ACA and the Three I s

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

The Three Is of the ACA

The Three “I’s” of the Affordable Care Act

The triple ‘AIM’ is a term often quoted by health policy pundits.

CALIFORNIA’S MEDICAID CONUNDRUM

While California’s Medicaid enrollment exceeded projections by 1.4 million, many of those new enrollees had already been eligible for the program. The federal government provides states a 100% Medicaid match through 2016, but that’s only for those individuals newly eligible under the 2010 health-care law; if individuals who had already been eligible for but not enrolled in Medicaid come out of the woodwork, states will pay a portion of those costs. In 2012, the Department of Health and Human Services estimated that states would pay an average of 43% of those enrollees’ Medicaid costs in this fiscal year.

Some states opted to expand Medicaid under the health-care law, raising costs and budgetary pressures at a time of volatile tax revenue. In some cases, the result has been cognitive dissonance. California Gov. Jerry Brown was quoted in Thursday’s Journal saying: “We can’t spend at the peak of the revenue cycle--we need to save that money, as much of it as we can.” But two days earlier, Mr. Brown had expressed pride in the “huge social commitment” that health-care expansion represented in his state--even as it caused a billion-dollar overspend.

Ultimately, states that expand Medicaid could face pressure to cut other important services, whether health-related or in areas such as corrections or education. Recent trends have moved toward reductions because when an irresistible force such as a shrinking tax base meets an immovable object--the rising costs from expanding Medicaid--something has to give.

SOURCE: Wall Street Journal

The three Is of the Affordable Care Act,  Inadequate  Ill-conceived,   and incompetent

Dr. Wes: It's Not About the Physician

Dr. Wes: It's Not About the Physician

Health Care Development Challenges have developed into a ‘crowdsourcing tool for health foundations. The rewards are substantial, and come at a time when developers are searching for funding.  Make your choice. More Challenges, More Prizes! We launched three more challenges this week. Apply Now! Pilot Health Tech NYC Deadline May 23, 2014 Total Prizes: $1,000,000 California Health Care Foundation Design Challenge Deadline: June 27, 2014 Total Prizes: $10,000   NYS Health Innovation Challenge Deadline: July 24, 2014 Total Prizes: $43,000   PCORI Matchmaking App Deadline: August 15, 2014 Total Prizes: $150,000 Palo Alto Medical Foundation Challenge Official Launch: June 11, 2014 RWJF Plan Choice Challenge Official Launch: Coming Soon

Health Affairs:FDA and Primary Care

Health Affairs briefing at the National Press Club in Washington, DC,

The clinical and economic virtues of provider consolidation have long been recognized by policy experts, but in recent years, research has shown that large provider organizations may use market power to obtain relatively high prices from payers without necessarily delivering superior quality. On May 19, Health Affairs will release a package of "Web First" papers examining questions regarding provider consolidation.

Follow live Tweets from the briefing at @HA_Events, and join in the conversation with #HA_ProviderConsolidation.  We invite you to a Health Affairs briefing at the National Press Club in Washington, DC, where the authors will present their findings and engage in a discussion with a panel of expert responders and the audience. The papers and the briefing are supported by a generous grant from The Commonwealth Fund.

WHEN:	Monday, May 19, 2014 9:00 a.m. - 10:30 a.m.
WHERE:	National Press Club 529 14th Street NW Washington, DC 13th Floor (Metro Center)

FDA  Fast-track for new drug development

Physicians and Pharma have long complained about the length of time for new drug approval by the FDA for clinical use.  Pharma is required to perform Clinical Trials, I, II, and III to test for toxicity, effectiveness, and possible side-effects. Various amounts are quoted for the process of approval.  These add significantly to the costs of biochemical and pharmacological production. Health Affairs and the Robert Wood Johnson Foundation describes a new expedited drug development pathway designed to speed up the Food and Drug Administration's (FDA's) premarketing approval process for drugs and devices that treat serious or life-threatening conditions. Created under a 2012 law, the Food and Drug Administration Safety and Innovation Act (FDASIA), a drug may be designated a "breakthrough therapy" if it shows far more promise over comparable treatments already on the market. At that point, the FDA will initiate a special rapid approval process. The pharmaceutical industry has responded positively to this law, and as of last month the FDA has received 178 requests for this designation. The law, whose full impact will not be known for several years, carries significant implications for approaches to clinical development, patient access to new drugs, and the drug regulations process itself.

Social Media Response to Release of Medicare Payments to specific Physicians

Josh Seidman discusses the implications of the social media response to the release of information on Medicare payment to specific physicians. This is the first time physician reimbursement amounts have been released to the public.

