LighthouseView

September 25, 2013

The Road to Value-Based Purchasing in Healthcare is Emerging

Filed under: Uncategorized — HankMayers @ 3:35 pm

In my conversations with practitioners and administrators, one common refrain is serious doubt that the change from fee for service (FFS) to value-based purchasing (VBP) can be achieved. Indeed, I have to acknowledge that I have seen many a good big idea get lost in the details. And make no mistake; This is a VERY big idea.

Fundamentally, the current quality reporting/incentive programs must ultimately morph into vehicles that can enable VBP. And one of our practical problems is that there are quite a few different quality reporting programs at the federal level, and others within the private payer realm, that must come together, or at least be similar enough to avoid unacceptable increases in administrative burden and related cost increases.

After listening to a CMS information session on the Value-Based Payment Modifier (VBPM) program yesterday, I can say that significant progress is being made. Furthermore, I can add that the VBPM is a logically-incremental program designed to move us down the road.

Key themes undergirding the VBPM program include:
…….Based on existing NQF quality measures (process and outcomes)
……….Special subset of 17 measures are available from the following domains, consistent with current national quality goals:
…………clinical care
…………patient experience
…………population/community health
…………patient safety
…………care coordination
…………efficiency
…….Cost measures focus on (1) COPD, (2) heart failure, (3) CAD, and (4) diabetes
…….Various existing electronic reporting methods for quality measures all remain valid, including the EHR Incentive and the PQRS Incentive
…….The VBPM program factors for the complexity or clinical risk levels of the mix of the practitioner’s Medicare patients (a very important achievement)
…….A single reporting method for physician groups that elect this option
…….Can satisfy CMS requirement for quality reporting to avoid the start of penalties in 2015 for non-reporters
…….Successful VBPM reporters not only avoid the 2015 penalties, but may qualify for incentive payment premiums (up to 2%) if their quality and cost performance exceed the national mean for similar care and circumstances
………..If enrolled for the incentive, practitioners are also accepting the potential of a deduction (“shared savings/risk”) of up to -1% if their performance is well below the national mean for similar care and circumstances
…….There are a variety of detailed claims and patient reports that a practitioner can use to see how CMS arrived at the scores that a provider has/will achieve

Another part of the VBPM program is that it provides reports with analyses for current FFS practitioners, that are in groups (a TIN registered with CMS) of 25 or more physicians, which they can examine to see, from current claims data, how they might fare if they were to enroll in the VBPM and elected for the incentive payment. This is very helpful, and is the result of a lot input from physician groups.

This is a critical but complex topic, and I encourage my readers to go to the following CMS website to get more information.

    http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

This is a very important topic that all of us need to (1) understand at a basic level, and (2) monitor as we go down this road, as it surely will evolve.

November 29, 2012

Do You Intend to Avoid the Medicare EHR Claims “Payment Adjustments” (Penalties)?? I have an important alert for you.

I trust by now that my readers know that any entity, that is eligible for the Medicare EHR Incentive, that fails to be a meaningful user (MU) by 12/31/2014, will be subject to a payment reduction of 1% on ALL professional claims paid by Medicare. Continuing failure to be a MU’er in 2016 means a 2% reduction, and 2017 and thereafter means a 3% reduction.

The EHR Stage 2 final regs, released on 9/4/12 clarified when these meaningful use calculations must occur, and it may be earlier than some folks had been thinking. Generally, the entity’s status 2 years prior will determine if a penalty will apply. So:

As 2015 will be the 1st penalty year, one’s MU status in 2013 will serve as the determinate

When we consider the implications of this, it is important to remember that the Medicare incentive requires that, once you have achieved MU status, you must continue to meet MU criteria to receive the incentive in each of the 3 subsequent years.

Back to the implications:

• If you 1st achieved MU in 2011, you must do so in 2013 as well
• If you 1st achieved MU in 2012, you must do so in the following year as well
• If you are seeking your 1st year of MU in 2013, you can select any 90 day period, including the final quarter in the year, to achieve MU and avoid the penalty in 2015.

The feds have created a special provision on the Medicare payment penalties for entities who are making their 1st attempt at MU during the year just prior to the penalty year. Regarding the 2015 penalty year, you can avoid the 2015 penalty if you achieve your 1st year 90-day MU status (and complete your attestation reporting) prior to the final quarter of 2014.

• Because hospitals use the federal FY, in 2014, the achievement date will be July 3, 2014. This means their reporting window in 2014 would start no later than April 2, 2014

• Because the EPs use the calendar year, in 2014, the achievement date will be October 1, 2014. This means their reporting window in 2014 would start on July 3, 2014

If you are receiving the Medicaid EHR incentive from your state AND submit federal claims under Medicare for those program eligibles, your MU status under the Medicaid EHR incentive can affect your vulnerability for the Medicare payment penalty.

