CMS for working with the various
stakeholders to gather and incorporate suggestions on how the survey and process could
be improved in order to develop a more accurate occupational mix adjustment. FAH is
very pleased to note that CMS's efforts developing the proposed changes have
significantly improved the survey.
Some of the key points that we support in the proposed survey include:
Full year collection period, eliminating concerns about seasonal fluctuations
Survey timing, which will allow for sufficient review during the normal wage
index review process

801 Pennsylvania Ave., NW, Suite 245 Washington, DC 20004-2604 202-624-1500 Fax: 202-737-6832

(

Also enclosed, is a description of the types of training a unit secretary, or medical
office specialist as they are sometimes called, typically undertakes to earn a degree in this
field. You will notice that a significant component falls far outside the realm of
administrative tasks and is directed to building a core body of medical and clinical
knowledge that clearly distinguishes this class of personnel from routine administrative
support staff, and that enables them to perform the most important part of their jobfacilitating the efficient delivery of direct patient quality care. In addition, the cost center
limitations on the survey will limit inclusion of these positions to clerical support in the
actual nursing departments and not general administrative staff.
This type of personnel is common in hospitals nationwide. An examination of the
listings on the job website found at http://www.indeed.corn/q-Unit-Secretarv-iobs.html
indicates the prevalence of unit secretaries.
Currently, Medical Assistants are included in the "nursing" categories on the
survey, while Unit Secretaries are not. Medical Assistants are more common in
physician offices and clinics, where they are more likely to be cross-trained in something
like phlebotomy. In a hospital, phlebotomists usually come from the lab, so it is not
necessary to do the same sort of cross-training. Thus, the Unit Secretaries generally do
less clinical work than Medical Assistants because of their location on hospital inpatient
floors, rather than in clinics or physician offices. However, their function is otherwise
generally the same: to relieve the other nursing staff of simpler and more administrative
tasks. It should also be noted that over 56% of the hospitals reported no Medical
Assistant hours on the 1" and 2ndquarter 2006 occupational mix survey. As Unit
Secretaries are more prevalent, are paid similarly and serve a similar function as
Medical Assistants, we believe Unit Secretaries should be included in the category
with medical assistants.
Should CMS decide not to include Unit Secretaries among the nursing categories,
we would strongly encourage the elimination of the Medical Assistant category. As
stated above, many of their job functions are very similar to Unit Secretaries. In addition,
the Unit Secretary position is far more common in hospitals as reflected in the BLS data
and by the fact that the majority of hospitals reported no Medical Assistant hours in their
lStand 2ndquarters 2006 occupational mix data.
We believe the inclusion of both Medical Assistants and Unit Secretaries will
address the apparent inconsistencies in reporting. We believe the alternative of excluding
both Medical Assistants and Unit Secretaries would also reduce this inconsistency.
We understand that CMS may have concerns about including Unit Secretaries,
since they do not, for the most part, provide hands-on patient care or clinical care. The
decision to limit the survey to positions that provide direct clinical care was a decision
that CMS made with the initial occupational mix survey. The FAH supported this
decision because we believed the survey process should begin with traditional nursing
areas. The FAH believes that CMS's decision to limit personnel in the nursing categories

