Health IT internships ONC HIMSS & ACO

“Health IT internships may be another means of meeting demands for HIT personnel in the health workforce”, according to Healthcare IT NewsDay.

HIMSS 2014

Although the REC programs have trained students in basic heallth information technology, hospitals and others report they have little practical experience, and are seeing an influx of students entering these programs who do not have clinical or information technology backgrounds.

Meaningful Use, Stage III and ICD 10 conversion are two two features scheduled for implementation later this year. Providers have indicated the challenge of performing this change simultaneously before the deadline.  HHS has indicated it will delay the ICD 10 conversion, and still insists on Meaningful Use.

“The Unvarnished Truth” is what CEO Mark T. Bertolini believes is what people want to hear during tough times.  Much of the controversy and tension between providers and government relates more to the timing of transformation rather than it’s content or goals.

There is very little meaningul communication or response to provider comments unless the conversation becomes very loud.

ONC (The Office of the National Coordinator), Four national coordinators discussed their years driving the health care information adoption over the past ten years.

Startups have created competition for funding and much interest by venture capitalists in health related strategies for improving healthcare with technology.

2014 promises to be a transformative year for HIT was a discussion at a CMS Townhall meeting.

Despite the challenges the United States is Set to Be the World’s Largest EMR Marketplace. Meaningful use did one thing right, filling hospitals and doctor’s offices with EMRs, despite controversy.

EMR is over ten years old and is no longer in it’s infancy, and is now an adolescent. Significant growth and early maturation now have positioned the EHR to become transformed just as adolescence transforms pubsence into adulhood.

Accountable Care is driving disparate hospitals to merge, be bought or buy neighboring systems. Individual organizations may very well use different EMRs.  Health information exchanges, either intra or extra hospital become a vital business and clinical information structure.

During and after the Affordable Care Act the HIT system must be flexible, and designed to be totally interoperable to serve health providers.

The End is in sight (Open Enrollment..that is

In several weeks (March 31 2014) the  open enrollment for  Obamacare will end for year 2014.   Many will pontificate on how successful or the opposite the affordable care act will be based on the initial numbers of who has enrolled.

Many in health care already know that IT never solves a problem by itself. IT is there to assist or enhance operational efficiency. HBE was only necessary because HHS, CMS and Obama wanted a rush job to fuel the startup of the affordable care act.   By itself the health.gov website, and coveredca.com did little to create an affordable care system. The ACA still has critical and possibly fatal flaws waiting to happen in the next several years.

Despite serious and growing concern about the present state of the ACA all segments of the industry have already planned to transitiion to a new system. Although the Republicans have offered alternatives to the fractious components of the ACA any legal  changes will not come until the mid-term elections, and even then it will require moral and political will to make a substantial change.

President Obama has already made many changes in regard to mandates, and waivers using executive privilege.  After the next Presidential election if the congress and/or presidency changes hands, the new President may use the same mechanism to amend, rather than  repeal Obamacare.

To be certain the current resident of the White House will use executive privilege and other administrative methods to modify ‘blocks’ to implementing the  Affordable Care Act using waivers, exemptions, delaying implementation dates, and whatever means are necessary to eliminate opposition to Obamacare.

PPACA and Outpatient Procedures

HealthCare LeadersMedia reports the Affordable Care Act will cause the number of outpatient proceures to increase for those opted-in for Medicaid expansion in the PPACA. And according to figures there is a spread seen as examined by state.   By 2015 California stands to perform 46 million outpatient procedures, while a state such as Texas (opted-out for Medicaid expansion) will decrease by 53 million cases.  (reported by Truven Health Analytics)   

These figures are further broken down by specialty. Two specialties which create a significant number of ambulatory surgeries, and among the top tier of expense are cardiology and orthopedics.  Medicaid opt-in vs opt-out produces some signifcant differences in reimbursement that outweigh numbers of cases.  The split per  specialty mirrors that of the total number gained or lost in 2016.  

Mental health services (Psychiatry) are already in short supply and  have previously been throttled by the lack of reimbursement by insurers.  PPACA has mandated an increase in these services as a covered benefit. For those states who are opted out the medicaid eligible population will suffer relative to states opted-in. Those who live in states opted-out of Medicaid expansion will not have access to insured  care for outpatient psychiatry services.