• If you achieved Medicaid A/I/U status in 2012, you were technically not yet a MU’er. So, your 1st year status as a Medicaid MU’er must be achieved in 2013 to avoid the penalty on your 2015 Medicare claims.

If you have been able to follow all of this (and this kind of thing generally takes more than one pass), you may be asking yourself why you cannot, as a Medicaid EHR incentive participant, be allowed to have the early part of 2014 to achieve your 1st year Medicaid MU Status and avoid the Medicare 2015 payment penalty. I have the same question. Once I get some clarification, I will produce another blog post.

Comments anyone???

March 25, 2012

Whose Data Is It Anyhow?

Filed under: Uncategorized — HankMayers @ 9:45 pm

As most of my followers know, I am a strong proponent of Application Service Providers (ASPs) as the best approach for securing an EHR, especially for the smaller sized physician practices.

While I continue to believe that the ASP is the option that most fully off-loads the technology burden inherent in using an EHR, I am hearing more and more frequently that it can be impossible to retrieve your patient records when it comes to “divorce time” with your ASP provider. Given that 500+ certified EHR vendors cannot survive the inevitable vendor shake-out in the EHR market, this lack of data portability is poised to become a very large problem a few years out.

It is my view that the federal EHR program agencies (the CMS, the ONC, and the Policy Committee) ) are in the best position to raise this issue and provide the necessary motivation for the vendors to be able to provide their clients with their patient records. And what I mean here is producing an electronic file that (1) includes the entire patient history that was recorded on their product for all practitioner patients, and (2) one that is structured so it can be used as a transaction driver on another vendor EHR product to build those past patient records.

Most assuredly, the technological considerations here are not minor. But they are most definitely not impossible. If the feds are going to penalize Medicare providers for not being EHR Meaningful Users, then they really are obligated to make the vendors deal with this important consideration.

Comments anyone?

November 7, 2011

Secrets For Coming Up With the HIT Solution With the Best Fit

Filed under: EMRs,Uncategorized — HankMayers @ 10:46 am

Recently, I got into an exchange with a colleague that was bemoaning the fact that healthcare entities frequently find thyemselves having to adjust to a vendor’s HIT product, rather than being able to use a solution specifically built for their needs.

I thought I’d further share my thoughts here on my blog…..

The conundrum that the industry faces is that any vendor HIT product has to be built with a vision of what the users need. The “users” in this case are the entire market. As a for instance, in the ED space, that means such products are built for most EDs of a particular scale. Yet such generalizing also means that the design is based upon design presumptions. If the vendor worked with an empowered user design team (regrettably, often it is a single medical adviser, or the product author), we can expect a design that will make sense to most of that market.

Even so, there will be compromises and the ultimate users will have to adapt to the product nonetheless. Otherwise, modifications to the product must be made to fit a particular customer’s ED, and either the customer takes over the maintenance of this customized product, or outsources this maintenance work to the vendor. As of right now, very few healthcare organizations are willing to make this kind of financial commitment. And given the current healthcare cost containment policy fixation (government, employers, and consumers), this financial limitation will be with us for a very long time.

It is my view that the upshot of all of this is that successful implementations of vendor products will require: (1) investment of serious/substantial effort by users in the evaluation selection of the vendor product (to find the least-disruptive solution), and (2) careful/adequate current state and future state process analysis by the clinical side under the watchful eyes of the CMO/CNO/CMIO, and (3) realistic resource (clinical staff time and funding) allocation so that the clinical organization is truly ready for the implementation.

There is an all-too-frequent tendency for the clinical side to simply pile on these kinds of assignments to current clinical staff who get no relief from ongoing care delivery duties. Because there are ALWAYS daily operational crises in healthcare, adding project duties to staff guarantees that the organization will not be adequately ready for implementation.

When we consider the nature of these business-intensive technologies, it is only natural that the “business” (clinical organizations) side be expected to make this kind of investment of its resources. However, most of our organizations are not used to thinking about information technology projects in this way. And, it’s not like the clinical organizations are flush with staff. Nonetheless, this is one of the implied commitments that are unavoidable with the newer, more valuable, clinical HIT solutions.

October 25, 2011

Cudos to GE for their forthright handling on MU problems

Filed under: Uncategorized — HankMayers @ 3:56 pm

It seems that the EHR market has experienced its first acknowledged serious customer problem, and the vendor, GE, has shown integrity in dealing with it.

According to Joseph Conn, at Modern Healtcare.com, a GE Centricity customer discovered that the MU reporting feature of their newly-implemented EHR was not working correctly and generating innaccurate attestation reports. GE, subsequently also discovered errors in data submission/recording for some patient demographics in the EHR.

