SAYING GOODBYE.....TO YOUR EHR

What remains the same in HIT since 2004 is a farily uniform opinion on the usability of EHR in daily clinical practice. (Doubt)

What  MD has not already spoken about the unusability factor buried deep in your key board and/or mouse. The requirements for HIPAA security, Meaningful use attestations, and interoperability are key requirements for MU.

30% of   EHR  users are dissatisfied with their current EHR and plan to replace them. (KLAS)   If your practice is one of them and you are faced with a large expense to upgrade your HIT system you will want to find a new EHR that meets all MU requirememts.

Vendors have received considerable feedback (criticism) about their present system’s inadequate framework for clinical patient flow and have time to redesign their software.

Prior to the finality of MU3 now may be the time for a new EHR.

The confluence of the Affordable Care Act, proposed Accountable Care Organizations, Increasing meaningul use mandates, improved Cloud services, vendor experience leading to some improvement in user friendliness, and user experiences and demand provide a fertile environment for change.

Calculating ROI with the old system vs a new one has to do with flow, efficiency, and the cost of replacement. If your EHR runs in the cloud the decision is simple...the changes are done at the host site. All software changes are performed off site in the vendor’s facility. eliminating any work disruption at the clinic.  Your original vendor contract should have had stipulations for the added expense of upgrading to meet eventualities of MU or other requirements. Since there is much competition among vendors, a competitive advantage may be the offering of enhanced maintenance and software upgrades.

If you are ‘retiring” your present system due to regulatory changes, consult with your accountant and legal counsel whether you can accelerate the depreciation and write off a portion of the expected life of your old system.  If possible this may ease some of the pain of a poor investment.

Most EHRs were built upon  features present in a practice management system, designed to maximize reimbursement, and maximize charge for each encounter. The new paradigm will be based not upon volume but upon improved outcomes, and decreased cost, for at least some of the encounters.

The field of ACO is new,  everyone knows what an ACO is supposed to do, but it is hard to find one. Several ACOs now are operating and some early statistics show savings and reduction in costs.

Interoperability is a requirment of MU1 and the ONC encouraged this with a framework for disparage EHRs to communicate with each other. Regional Health Information Exchanges experienced a challenge in developing sustainable business plans not dependent upon long term government grants, although the HITECH Act provided start up capital.  A new niche industry developed for HIE infrastructure.  

Some hospitals and providers have committed to these HIEs, but there is a significant difference between potential users and those in the HIE.  Many providers have interoperable systems, and have attested to it’s use. However many do not use the feature either because pre-existing methods are in use or there are no other providers to communicate.

An analysis of our regional health information exchange IHIE.org reveals this fact. The analysis is from the largest HIX in Southern California, and may differ significantly from other organizations.

Accountable Care Organizations will require data and the HIX may provide that avenue to collect and display operational numbers for the ACO.  HIX may become more affordable with expanding functionality to include ACOs requirments without building an entire new infrastructure.

HHS AND WAR ROOMS

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, and 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 simultaneous users, 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 (Obamacare)_should be abandoned entirely.  Yes, on October 17 the President was ready to scrap the whole thing.

The HHS War Rooms

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, and 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 simultaneous users, 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 (Obamacare)_should be abandoned entirely.  Yes, on October 17 the President was ready to scrap the whole thing.

DISAPPOINTING TO SAY THE LEAST

In the beginning there were over 40 million uninsured in the United States. President Obama said, “This is not good “ and commanded “Let there be light” and behold it was so (or was it?)

The latest figures for the uninsured who have enrolled in  the Affordable Care Act is around 4.6-5.0 million.  The original number targetted by health.gov was 5.0 million new enrollees.   Their goal was very conservative since the original number for the uninsured was over 40 million.

Either way the reality is that the number of uninsured has only diminished to 45 million. Perhaps HHS and CMS were prescient in setting such a low goal to not disappoint, or make themselves feel successful.

The 5.0 million enrollees was the threshold for the new algorithms to guarrantee solvency for the new risk pools, and that may be why that goal was named.

Unfortunately the enrollment period ends on March 31st.  This date is not an arbitrary date mandated by HHS, and is the insurance industry standard for enrollments.

There is nothing preventing the date from being extended.

The options would be to:

1. Halt enrollment and  have enrollees insured this year.

2. Continue enrollment throughout 2014

3. Consider halting further enrollment until another plan is designed.

Many uninsured evaluated the offers and decided to wait and see. Many factors were in play, including provider directory errors, web site difficulties, subsidized rates were confusing as generated by the benefit exchanges. There was a lack of clarity how Medicaid would be expanded and no details in regard to financial requirements, assets, family size, etc.  For those familiar with Medi-caid there are asset restrictions to remain eligible for Medicaid.    There was no mentioin of how  ACA Medicaid is different from ordinary Medicaid.