As expected the variance is greatest for California and Texas which are outliers in the data. In 2016 the volume of Cardiology cases in Califonia will increase by 672,000, while Texas will forgo 840,000 cases.  These figures also reflect population differences and the number of medicaid eligible patients in each state.

For orthopedic surgery California (opted-in) will benefit from over 299,000 outpaitent orthopedic cases, while states such as Florida and Texas (opted-out) stand to lose near 300,000 orthopedic cases.

The choice to opt-in vs opting out not only effects who will receive benefits in the eligible  population but will have significant effects on the hospital industry.  The number of outpatient surgeries outweighs the number of inpatient surgeries.  Using the present fee for service reimbursement rates under FFS hospitals have been advantaged by higher reimbursement reflected by higher cost.  The loss of coverage for medicaid eligible patients not only places them in jeopardy, it also creates significant differences in the infrastructure necessary to deliver these services.

Outpatient services in states who have opted-in will need a business plan to expand capacity which includes not only physical plant, but skilled workers, such as surgical techs, surgeons, expendables as well as revising operating schedules, reducing turn-a-round times and the like.

DME suppliers will reap these benefits in opt-in states.

The figures represent the number of cases gained vs the loss of gain by opting out. The opt-out numbers are a speculation, and do not represent an actual decrease in cases.  The number of procedure in any case will not decrease in states that have opted-out.

Increased demand for services always encourages efficiency and technical breakthroughs, to decrease loses and encourage profitability, much as occured with small incison cataract surgery and the development of small incision surgery in cardiology,general surgery and orthopedic surgery.

While ‘futurists’ attempt to predict the effects of the new law, serendipity and the butterfly effect can be expected  to yield surprising changes as well.

This article also appears in Health Train Express, February 22, 2014. http://healthtrain.blogpot.com

The author also publishes at Digital Health Space http://digitalhealthspace.blogspot.com

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Three War Rooms for Health.gov

CMS opened three “War Rooms” during the start of the Health.gov website. It was a high priority for the White House Chief of Staff, Denis McDonough who commuted almost daily between CMS headquarters in Bethesda, MD  (home of CMS) and  1600 Pennsylvania Avenue. It was so disorganized that 3 war rooms were needed either by design or by default.

The ‘Joint Chiefs’ of Health.gov included CMS head Marilyn Tavenner, Jeanne Lambrew, HHS head Kathleen Sebelius.  The group failed to find ‘actionable intel’ about how and why the website was failing for all to see  They resorted to opening their laptops at the White House and tried to log on to health.gov .

The initial findings were the website was not able to process the number of simultaneous users. Five days after it’s opening Todd Park, the U.S. Chief Technology officer told USA today health.gov was designed for 50,000 and 250,000 attempted to use it at the same time.  The real amazing fact was that  Todd Park was never involved in the design of the system. Park is a highly successful health-care tech entrepeneur.  During the redesign it was found the site was designed to only handle a few thousand users.

Chief of Staff Denis McDonough’s assignment was to determine if it should be abandoned entirely.  Yes, on October 17 the President was ready to scrap the whole thing.

Electronic Medical Records, Still problemmatic for Providers

Altlhough we have witnessed the growth of EMR acquisition an overwhelming number of remain skeptical.  Many plan to dispose of their current EMR and invest in new systems.

Medical practitioners are basically applied practical scientists, and have relied on science based on ‘big data’ derived from clinical trials and peer reviewed data accumulated over many years. It is therefore somewhat of an enigma why they would be unhappy with elctronic medical records which surely has the capability of reliably gathering and recording data and also the availabilty for analytics.

The installed base by fait accompli has established an infrastructure which could be compared to  vs DSL as compared fiber-optic internet This was encouraged largely by federal incentives and a rush to establish a national network.  The aspects of interoperability were then layered upon the electronic medical record, and also “meaningful use’ which is a misnomer since it has nothing to do with meaningful use on the provider side of the equation.  Meaningful functionality was neglected in encouragement of  ‘the adoption of EMRs.  Caution was advised over a decade ago that the current generation and versions of electronic health records was ill suited to the task.  