After assessing the client’s concern, GE’s Vice-President, Michael Frigueletto, promptly advised its clients of the finding, and also advised the ONC and CCHIT. He has promised a fix by the end of November.

There will surely be other vendor missteps along the road to meaningful use. Let’s hope that everyone follows GE’s example of quickly and candidly responding to such events.

Comments anyone?

July 29, 2011

EHR Funding for Community Mental Health Centers?

Filed under: Uncategorized — HankMayers @ 10:47 am

On June 17, 2011, CMS published its proposed rules for Medicare regulations [Conditions of Participation (CoP)] for Community Mental Health Centers [ http://www.regulations.gov/#!documentDetail;D=CMS-2011-0123-0001 ]. CMS specified 6 CoPs, one of which was the requirement of a quality assessment and performance improvement program. Within that CoP, CMS refers to its acceptance of “an IT performace improvement project that allowed the CMHC to invest in information technology..” The wording goes on to say”… investment and development of an IT system that was geared to to improvements in patient safety and quality, as a QAPI project.”

While an EHR generally has significant potential to improve the quality of care, one could also simply invest in a whole lot less IT, such as a patient registry solution. Indeed, an EHR would directly further the achivement of at least 3 of the other 5 CoPs. Will CMS allow/encourage the pursuit of comprehensive EHRs under this rule?

Opinions, anyone?

April 16, 2010

Next Phase for the EMR in the Ambulatory Sector?

Filed under: EMRs,Meaningful Use,Specialty Clinical Systems,Uncategorized — HankMayers @ 12:56 pm

Historically, the value premise of the EMR is that:
1. It can simplify the exploding amount of paperwork associated with the medical claims processes, government monitoring of the public health, and access to and support of medical research,
2. It can reduce the significant costs in storing and moving paper charts,
3. It can greatly simplify the effort in sharing paper records amongst external practitioners,
4. It can largely eliminate the legendary complications associated with physician handwriting

None of those factors are going to change to any great extent; they are part of the very nature of health care in the 21nd century. Put another way, anyone hoping that EMRs are a fad is destined to be disappointed. The momentum for EMRs was building long before the feds put $34 billion on the table.

In the Healthcare Information Technology (HIT) market, EMRs have come to mean:
• A generic framework for a digital record of the care provided to a patient by a practitioner
• An electronic care record that is based on sufficient data standards that information within it can be exchanged electronically with other practitioners caring for the patient
• Provision of evidence-based care guidelines, care logic rules, or other capabilities to advise the practitioner on relevant treatment options, or alerts when a course of planned treatment may initially appear to conflict with care guidelines
• A convenient mechanism to report relevant quality measures to payers and the consuming public
The newest, generally acknowledged, expectations of an EMR is that
• Its data is sharable with a Patient Health Record system that is used by, and is focused on, the patient
• It provides an array of information to the patient to enable a greater engagement of the patient in managing their care and level of health

In vendor marketing of EMRs to serve a broad array of physicians, various specialists have found that EMRs do not address quite a few dimensions of their practice of medicine, and the management of essential patient and clinical information relevant to their slice of medical care. Indeed, a significant number of specialties have been using a specialty clinical system, specifically designed to support the care that they deliver. So it is not surprising when my conversations with some of them result in their sharing their conclusion that EMRs are really built for generalists.

It is my conclusion that they are more than half right.

However, specialists are unwittingly overlooking some of the things that EMRs, as a class of HIT, do so well. I would argue that an EMR, for a specialist, should be their link to the rest of the medical community. After all, it provides that ability to construct the base medical record. It also does that in a way that makes it sharable with the rest of the patient’s care team. It also puts them in a position to be informed of care events from beyond their walls. EMRs can also greatly ease the advanced clinical documentation/coding being increasingly requested by payers, including quality reporting. Finally, many EMRs provide patient-portals to help manage communications and basic transactions with patients.

While most specialists won’t dispute these features as valuable, they all are logically saying that the real value for an EMR for them is to seamlessly integrate with their specialty clinical system. In that regard, they have the same reasonable desire as their cousins in the inpatient setting.

This is a reasonable, but not necessarily easy to achieve, expectation.

The EMR vendor community has not been blind to this challenge. Many of the EMR vendors provide versions or features built to address the unique treatment models used by various specialties. One of the earliest additions was the ability to process and record DICON-based images as part of the chart. But it is clear, for many specialists, these are half measures.

I find myself quite interested in knowing more about how the vendor market is moving to address the evident need for the EMR products to integrate with the specialty clinical systems. Seems to me that there are 3 potential directions:
1. EMR vendors building strategic relationships to fully integrate with one or more market-leading specialty clinical systems, or
2. EMR vendors choosing to offer fully integrated specialty clinical systems for certain specialties, or
3. Specialty clinical system vendors building EMR “front ends” for their existing products

What are folks seeing in the vendor market on this front?

