Month: November 2012

Trust But Verify: Why CMS Got It Right on EHR Oversight

Nov 30, 2012• 7

By Ashish Jha, MD

Yesterday’s New York Times headline read that “Medicare Is Faulted on Shift to Electronic Records.” The story describes an Office of Inspector General (OIG) report, released November 29, 2012, that faults the Centers for Medicare and Medicaid Services (CMS) for not providing adequate oversight of the Meaningful Use incentive program. Going after “waste, fraud, and abuse” always makes good headlines, but in this case, the story is not so simple.

For those not intimately familiar with the CMS policy, in 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act. The program, administered through CMS and state Medicaid programs, created financial incentives for doctors (and other eligible professionals) and hospitals to adopt and “meaningfully use” a certified electronic health record (EHR). To receive financial incentives, which began to be paid in May 2011, doctors and hospitals “attest” that they have met the meaningful use requirements, providing an affirmation for which they are held legally accountable.

The process works as follows: health care providers visit a CMS website, register, and enter data demonstrating that their EHRs are “certified” and that they met each of the individual requirements for meaningful use. Then they attest that that all the data they entered is true. For example, a physician might have to report, to meet just one of the 20 meaningful use measures, how many prescriptions she wrote over the past 90 days, and how many she wrote electronically. My conversations with colleagues suggest that it can take a lot of time for providers to gather all the data they need to “attest” to meeting Meaningful Use. Then, CMS runs logic checks to ensure that the numbers entered make sense and, if there are no errors, they cut the provider a check. Through September, 2012, CMS paid out about $4 billion in incentives to 82,000 professionals and more than 1,400 hospitals.

Why Health Care Is Reshaping Itself

Nov 30, 2012• 39

By Joe Flower

Costs and revenue: This is the oxygen of any business, any organization. What are your revenue streams? How much does it cost you to produce them? Life is not just about breathing, but, if you don’t get that in-out equation right, there is nothing else life can be about.

Right now this enormous sector is turning itself inside out. It has turned the “transmogrification” setting to “warp.” Why? It’s all about the in-out. It’s all about increasingly desperate attempts to get that right — and the clear fact that we cannot know if we are getting it right.

Let’s do some school on the two sides of this equation. Let’s just go over the new weirdness, and the implications for you and your organization. Revenue first.

Hunting for True Revenue

In traditional health care (the way we did business until about five minutes ago) the revenue side was complicated in detail, but simple in concept: You do various procedures and tests and services, and you bill for them. You bill each item according to a code. You bill different payers; each has its own schedule of payments that you negotiate (or just get handed) every year. There are complications, such as people on Medicare with supplemental insurance, dual eligibles on Medicare and Medicaid, and self-pay patients who may or may not pay.

That’s the basic job: aggregating enough services that reimburse more than their real cost so that you can cover the costs of services that don’t reimburse well. This is cost-shifted, fee-for-service management. Cut back on those low-reimbursement services; pump up the high-reimbursement ones. Corral the docs you need to provide the services, provide the infrastructure and allocate costs across the system.

The incentives all point in the same direction. The revenue streams are all additive. The more you do of the moneymaking items on the list, the more money you make.

Meaningful Scrutiny for Meaningful Use

Nov 30, 2012• 13

By Nicolas Terry

Today the Office of the Inspector General (OIG) in the Department of Health and Human Services released a report, here, that is decidedly critical of CMS and ONC oversight of the Electronic Health Record (EHR) subsidy program.

Over the last couple of years there have been growing criticisms of the Meaningful Use program and its disbursement of potentially $30 billion in ARRA funds. I have detailed many of these concerns, such as the overall effectiveness of electronic records, my doubts as to the robustness of the first two Stages of Meaningful Use requirements, the safety record of the technologies, their ability to actually save money, their real-world interoperability, and their general usability in the healthcare workflow, here.

Recently, additional questions have been raised that go to the very heart of the subsidy program. First, the Center for Public Integrity, here, and the New York Times, here, set off a firestorm with allegations of EHR use leading to extensive upcoding. This led to a scolding letter to the healthcare industry from Secretary Sebelius and the Attorney-General, here, and combative words back from some of the addressees, here.

THCB Calendar Dec. 18 — Donald Berwick: Is a Bright Future for Health Care Possible?