1. Our study ten years ago revealed that the human-interface was ill-suited to patient-provider interaction. This due to the discontinuity between face-to-face interaction in a patient and provider encounter and the unfriendly user interface

2. The data entry in the form of clinical history, and physical examination input is not in the structure that physicians use in conventional medical written medical records. This creates more distraction and loss of efficiency as the provider struggles to be accurate in recording a clincal encounter.  Some EHRs force the provider to enter some date prior to moving along to the next step. After some time Providers  familiarize themselves with the routine flow, however many times there may be an entry or section with which the provider is not familiar.   These systems were not designed in an era of user friendly, nor intuitive navigation in the Electronic Health Record. Graphic User Interfaces (GUI) are almost unknown in most EHRs.

3. Medical Economics published a recent survey of providers revealing the significant majority of MDs (75%) who are very dissatisfied with their present electronic medical record.  And now many plan to replace their current system. 45% of 967 respondents to the survey indicated patient care is worse with EHR devices, and 67% said their investment was not worthwhile.

The good news is that the IT industry is eager to profit from this revolution of Health Information Technology. The Industry has a specialized organization known as the Health Information Society, also known as “HIMSS”. The group has a collection of IT, health consultants, physicians, hospital administrators (CIOs, CTOs) and others who collectively work together to advise the industry, vendors, and software developers about what is needed by health providers and data analystis.

Black Book ranked EHR providers for 2014 scoring vendors across six different client experience categories.

EHNAC and WEDI will certify an assurance of quality and functionality of software for providers..The goal is to enhance usability for providers. This is a step in the right direction.

IOM FORUM

In late February 2014 the Institute on Medicine’ Roundtable on Value and Science Driven Health Care published a discussion paper on Return on Information….a standard model for assessing institutional return on investments for electronic health records.

The formation of accountable care organizations presents many challenges, and many needs for information technology to synthesize patient care across a continuum.

Measurements and a standard model are needed to compare different institutional experiences implementing different technologies and approaches for accountable care organizations.

While the emerging roles of  patient, family and public participation are acclaimed to be a necessary componet for improved health the IOM discussed the changes as possibly disruptive innovations on affordability, quality and outcomes in health and health care.

 

Affordable Care Act II

The Affordable Care Act is much more than health care financing and healthcare.  As time elapses and the internal workings of the ACA as well as reactionary events on the part of insurers take  hold there will be many surprises.

Some have already ocurred.

Politics and political correctness have created  an image of ‘consumerism’ for health care.  That image creates a “Wild West”, rather than a scientific approach.  It  created the illusion that health care has been a ‘free market’.  That is not true.  Access to care is throttlel by employers who chose what plans employees can access, and there are regional and state differences as well. Layer upon that limitation  providers and hospitals select the plans they accept. Some of these plans refuse to accept certain policies due to low reimbursement and/or cumbersome bureaucratic requirements.

The ACA has levelled the field in some respects by standardizing the offerings among health insurance companies.

It is still too early in the adoption of the ACA, however some ‘cracks’  have appeared.

Consumer Power Report

Contributors: Heartland Institute (Benjamin Domenech), The Washington Examiner,Michael Canon, The Arkansas Times, The Hill, Time, the  John Loche Foundation, The Daily Beast,

Obamacare is affordable, so long as it’s outside Obamacare

The Washington Examiner reports there are many cheap and affordable plans, if they look outside the Obamacare Exchanges. A careful study compared the offerings of the healthcare.gov health benefit exchanges vs private wesites, such as e-HealthInsurance, and finder.healthcare.gov. President Obama enabled this by unlawfully altering subsidies to include policies outside health.gov.

Since the ACA was passed the Obama administration has used the law of  “standing” to implement the act.

This change introduced the concept of ‘moral hazard’ whereby lower copays lead to more demand for provider visits, and conversely higher copays will cause exchange patients to avoid visits to the doctor. This feature creates differences in cost sharing and prompted insurers to consider ‘declatory judgement’ to challenge the new guidance OBAMACARE’s health exchanges will also trigger illegal taxes against employers.