Those who have already enrolled should not be disadvantaged by a newer version of the ACA and can be maintained until the new program is operatiional.

Government, insurance companies and other regulators have piled more bureaucracy with each new idea on how to save money.  Each change decreases reimbursement and increases overhead for providers and hospitals. Despite this never-ending demand, providers and hospitals have outsmarted all these efforts as a meaure for survival.

The initial result is not only disappointing and reveals the inadequacy of the planners and the impossibility to predict demographics of enrollees.

The only thing which will guarrantee solvency will be federal guarrantees. This may be the first phase of a health industry bailout .  The Federal Reserve needs to warm up the printing press.

AFFORDABLE CARE ACT AND RISK ANALYSIS, OR WHAT WILL MY PREMIUM BE IN 2015?

ACA and Risk Analysis

Health Insurance companies may be at great risk participating in ObamaCare. Some large insurers have taken a ‘wait and see” attitude.

Setting insurance policy premiums can be challenging.Obamacare has already set a limit on administrative expenses and the amount that must be spent on patient care by insurers.

ESTIMATING RISK FACTORS:

Obamacare and Health benefit exchanges add another set of unknowns. The ACA stipulates that pre-existing illness cannot be a reason for denial of insurance. This eliminates any means of estimating risks in the newly insured. Statistically speaking young persons spend less on healthcare, which is why health benefit exchanges must sign up many young people who do not consume healthcare vs. older patients who consume much more.  

There is no real experience on risk pools in the ACA.  Perhaps there may be some estimation by looking at previous risk pool analysis in each demographic.  However the availability of insurance to previously uninsured could produce an entire new set of figures.  So, despite not being able to use pre-existing conditions as a parameter for insurance, insurers such as Blue Cross and Blue Shield of North Carolina is asking enrollees to fill out health risk assesments by offering free gift cards to those who fill out the survey.  In addition they are encouraging screening tests, and initial primary care visits for evaluation. It is hoped this will accelerate the rate setting process.

Insurers are not confident in forecasting premium rates for 2015. Even if statistics from January 1, 2014 until mid 2014 are utilized it is still a very short time period for newly insured to obtain health care.  Many uninsured can be expected to seek out health care for neglected and longstanding chronic conditions.  Utilization figures could be biased by this initial demand for health services.

Most statisticians would most likely prefer a 24-36 month period to determine risks.

Options for Obamacare Health Insurance Policies.

Options for Obamacare Health Insurance Policies.

Depending on  your level of income there are several options.

1. Purchase a very high deductible catastrophic medical insurance policy

2. Use your monthly saving to put money into your self-funded medical savings accout you control.

3.Consider joining a religious group cost-sharing program such as Liberty Healthshare,Christian care, Medishare and Samaritan Ministries.

4. Seek out direct pay practices imaging centers and hospitals that offer discounts for cash-pay for only the services you choose.  These practices and hospitals save significant overhead by not billing insurance companies to only be denied.

5. Consider medical tourism and purcase a ig-deductible international health insruance policy for much lower premiums that offer medical services in lower cost countries such as Chile, Costa Rica, Panama, Mexico, Singapore, Tailand,  India and others. There are professional agencies that provide these services.  Many foreign medical providers are educated in the United  States and the United Kingdom.

Our overall advice is to take control of your medical care in your own hands in partnership with physicians of your choice

At it’s core, Obamacare is about controlling YOU, and limiting your choices for medical care and how you spend your money. Obamacare is not about “affordable care” or “patient protection”

Fourth Down and Ten to Go

Your health is a political football.

There are some Democrats that are disenchanted with the Affordable Care Act, however the majority still seem intent upon disregarding the early warning signs of catastrophe.

Public opinion:  According to a CNN poll  39% of Americans say they support the heal th care law, up from 35% in December, which was it’s record low. The four percentage point increase is within the survey’s sampling error. Fifty-seven percent questioined say they oppose the measure, down five points from December.”

This is the good news ?

The White House says that 4.2 million people have signed up for coverage on the exchanges but have refused to report how many have actually paid, and are therefore enrolled.  It is estimated that only 1 million of those who  “signed up”  were previously uninsured. These numbers fail to make a serious dent in the nearly 50 million people promised help by Obamacare.

from the National Review Online: The Corner March 17, 2014