Nov 30, 2012• 2

Donald Berwick, M.D., Former President and CEO, Institute for Healthcare Improvement; Former Administrator, Centers for Medicare and Medicaid Services. The second annual Lundberg Institute Lecture welcomes Dr. Berwick, who studies the management of health care systems with emphasis on using scientific methods and evidence-based medicine and comparative effectiveness research to improve the tradeoff among quality, safety and costs.

Event Description: In the ongoing difficult transition to the Obama health plan, Dr. Berwick’s analysis of these issues has been resisted, and even distorted, by some political opponents in the current public debate. Dr. Berwick concludes that “Any health-care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.” Also, hear Dr. Berwick’s ideas on how true delivery system reform – changing care to better meet the needs of patients, families and communities – provides a sensible and effective alternative to the much-feared threat of rationing of care. Click here for more information and to purchase tickets.

MLF: Humanities
Location: SF Club Office
Time: 5:30 p.m. networking reception, 6 p.m. program
Cost: $20 standard, $8 members, $7 students (with valid ID)
Program Organizer: George Hammond
Also know: In association with The Lundberg Institute

What the Rick Scott Decision Says About the Future of Health Care in the U.S.

Nov 29, 2012• 12

By Dan Diamond

In 2009, Rick Scott founded Conservatives for Patients’ Rights, a health care pressure group opposed to President Obama’s health reforms.

In 2010, Scott ran for governor of Florida on a mission to repeal Obamacare.

In 2012, Scott … will work to implement Obamacare.

For some conservatives, it’s a shocking reversal. Leaders of Americans for Prosperity, the conservative organization backed by the influential Koch brothers, were publicly disappointed in the Florida governor — who not so long ago said the Affordable Care Act was “the biggest job killer in the history of the country.”

Now, it will be Scott’s job to help implement it.

Changing Tune

Given his prominence, Scott’s move from Obamacare opponent to grudging supporter may be the biggest symbolic shift on the law since its passage.

The Florida governor was reportedly pressured by state legislators to negotiate with federal officials over the ACA, once November’s election made clear that Obamacare was here to stay.

But Scott won’t be the last GOP official to change his tune. More health care groups in other Republican-led states are putting similar pressure on their leaders to opt into the ACA’s Medicaid expansion, in hopes of securing additional dollars for providers.

Tobacco Companies Must Punch Selves in Face, Implement Court Orders

Nov 29, 2012• 6

By Christopher Robertson

The Washington Post covers a new order by DC district court judge Gladys Kessler, arising out of an old RICO case brought by the federal government, requiring that the tobacco companies publish advertisements to confess publicly that they previously lied about the safety of smoking and manipulated cigarettes to make them more addictive. I have pulled the district court order and posted it, along with this appendix. The order provides the exact language of the mandated advertisements, but no analysis. Below the fold, I trace the convoluted path this case and a related case have taken through the compelled speech doctrine around the First Amendment, all thanks to a single judge on the Court of Appeals.

A. Adverse Health Effects of Smoking

A Federal Court has ruled that the Defendant tobacco companies deliberately deceived the American public about the health effects of smoking, and has ordered those companies to make this statement. Here is the truth:

• Smoking kills, on average, 1200 Americans. Everyday.
• More people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol, combined.
• Smoking causes heart disease, emphysema, acutemyeloid leukemia, and cancer of the mouth, esophagus, larynx, lung, stomach, kidney, bladder,and pancreas.
• Smoking also causes reduced fertility, low birthweight in newborns, and cancer of the cervix and uterus.

ACOs: Is There a “There” There?

Nov 29, 2012• 2

By Vince Kuraitis, JD

A recent analysis of the ACO market by Oliver Wyman market suggests we’re well on our way toward being “there.”

My personal take on this report:

Provocative, fresh, thoughtful, well reasoned, expansive — albeit a bit of a stretch

However, I suspect many others will describe it as:

Speculative, harebrained, unsupported, overly extrapolative, out-to-lunch, wishful to the point of being woo woo.

So now that I hopefully have your attention, what’s this report all about? In a nutshell:

The healthcare world has only gotten serious about accountable care organizations in the past two years, but it is already clear that they are well positioned to provide a serious competitive threat to traditional fee-for-service medicine. In “The ACO Surprise,” our analysis finds that 25 to 31 million Americans already receive their care through ACOs—and roughly 45 percent of the population live in regions served by at least one ACO.