The Obama administration is in a rush to enroll as many people as possible to create as much difficulty for repeal in 2017 . Human nature being what it is , who would give up a free product ?  It is still too early to know how effecive, or not the exchanges have been until March 31 when enrollment ends for 2014 and we find how many actually paid their first premium.

Politics play a major role in the recurring delays implementing the Affordable Care Act.

This week the White House will announce a new directive to allow insurers to continue offering health plans that do not meet OBAMACARE’S  minimum coverage requirements. The ‘keep your plan’ fix avoids another wave of policy cancellations. The timing of the delays is more than fascinating. The extensions go beyond the midterm November elections and in some cases beyond the the end of Obama’s last term. Obama

Could the Affordable Care Act be a thinly disguised ‘bail out’ for an industry responsible for 1/6th of the economy?  We have witnessed bail outs for two other ‘too big to fail’ segments of the economy, the financial and the automobile industry.  There are some aspects to this thought.

The initial goal of recruiting young people has still not been accomplished and will not be known until the enrollment deadline of March 31 when final figures become availabale of who has paid premiums.

The 2015 White House Budget includes a ‘slush’ fund of $ 5.5 billion for Obamacare. The ACA creates a temporary pool of money known as risk corridors to pay for insurers who enroll a higher-than-expeted number of sick patients through 2016. The financial device intends to transfer money from lower risk plans to higher ris plans to keep premium prices stable.  Republicans say the government is likely to be is likely to make some of those payments, which they say would be  tantamount to a taxpayer bailout of the insurance industry.

Continued:

Economic Changes in Health Care and the Economy

Changes in Health Care Reflect the general changes in America’s Economy

Our health system developed over the past four decades in a reactionary manner to meet the immediate demands of the time. During this same time science and technology grew so quickly we are now unable to afford these advances for all.

The affordable care act may increase access to more for advanced treatments. Because of the increased demand insurers themselves will increase the necessity for prior authorization according to their own set of parameters.  The ACA provides no guidelines for these standards. Undoubtedly in the name of equanimity these standards would apply to non-ACA as well as ACA patients.

In the past there was no overall plan to integrate reimbursement for health providers. The Affordable Care Act, attempts to modify this course, but also creates major challenges for the overall economy, national debt, and business expenses.

Many states have refused to participate in the expansion of Medicaid to cover some of the uninsured, despite federal subsidies for several years to fund the increased cost.

Our approach has been much like that of Henry Ford who created mass production and educated students for specific jobs. The object of public schools at that time was to produce workers for specific jobs.  

What has happened is the job market has changed radically.  How many college graduates can not find jobs in their chosen area upon graduation ? We have been educating students for jobs of the previous century, which no longer exist.  We no longer see vocational schools, no apprenticeships.  Certfication has become a lifeline for proving a skill, and education has become expensive as the educational-industrial complex has grown.

Economic productivity can no longer be measured by the number of widgets built, nor can reimbursement for health care continue to be strictly fee for service. True incentives should be available for innovation and creativity in deliverying more health care, while increasing quality of life and wellness.

There are several challenges to this paradigm shift. How do we measure  quality improvement or a decrease in quality. What are the metrics ?  One of the first measures imposed by CMS has been the readmisson rate to hospital within 30 days of discharge. Patient compliance is a nother measure being used in some practices...how often is blood glucose, blood pressure, weight, and medication complicance. What is the availability and use of patient education, tutorials, and appointment compliance?

A more accurate measurement may be the real measurement of clinical condition such as control of blood pressure, blood glucose, weight, pain control, ambulatory and functionanl ability.

Will there be a reward or improvement, and/or a penalty for failure to improve a measure?  What will the factor be for these changes?

Finally are these measures really necessary and/or will they be effective in improving quality or just another means of controlling cost?

A Sheaf of ObamaCare Alternatives

Despite pronouncements by Obamacare, and the Republicans that the Republicans had no alternative plan for the Affordable Care Act there were alternatives, The Patient Choice, Affordabilty, Responsibility, and Empowerment Act  (CARE) was sponsored by Senators Richard Burr R-NC, Tom Coburn R-OK, and Orin Hatch  R-UT.     The goals sought to execute te same goals of Obamacare to lower health care costs, eliminate pre-existing condition dilemma and reduce the number of uninsured Americans.