?$I7
to specific cost centers resolves this concern. As shown above, we believe that inclusion
of unit Secretaries in the nursing categories (i.e., within the Medical Assistant category)
will significantly improve the accuracy of the Occupational Mix Adjustment. Should
CMS determine that Unit Secretaries do not meet the current criteria of providing clinical
care the FAH would encourage CMS to amend its decision in this limited instance in
order to include Unit Secretaries within the Medical Assistant category in light of their
substantially similar contributions to increasing efficiency in the direct delivery of patient
care.
Below are some of our detailed comments and suggestions on the other issues
regarding the survey.
Collection Period
The FAH strongly supports CMS decisions related to the collection period and
pay periods to be included in the specifications. The collection period from July 1,2007
and June 30,2008 will eliminate our concerns related to seasonality. In addition, this
timing will allow the occupational mix data to go through the same review and
developmental process as normal wage index data prior to being implemented. In
addition, the specification that the survey will include pay periods ending from July 1,
2007 to June 30,2008 will greatly simplify hospital efforts to accumulate the data.
Home Office and Related Party
The FAH strongly supports the CMS position that Home Office and Related
Organization hours and salaries should be reported on the survey. Failure to consider
Home Office and Related Organization hours and salaries would overstate the general
service categories' percentage of the total and therefore overstate the entire occupational
mix adjustment for providers. Over 50% of the hospitals have reported 292,923,2 1 1
home office hours in the latest PLF for 2008.
Use of Cost Centers to Determine Personnel to Be Included in Nursing Categories
The FAH strongly supports the CMS decision to require that only nursing
personnel working in specific cost center be reported in the various nursing categories.
This allows hospitals to focus their review efforts on nursing departments and increases
the consistency between hospitals. Further, the FAH supports the addition of the 3
specified cost centers -53, 58 and 59 -- that CMS has proposed on the occupational mix
survey. We would suggest one addition and some additional parameters be added to one
cost center.
We reviewed detailed information for 20 hospitals in four states to measure how
well the existing cost center definitions were capturing traditional nursing personnel. An
internal skill mix indicator for Registered Nurses-Direct Patient Care served as a proxy
for this review. For the 20 combined hospitals, we noted that the existing cost centers
managed to account for 93.6 percent of traditional nursing personnel, ranging from 83.7

4; $'Y
percent to 98.9 percent from hospital to hospital. Only one hospital's percentage was
below 89.1 percent.
If the three cost centers mentioned above are added to the survey, the categories
would then account for at least 96.9 percent of traditional nursing personnel in the sample
hospitals. The percentages by hospital range from 93.9 percent to 99.6 percent. This
demonstrates that the cost centers chosen by CMS for the previous survey captured the
vast majority of nursing personnel. Any additions should be restricted to areas of the
hospital with a high percentage of nursing personnel whose exclusion may unfairly
advantage or disadvantage some hospitals.
Line 53 Electrocardiolo~- Based on a review of a sample of hospitals, the largest single
concentration of direct patient care RNs that were not included in the survey was in
cardiac catheter labs. These labs can be subscripted under Line 53 or 59. Because of the
typically high percentage of traditional nursing staff working in these labs, we believe
this cost center should be captured in the survey.
Line 58 ASC (Won-Distinct Part) - This cost center includes the cost and staffing
information for outpatient surgeries paid under the outpatient PPS and is included in
Worksheet S-3 on the cost report that is utilized to calculate the wage index. These are
not Ambulatory Surgical Centers that are paid under their own fee schedule (Please note:
cost center 92 Ambulatory Surgery Center (Distinct Part) should not be included since it
is excluded from the S-3 wage index information utilized to calculate the wage index).
Since the operating room and recovery room cost centers are already included in the cost
center listing, it would be inconsistent to exclude this cost center.
Line 59 Other Ancillaw - This cost center should be included since many areas within it
are subscripted cost centers with high usage of nursing staff such as cardiac catheter labs,
cardiac rehabilitation and endoscopy. However, a review of HCRIS data indicates that
many and various types of services can be subscripted under this cost report center. We
recommend that CMS specify the services that should be included under this cost center
to ensure consistency between hospitals. Inclusion or exclusion of all cost centers
subscripted under this cost center will lead to inconsistency. We would recommend that
the following areas be included:

Operating Room
Endoscopy
Recovery Room
ASC
Delivery Room & Labor Room
Birthing Center
Electrocardiology
EKG and EEG
Electromyography
Cardiopulmonary
Stress Test