Let’s dig in to the report. In this blog post, I’ll summarize their math, surface their critical assumptions and observations, and comment on their reasoning. I’ve indented direct quotations from the report.

While I don’t agree with all of Oliver Wyman’s math and assumptions, I applaud them for the process they have gone through. Please take my commentary as “quibbling at the edges” and that overall I’m on board with their methodology and conclusions.

Health 2.0’s Berlin Code-a-thon, Sponsored by Aetna International Spurs Creation of New Mobile Apps to Improve Health

Nov 28, 2012

By Health 2.0 Staff

On the weekend before the third annual “Health 2.0 Europe” conference, Health 2.0 and the international arm of Aetna (NYSE: AET), the global health solutions company, invited the best developers, designers, health experts and health tech entrepreneurs to compete for € 10.000 in prizes at Health 2.0’s Berlin Code-a-thon, Sponsored by Aetna International. Their challenge was to develop innovative mobile apps to promote health and wellness across the globe.

The event kicked off on November 3 with the participants pitching their mobile app ideas to attract the other developers to their projects. Then, the real work began—small groups spent the next 29 hours transforming their concepts into working prototypes. On the evening of November 4, a panel of expert judges that included representatives from Aetna International and Health 2.0 announced the best of the best.

The winning app was “Jog of War,” created by four talented developers and founders of start-ups from Slovenia, Macedonia, Finland and Colombia. The app is designed to motivate people to be more active outdoors by encouraging them to run through their cities, and in so doing, “conquer” territories. The app tracks the jogger’s positions and marks the corresponding areas of the city in a map. Other joggers who run in the same area can reclaim the territory by running through it themselves. Once a territory is occupied, rewards and discounts from local businesses will be unlocked to the users.

Is the Readmissions Penalty Off Base?

Nov 27, 2012• 27

By Ashish Jha, MD

I’ve been getting emails about the NY Times piece and my quotation that the penalties for readmissions are “crazy”. Its worth thinking about why the ACA gets hospital penalties on readmissions wrong, what we might do to fix it – and where our priorities should be.

A year ago, on a Saturday morning, I saw Mr. “Johnson” who was in the hospital with a pneumonia. He was still breathing hard but tried to convince me that he was “better” and ready to go home. I looked at his oxygenation level, which was borderline, and suggested he needed another couple of days in the hospital. He looked crestfallen. After a little prodding, he told me why he was anxious to go home: his son, who had been serving in the Army in Afghanistan, was visiting for the weekend. He hadn’t seen his son in a year and probably wouldn’t again for another year. Mr. Johnson wanted to spend the weekend with his kid.

I remember sitting at his bedside, worrying that if we sent him home, there was a good chance he would need to come back. Despite my worries, I knew I needed to do what was right by him. I made clear that although he was not ready to go home, I was willing to send him home if we could make a deal. He would have to call me multiple times over the weekend and be seen by someone on Monday. Because it was Saturday, it was hard to arrange all the services he needed, but I got him a tank of oxygen to go home with, changed his antibiotics so he could be on an oral regimen (as opposed to IV) and arranged a Monday morning follow-up. I also gave him my cell number and told him to call me regularly.

What If Success Sucks?

Nov 27, 2012• 15

By Rob Lamberts, MD

“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees. I pay him to give me the stark reality of things, but his optimism made me uncomfortable. ”You’ve got to go for this. I know you don’t feel ready for it yet, but this could really be huge for your business, and I don’t think you should pass this up.”

I sighed. Yes, this is a victory of sorts (still only theory, not reality), but what if I can’t deliver? What if I fail?

“You know,” a colleague told me during another phone conversation, “you are the buzz of the medical community right now. We talked about you for half an hour at lunch today…and it was all good!” He went on to use phrases like “our only hope,” and “the way out,” to describe the potential for my practice model.

“No,” I thought, “I am not Obi-Wan. I’m not your only hope.” I sighed. I don’t want that kind of pressure on me before I even see my first patient. What if I fail?

Even worse: what if I succeed?

One of the main things that separates good clinicians from the rest is the ability to think through contingencies. When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z. Or, here’s the plan if you get better on the medication, and here’s the plan if you don’t. The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem. I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.