CARE act operates on incentives, not mandates, offering carrots, not sticks. It used consumer-driven principles and patient choice into the health care delivery system.

John Goodman, President of the National Center for Policy Analysis suggested that a universal tax credit for the purchase of health insurance. Surplus tax credits would be funneled to safety-net institutions to provide services which the uninsured cannot pay on their own. The 2017 Project would not auto-entroll anyone in a plan, and would not limit tax-exclusion for employer-sponsored insurance as the CARE Act would.  Other age adjusted tax credits, and surpluses going into Health Savings Accounts. States would be allowed to funds to run high-risk pools for individuals with costly, chronic medical conditions.

ObamaCare Lawsuit Attempts to re-instate cancelled plans

Lawsuit seeks to reinstate canceled health plans By JULIET WILLIAMS Associated Press * SACRAMENTO, Calif. (AP) -- A state lawmaker who is running for state insurance commissioner said Wednesday that he is suing California's health benefits exchange for wrongly cutting off more than 1 million insurance policies and for what he called wasting taxpayer money on useless marketing campaigns. Covered California violated federal and state laws by telling insurers that wanted to participate in the exchange that they must eliminate plans that fail to meet the higher standards of the federal Affordable Care Act, Sen. Ted Gaines, R-Roseville, alleges in a lawsuit filed in Los Angeles County Superior Court. He claims the agency's board violated the law a second time when it voted last November not to extend those policies after President Barack Obama made that option available. A spokesman for Covered California, James Scullary, said it would be inappropriate for the agency to comment before it has been served with the lawsuit. Covered California says 829,000 Californians have enrolled in health insurance plans through the exchange, but it has acknowledged that more than 1 million policies could be eliminated. The number of those gaining coverage through the exchange is expected to rise as the March 31 enrollment deadline for the year approaches. Additionally, some of the people whose previous policies were cancelled are likely to have purchased new policies sold through Covered California. The Obama administration on Wednesday announced a two-year extension for individual policies that don't meet requirements of the new health care law for the states that had opted to allow them to continue, which about half the states did. In California, Gaines, who also owns an insurance agency, said hundreds of millions of dollars in marketing and outreach have been wasted because fewer people overall will have insurance, given the cancellations. Millions more, he said, will be phased out next year when a new mandate takes effect that requires certain employers to offer coverage to employees. Among the wasted money Gaines cited in the lawsuit are $106.2 million on outreach that "has failed to obtain significant enrollment, or a demographically or actuarially diverse enrollment," more than $10 million on a contract with public relations firm Weber Shandwick and $1.3 million for an infomercial starring fitness guru Richard Simmons. Gaines' campaign for insurance commissioner immediately sent an email Wednesday announcing the lawsuit and soliciting contributions to help him in his "campaign against Obamacare." Gaines said in a conference call with reporters that he asked Covered California Executive Director Peter Lee to provide details on how much has been spent on marketing and outreach and for what, but "I didn't get any clarity in terms of how that money is being spent."

COVERED CALIFORNIA BOTCHS PROVIDER DIRECTORIES

Peter Lee, head of the Covered Califonria Health Benefit Exchange announced the removal of it’s provider directories on the Covered California website, effective immediately.

Prospective enrollees will now have to coordinate the insurer, the plan, and the providers by going to the insurer web site directly, ie Blue Shield, Healthnet, Kaiser, Anthem, and others.  

This was necessary due to the massive errors in listings of providers who have not been contacted, nor enrolled in the Covered California program. Many patients called the listed providers to find out their provider had not enrolled, and were listed in error. Covered California copied the provider lists for each insurer participating in Covered California.

This is merely the top of the iceberg and we head further into the Affordable Care Act. Many more ‘surprises’ will surface as patients and providers begin using this system.

Nancy Pelosi was correct. We won’t know what is in the Affordable Care Act until it is passed.

Apparently the ‘Amazon” shopping cart model is a FAIL.  