Cardiology
Holter Monitor
Cardiac Catheterization Laboratory
Inpatient Routine Areas
Clinics
We believe that Cardiac Catheterization Laboratories and Endoscopy are the two
biggest areas of concern. All of these areas would generally fall under the existing Cost
Center lines if they were not subscripted.
Line 57 Renal Dialvsis - While this cost center was not recommended by CMS, we
believe it should be considered given the high utilization of traditional nursing staff in
this area.
Other lines considered - The FAH does not support the inclusion of X-Ray, line 4.1,
because imaging has a fairly low percentage of RNs to the overall cost centers (6 percent
in our sample) and because adding line 41 would likely require lines 42 and 43 as well.
Nor do we recommend that Social Services be added to the survey, unless a new Social
Worker category is added. Much of the staffing in this area can be accomplished with
either RNs or Social Workers. Therefore, reporting only RN staffing would overstate
hospitals' RN percentages and could result in adverse occupational mix adjustments in
areas where Social Services are staffed by a higher percentage of RNs. Our overall
sample indicated that greater than 5 1 percent of staffing in these areas is not RNs. Seven
of the sample hospitals showed no RN staffing, while five hospitals showed 100 percent
RN staffing.

We also have a concern about the wording on the first sentence on page 3 of the
occupational mix survey document. The sentence states the following: "Only nursing
personnel working in the following cost centers as used for Medicare cost reporting
purposes may be incIuded in the appropriate nursing subcategory". We are concerned
that the word "may" could be interpreted by providers that this requirement is optional.
We feel that all nursing personnel that fa11 within the nursing subcategories on the survey
should be reported. The FAH recommends the sentence be changed to "Nursing
personnel working in thefollowing cost centers as used for Medicare cost reporting
purposes must be included in the appropriate nursing subcategory".
Suwey Categories

Surgical Technologist
The FAH strongly supports the CMS decision to add Surgical Technologist to the
LPN category of the survey. This position represents 1.21% of total hospital employees
per the May 2005 summary information from the Bureau of Labor Statistics (BLS) for
General Medical and Surgical Hospitals. This is significantly higher that the .99% for
Medical Assistants. In addition, combining LPN and Surgical Technologist makes sense
since their pay level is very simiIar. The May 2005 BLS information indicated the mean

hourly rate for Surgical Technologists (SOC Code Number 29-2055) is $16.96 versus
$16.65 for LPNs (SOC Code Number 29-2061).
Unit Secretaries
The FAH has significant concerns related to not including Unit Secretaries in the
occupational mix survey that we have covered previously in this comment letter.
RN Category Consolidation
The FAH supports CMS's decision to consolidate the two RN categories into a
single category. However, we feel there will be confusion on where RNs with some
management responsibility should go. We would recommend that CMS clarify the RN
definition to include RN managers in the consolidated RN category.
All Other

.

The FAH supports CMS in its decision to include paramedics, phlebotomists,
information technology personnel and general business office personnel in a all other
category on the survey
Advance Practice Nurses
The FAH has concerns about how Advanced Practice Nurses (APNs) are to be
treated on the survey. Some hospitals may utilize APNs in nursing areas where their job
function will not support billing Part B. It is our understanding in this situation that they
would be included in the S-3 data utilized in wage index development. We feel they
should be excluded from the survey if they are excluded from the S-3 data due to billing
for their services to the Part B carrier, but they should be included if they are in a nursing
cost center and are included in the S-3 data. We recommend that CMS specifically state
this on the survey form.

The FAH appreciates CMS's review and careful consideration of the comments in
this letter, and we would be happy to meet, at your convenience, to discuss them. If you
have any questions, please feel free to contact Steve Speil, SVP at (202) 624-1529.
Respectfully submitted,

cc:

Valerie A. Miller, CMS
Job Description Enclosure

10$ lY

Source: Dictionary of Occupational Titles

CODE: 245.362-014

Buy the IlOT:DownIoad/CD-ROM

TITLE(s): UNIT CLERK (medical ser.) alternate titles: health unit clerk; ward clerk
Prepares and compiles records in nursing unit of hospital or medical facility: Records
name of patient, address, and name of attending physician to prepare medical records on
new patients. Copies information, such as patient's temperature, pulse rate, and
blood pressure from nurses' records onto patient's medical records. Records
information, such as physicians' orders and instructions, dietary requirements, and
medication information, on patient charts and medical records. Keeps file of medical
records on patients in unit. Prepares notice of patient's discharge to inform business
office. Requisitions supplies designated by nursing staff. Answers telephone and
intercom calls and provides information or relays messages to patients and medical staff.
Directs visitors to patients' rooms. Distributes mail, newspapers, and flowers to patients.
Compiles census of patients. May keep record of absences and hours worked by unit
personnel. May transport patients in wheelchair or conveyance to locations within
facility. May key patient information into computer.
GOE: 07.05.03 STRENGTH: L GED: R3 M3 L 3 SVP: 3 DLU: 87
ONET CROSSWALK: 55347 General Office Clerks

Enclsoure - description of the types of training the unit secretaries go through
MT. Hood
Medical Office Specialist - Unit Secretary
(Associate of Applied Science Degree Program)

Catalog Year 2006-07
MHCC Faculty Advisor:
Carole Wickham: 503-491-7195 - Room AC 2772 Carol.Wickham@,mhcc.edu

A Medical Office Specialist as a Unit Secretary functions as the center of the
communications hub found in a hospital unit. S h e works in a dynamic medical setting
with physicians, nurses, and other healthcare professionals. Desirable traits of a Unit
Secretary include strong communication skills, flexibility, professionalism, and
responsibility. Students should have typing competency and basic formatting knowledge
before enrolling in classes in this program.
Upon graduation, students may be hired to work in physicians' offices, public and private
hospitals, teaching hospitals, clinics, laboratories, insurance companies, and
governmental facilities.
Please check the MHCC website for any cunicular changes that have occurred since the
catalog was published.
..................

...................................

i First Quarter (Fall)
-

--

--

~ 0 1 0

"-

.-........

.

--

"
-

- ...

--- .

Powerful Strategies for the Office Team

..................................

I

- --

.:

Cr

--- -

4

Medical Terminology I1

, WR121

English Composition1

3

;

Third Quarter (Spring)

M 0 12

- --

Diversity and Healthcare

-- - -

"--

M027
-

-

I

-

-

-

-

I

-

3

"-

-

I
-

Medical Transcription I

--

-

-

HPE295
"

--

-

--me

^1

-

-

-

^

I

' Communication

-XI^I

.
.
.
.
--"

-XI^-

"-

.

"

;Medical Coding I - ICD-9-CM
i M036

s

Medical Transcription I1

I

: BA205

-t

Business Communications
Essentials of Human Anatomy and

-.

-"-,-.-,..XI-...*-,

*

--

edical Law and Ethics

--

lectronic Calculator and 10-Key

armacology for Medical Office
Disease Processes

3
"

-.

3
3

or SP 100 Basic Speech

Fourth Quarter (Fall)

r..-" m...--...

-

-

r

i Introduction to Intercultural
I Communication

9

4

L

- * - *

$Healthand Fitness for Life
IXI^-III-XI-*

-

_ - - I

- -

M034

SP115

-

Hospital Administrative Procedures

-

F-"--"--.

--

I

.

.

,

. . . .. .

1 M039

,

,

.

.

.. , . . . ,

.", "

.

.

. . . .. .

. . ,. . .

I

: Building a Professional Portfolio
General Psychology or PSY 101

, Psychology of Human Relations
"

-""

"

-

WE280MOB Cooperative Education Internship

1 Prerequisite. See course description in back of catalog.
2 Students may not use demonstrated proficiency on the College Placement Test (CPT) to
satisfy this requirement.

$ See pages 7-10 of the printed catalog.
The student must document initiation of the three dose Hepatitis B vaccine series, the
second dose of measles immunization, and current Tuberculin skin test (PPD) by the first
week of classes.
Note: A minimum grade of "C" grade is required in all courses.