Primary care physicians are suffering "agenda overload"

ABOUT HEALTH AFFAIRS:

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at www.healthaffairs.org.

Laudable but excessive prevention and public health initiatives have been added to the work load of primary physicians who are already hard-pressed to comply with a multitude of bureaucratic requirements. These additonal requirements may have a negative effect on primary care duties.

Receive new Health Affairs article alerts in your choice of format:

• E-mail alerts of new articles and tables of contents from Health Affairs.
• RSS feed for new article headlines delivered to your Web site or reader.
• Sunday UpDate: a weekly e-mail summary of what's new in Health Affairs.
• Follow Health Affairs updates on Twitter.

Developmental challenges for HIT

Health Care Development Challenges have developed into a ‘crowdsourcing tool for health foundations. The rewards are substantial, and come at a time when developers are searching for funding.  Make your choice. More Challenges, More Prizes! We launched three more challenges this week. Apply Now! Pilot Health Tech NYC Deadline May 23, 2014 Total Prizes: $1,000,000 California Health Care Foundation Design Challenge Deadline: June 27, 2014 Total Prizes: $10,000   NYS Health Innovation Challenge Deadline: July 24, 2014 Total Prizes: $43,000   PCORI Matchmaking App Deadline: August 15, 2014 Total Prizes: $150,000 Palo Alto Medical Foundation Challenge Official Launch: June 11, 2014 RWJF Plan Choice Challenge Official Launch: Coming Soon

Meaningful Use--------for Whom ?

Meaningful Use for Whom ?

Some time ago when EHR was fairly new and systems were immature and not user friendly a new term came into existence,  “Meaningful Use”.

At the time I was never impressed with the early user interface, it was clunky and more important not intuitive.  Intuitive systems are designed with a GUI that leads the user to the next step. It also affords a quick learning curve.  I focused on the ‘ethnology’ or the study of the human-machine interface.  The center of that is the human, not the technology, ie. Provider Centered.

Ethnology is hindered when the user is forced to guess where to go next, or find the screen that  he/she needs to perform the next step.  Based upon current average levels of intelligence and reading comprehension (as studied and defined by competent educators), that is at the eigth grade level, with large print, and pictures.

Be that as it may when I heard the term ‘meaningful use’.  I was excited to interpret that term as what I recommended in many blogs and in conversation with HIT and Health Consultants.

My optimism was bashed when MU was defined. Like many I read into the term as something I wanted to occur.  Nothing could have been further from the truth. I am disappointed as well as most providers.  It cost a fortune.  The coming conversion to ICD-10 will accomplish the same end point.

M.U. has turned out to be nothing more than bureaucratic bloat of the worst type, mandated and defined by an agency that was not interested in EHR as useful for users.  Those who desigined it  were focused passively on receiving the data for analytics.  They placed the cart before the horse.  The resulting system is sabotaged by the disinterest, as well as outright hostility by providers and even health consultants. The system was designed by health bureaucrats and pseudo population health experts.   In my day it was called ‘epidemiology”, a term that evaporated in the last two decades. Epidemiology is defined in Wikipedia and the Dictionary. It was subverted and re-defined by HHS and CMS.

Fear and loathing in meaningful use

When it comes to the topic of meaningful use, Colin Banas, MD, is driven by fear. And he's far from being the only one.

Although several stages have been adopted by providers with some arm twisting and extortion using reward and penalty to incentivize installation of EHRs with MU embedded.  This required expensive alterations to existing EHR systems. Although late in the  game, several medical organizations caution:

AMA Wants Major Changes in Meaningful Use

Meaningful use has been around for two years. A large number of users have attested to stage I, fewer to stage II and the deadline for stage III is pending. Meaningful use has been a great source for consternation among providers, and a boon to HIT consultants.  It is an expensive journey for provider and hospitals. HHS produced incentives for providers to adopt electronic health records. and penalties for those who would not adopt EHR a penalty. The incentives were inadequate since few providers realized there were 3 stages for meaningful use.  Deadlines are approaching for the implementation of MU and penalties in the form of penalties (reduced reimbursement) are near. ICD-10 deadlines have been extended due to pushback from providers.  This is due to a lack of resources, and the preceeding upgrades of EHR and meaningful use.

AMA has a wish list of MU improvements

In a detailed letter sent to both CMS Administrator Marilyn B. Tavenner and National Coordinator Karen B. DeSalvo, MD, the American Medical Association has put forth a long list of ideas to make meaningful use work better for physicians.

This effort must be joined also by specialty societies, other provider advocate organizations, such as Doctors4PatientCare, the Association of American Physician, The support of these parallel organizations is critical since the AMA represents only 25% of the physicians in the U.S.