It becomes extremely obvious there was little if any congressional oversight in planning and implementing the workings of the exchanges despite several years of forewarning.

Despite Obama’s promises of ‘if you like your doctor, your hospital”…….etc that may not be the case without much head scratching, or even not at all if your doctor has not signed up for the health benefit exchange roster.  And many have not enrolled as providers, taking a wait and see attitude how well it is going to work. It will take at least one year for an assessment of each plan by individual providers.

You see it’s no longer about the patient which really  exasperates most of  us who are licensed and given the responsibility with diminishing authority to care for our patients.  

Ignoring these problems will not improve  health care delivery. Why was the insurance industry not consulted on the process of enrollment and the administrative process ?

HEALTH REFORM AND SAD FACTS

It is a sad fact that those who propose a government run health care system, are misinformed about containment of health care costs.  They argue that ‘non-entrepenurial’ systems elimlinate abuse and misuse of health care resources. However,the end game of reducing costs to the  patient, and payor is offset by the increase in bureaucracy. Institutions, and provider groups will hire watchdogs as overseers to monitor the ‘quality’ of healthcare. The expense of this will be considerable to providers organization. The cost however will be absorbed and shifted to the ‘producers’ of the organization.  I was mistaken about this in my own ‘opinions’ about containing costs until I worked at a military hospital as a civilian contractor.  These organizations compete internally for allocation of ‘fixed dollars’ by ‘proving’ they produce. Departmental budgets are determined by ‘utilization, which is monitored by evaluating RVUs generated by providers. If RVUs diminish so too does there budget.  (or overall institution).  Coding experts regularly ‘train’ providers to ‘upcode’ their services. The military in particular has their own system of using

CPT codes. I would be honest in stating that this is not due to greed, but the fear that by not reporting every RVU nickel that department would be penalized. The emphasis is to ‘spend every dollar’ each fiscal year for fear of losing it in the next billing cycle.   I was amazed one day to see an emergency patient who came in with a ‘simple migraine headache’  The ER provider note’s treatment plan included a  “screening MRI”.  Perhaps this is the new paradigm for younger   providers who do rely much more heavily upon technology. Providers in this environment also seem to order more lab tests because they don’t think it ‘costs’ the system’ when a patient (or they ) never see a ‘bill’ to whomever supplies the services.  Particularly in the military these services are provided by ‘outside contractors’ who must be reimbursed as well. 

Many of the military functions are now provided by  outside civilian contractors, such as security or supply chain functions.  This also occurs for medicine and health. For the short term of needed services hiring a contractor also involves a human resources company who does the actual hiring. The intermediary company is often paid on the basis of the reimbursement for the contractor. These firms often charge an equal amount as to what the contractor is reimbursed.  Hidden in this cost if housing and transportation.

Those who observe “our system’ from 40,000 feet really have inadequate knowledge of how the systems work internally.  Those who regulate have little involvement in how and how much it costs to regulate. That is contracted out to third parties, whose costs are ‘hidden’  Congressman Pete Stark frequently tell us the overhead for medicare is 2-3%. That is just not true.  Medicare costs us much more due to cost shifting to private payors and hospitals because their rates are miserably low, and other payors pick up the difference.  Medicare and Medicaid do share in only a portion of the costs of the uninsured. This is passed on to County and State governments.  Statistic lie.

A loud rumbling is beginning in the Internal Revenue Service.  During 2013 complaints were filed by many organizations filing to become  non profit status. Delays have increased, telephone inquiries are answered less than 80% of the time by live personell, tax return and income verifications are not done in real time, as well as bizarre events such as over 2,000 refund checks being sent to the same physical address.  It seem automation and computerization can only go so far. Increasing public, national debit have resulted in sequestration, a budgetary fix that among other things has reduced the IRS budget by 10%, and IRS training by 87%.  Taxpayers can no longer obtain accurate or reliable information from the IRS.

Couple this with the  Affordable Care Act and the additional mandate for the IRS to administer compliance with the indivual insurance mandate and for enforcement…..this is an event and disaster waiting to happ

If you are upset about the government running General Motors, just wait….Is health care deemed “Too big to fail?” or Too big to suceed”?