SISTERS OF MERCY
HEALTH SYSTEM
March 30,2007
Ms. Bonnie L. Harkless
Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Room C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
Attention: CMS-10079
Dear Ms. Harkless:
Sisters of Mercy Health System (Mercy) welcomes this opportunity to comment on the
Centers for Medicare & Medicaid Services' (CMS) proposed revision to the survey
instrument for the occupational mix adjustment entitled "AgencyInformation Collection
Activities: Proposed Collection; Comment Request ", 72 Fed. Reg. No. 22 (February 2,
2007). Mercy is a 19-hospital system operating in Missouri, Kansas, Oklahoma and
Arkansas.
Mercy appreciates CMS's consideration of provider comments and suggestions on the
2008 Occupational Mix Survey (OMS) and their willingness to incorporate into the 2010
Occupational Mix adjustment.
I.

Impact of Registered Nurses (RNs) in the Occupational Mix Adjustment

The financial effect of the Occupational Mix adjustment is in our belief a
contradiction to the effort to promote a higher level of quality care. CMS,
Congress and President Bush are advocating for an increase in quality of care
for patients at all levels. It is reasonable to expect that the quality of care
provided by an RN is superior to the level of care provided by an LPN, CNA,
or any other health care worker with a lower level of expertise, training, and
education. However, the construction of the Occupational Mix adjustment is
such that a facility with a high percentage of RN's receives a negative
financial adjustment. We ask that you take quality initiatives into
consideration and consider a higher percentage of RNs to be a positive

adjustment to the Occupational Mix adjustment as opposed to the current
impact,
11.

Wage Data Reporting Period

Mercy has contended that a full year of retrospective wage data would reduce
or average out peak and slow utilization seasons. Mercy commends CMS for
extending the OMS period to one year.
111.

Advance Practice Nurses (APN)

CMS has not changed the position from the 2006 survey to exclude APNs
from the 2006 OMS. The rationale has been that the services provided by
these employees are billed and paid under a Part B fee schedule and not IPPS .
Mercy agrees with this rationale as long as their services are billed under Part
B. We employ hundreds of APNs throughout our System. The vast majority
of their services are for non-Medicare patients. A significant portion of
managed care plans do not recognize this level of service and therefore we do
not bill. It is not cost efficient for our hospitals to bill, monitor, and collect for
such a small portion of claims. These employees represent a true cost to IPPS .
Mercy believes CMS should reconsider excluding APN wages and hours from
the 2008 OMS.
IV.

Reporting Deadline

CMS proposes that completed 2008 OMS be submitted to fiscal intermediaries
by September 1,2008. Mercy would suggest this deadline be moved to allow
for additional analyses and validation of the data. Compilation and review of
the required data will take the coordination of several departments such as
Human Resources, Payroll, Finance, and Reimbursement. Mercy's fiscal year
end is June 30 - as is many providers - therefore Human Resources and
Finance are working through year-end activity through August. We believe a
more realistic and manageable timetable would be the month ending 90 days
following June 30,2008. Mercy urges CMS to revise the deadline to be
September 30,2008.
V.

Common Review of Wage Index data

Mercy contends that the propriety of all Wage Index data, including the
Occupational Mix adjustment, is of great value to all providers. However, this
data is subject to varying levels of review and interpretation by multiple Fiscal
Intermediaries. As in a previously submitted comment, Mercy suggests that a

single Fiscal Intermediary be appointed to audit all Wage Index related data to
better adhere to common review practices and reporting of valid and
comparable data.
Conclusion

VI.

Thank you for this opportunity to present our views. We welcome further
discussion with CMS on any of the issues discussed above.

If you have questions concerning these comments, please feel free to contact Kyle Lee at
(4 17) 820-8640.

Sincerely,

James R. Jaacks
Senior Vice President and Chief Financial Officer
Sisters of Mercy Health System
c:

Ron Ashworth
Randy Combs
Ron Trulove