Comments, anyone?

Cheers
Hank

October 16, 2009

An Interim Approach To Sharing Patient Information Within Safety Net Providers

Filed under: Uncategorized — HankMayers @ 5:47 pm

It is generally known that the patients that  are served within the health care ‘saftey net’ are very mobile.  This, of course,  plays havoc with providing continuity of care. And enhancing the ability of the primary care physician (PCP) to deliver such care is one of the cornerstones of most versions of Health Care Reform being debated in the US Congress. Similarly, the safety net has a great need for the kinds of information sharing that goes to the heart of the objectives that lie behind the federal ‘meaningful use’ criteria in the recent ARRA Stimulus legislation.

In the health care safety net, one finds a wide array of providers: publically-funded hospitals, charitable hospitals (especially their emergency departments), federally-qualified clinics, rural health clinics, rural hospitals, nurse-managed clinics, private inner city clinics, etc. Many of these organizations are beginning to invest in various kinds of HIT (such as EMRs, e-prescribing, etc). The federal HRSA funding is a major provider of such funding, but its provider scope has been somewhat limited until quite recently. While the ARRA and its stimulus funds has not ignored this constituency, there is still is a need for a lot more clarity on how they can secure funds through related channels such as the states’ share of the stimulus program and the HITECH provisions of ARRA.

In the meanwhile, the inter-networking capability inherent in the NHIN/HIE funding would seem to be a very high priority/opportunity for the safety net providers. For this is the technology that promises to link them together in a way that will allow any PCP serving these very mobile patients to always have the full picture when a patient is presented. Until ED usage by this constituency can be deflected to other abulatory providers, ED units will be equally grateful to have this information at their finger tips.  It seems that a big question is: What data sharing arrangements can be made via the HIE  for little or no addtional costs to the safety net providers while this sector tries to secure funding for EMR technology?  For instance, the comprehensive EHR, that is expected to be continually updated inside of the HIE with summary information from care transactions, would seem to provide a valuable ‘minimum data set’ that could be used and updated by safety net providers. This would serve as their “EMR-Lite” until such time as they secure sufficient funding to embark  on a fuller EMR implementation.

This could serve as a high-priority objective for the HIE planning that is part of the current wave of state applications for federal HIE funding under HITECH. The recent federal guidelines relative to the regional extension centers (RITECH) already are placing an emphasis on services to safety net providers and the medically underserved. How about a similar expectation for the HIEs? This could come together quite nicely.

Comments anyone?

September 3, 2009

‘Unfriendly’ Personal Health Records (PHRs)?

Filed under: Uncategorized — HankMayers @ 3:42 pm

It seems that we may have some unintended consequences from the early versions of the PHRs.

A physician shared with me an increasingly frequent experience he is having with PHRs. This physician is a gastroenterologist. Apparently, patients are providing print outs of their PHR as a way of giving him their patient history info during registration.  It seems that these print outs can be rather massive. And, they inevitably include much information that has little relevance to the care that he provides his patients. Yet, there may be some historical information buried in there that may have bearing on anestheologies or other drugs that the patient has not tollerated well in the past.

The physician, who is usually time-constrained, is forced to apply significant time in revieiwing this material. Failure to do so, in any later dispute, will likely result in an assertion that s/he failed to apply due diligence. I am curious if other practitioners are similarly concerned, or other observers of the industry have heard similar comments.

Seems to me that the PHR systems could come up with data extract features that customers could use that would be less burdensome. Like, a feature that allows the user to define the time window of history that gets extracted.

July 2, 2009

Maybe Meaningful Use Will Not Require Buying a Full EMR Solution?

Filed under: Uncategorized — Tags: , , , — HankMayers @ 11:47 am

It appears that the CCHIT has taken a major step on 6/18/09 by preparing to allow provider entities to implement EMR solutions that are not based on purchasing a comprehensive, and in some cases, high cost, vendor package. It is my opinion that this is a MAJOR concession to the small practice entities, or other healthcare entities that have have built EMR capability over time with multiple solutions for which they added needed integration. The implementation of this change by CCHIT is subject to the finalization of meaningful use by the feds this fall.

For entities that do not want to purchase a comprehensive EMR, they would be able to opt for the EHR-M ProgramA new, modular certification program for electronic prescribing, personal health records, registries, and other technologies. These components would have to be certified products

There will also be Site-Level Certifications – …enable providers who self-develop or assemble EHRs from non-certified sources.

What draw-backs might the ONC perceive with this recommendation from the CCHIT?

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