Thrill is gone as meaningful use strains

It seems just about everybody has a gripe or two concerning the meaningful use program: software vendors that make electronic health records systems, hospital CIOs, the very people charting the related committees and, of course, physicians.

There still remains a lack of a guiding organization with standards of ethnology.  It may exist for other industry IT and record systems, however for health care it is a ‘black hole’.  There are indications that the Food and Drug  Administration is considering EHR as a patient related function and should be included in the FDA’s regulatory arm.  The FDA is well  along with proposals to regulate mobile health apps.

Source:  Meaningful Use Table and Charts for Staging.  (CMS)

Openness and Transparency

Medicare recently released figures for physician billing It included all physicians who bill CMS for services.  CMS requires a ‘current procedural code’ (CPT) for each visit, outpatient, inpatient, laboratory, imaging and/or medication and durable medical equpment. There are numerous modifiers, such as those for bilateral proceduress and the like. The data was released without explanation or definition.  The codes are uniform and identical across all specialties.  This is the first time such complete information was released to the general public.

CMS uses the data to track and analyze billing practices. It is used to analyze for fraud and abuse. CMS studies the numbers for outliers...who bill the most….using a specific code. Some CPT codes are used to determine the amount of complexity or time involved in a patient visit.  CMS has specific items which are required to code for the level of complexity of the visit.  The CPT codes are complicated and providers will often consult with or have a ‘reimbursement expert’ to code. Except for general internal medicine most specialists use a relatively narrow range of CPT codes according to the procedures they do. (gastroenterology, ophthalmology,urology, radiology etc.

(NPR) National Public Radio broadcast information given by CMS and also commentary by a  physician who  heads the kidney transplant program at the University of Colorado.  The program is the only facility in Colorado providing these services and referrals come from a wide area, even beyond Colorado.

The data revealed the following. Some physicians  coded every visit at the maximum level of reimbursement (rare), some appeared to up-code or bill more than the standard level for some or all visits. Some even down-coded to avoid being selected for an audit.  They chose to decrease income to avoid such an audit which is time consuming and expensive. The outcome of many of the audits is a demand for repayment of the amount CMS determined was billed in excess of the supporting documentation.  Providers must document in the medical record exactly what systems (kidney, lung, heart, skeletal) were examined, and the amount of time for the visit.  The CPT code must be justified by the medical record.  CMS provides guidelines for each level of care. In surgical cases the code also includes all post-operative care for a defined period of time depending on the complexity of problems.

Physicians are the ultimate responsible person who attests to the level of billing and it’ accuracy.

In some cases the data reflects billings for multiple providers who  work for another provider. The data has nothing to do with quality of care. Frequently new procedures develop and it may take months for CMS to announce a code for the new procedure.  The rapid advances in medicine and surgery often result in procedures and/or tests for which there is no code.

Missing from the information is the necessary linkage between a diagnosis and a procedure, without which the claim is denied. If the ICD code and CPT do not fit CMS’s definition the claim will be denied.  CMS has a vast data base on what CPT codes match which ICD code.

The ICD-9 codes have been in existence since       . To further complicate matters a new expanded series of codes, ICD-10 will go into effect in the next 12 months.  The original date for compliance (October 2014) was extended because of providers and hospitals informing CMS and HHS they would not be able to comply with that mandate.  The number of ICD codes expands from 14,000 to over 60,000.  The data in the released information is based upon ICD-9.   The expansion of the ICD codes will require expensive EHR software upgrades and in some cases a new EHR.  Some  providers already replaced their systems several years ago due to early mandates for interoperability and other features.  This amounts to billions of dollars for providers.  The cost may well be more than the ‘fraud and abuse’ claimed by CMS.   CMS  has no provision for the expense of providers to continually be required to upgrade in order to bill.  This is a recurring problem.  CMS quarterly modifies its list of CPT codes and instruction for modifiers as well.  These are hidden costs to medical care, and their is little to no information available to the public regarding these CMS requirements.  The expense from these requirements is never ending and repetitive.

Private Insurers also becoming more open and transparent

Aetna, Humana, UnitedHealthcare to supply healthcare cost data for new transparency tool

Three major insurers are partnering with a not-for-profit group to provide consumers with greater access to healthcare cost information, the group announced Wednesday morning. (MODERN HEALTHCARE)

FULL STORY »

Openness and transparency not only apply to financial information, but more important to the physician-hospital-patient interaction.  Unfortunately patient centered medicine is still far from reality.  The transition from a physician led system has been a subtle erosion of ‘captain of the ship’ to a member of the team mind-set.