May 25, 2017

Medicare Bundled Payments Starting to Get Push-back?

Filed under: CMS,Incentive Payment Programs — HankMayers @ 4:00 pm

HealthAffairs Blog published, on May 9th, an article on the “fatal flaws” inherent in the Medicare bundled payment (BPCI) program. See:

Their concerns are as follows:

  • Their specified bundles are currently focused exclusively on in-patient care
  • Bundles lack factoring in consideration of patient severity
  • Encouraging hospitalizations for acute exacerbations of chronic conditions that could be otherwise adequately treated in non-inpatient settings
  • Quality measure reporting is just reporting – no performance thresholds on which to measure payment incentives
  • The quality targets are designed to move with trends, but the delays in notice can take up to 6 months so providers are not sure of the targets that their care will be judged against while care is actually delivered

One senses that there is a desire to have physicians be more in the driver seat on defining and controlling the encounters and the resulting quality. Indeed, HealthAffairs goes on to cite the recent recommendations of the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Their recommendations apparently support an “episode of care model” developed by the American College of Physicians. Those recommendations include the following elements not currently in the BPCI

  1. Adjustments for patient severity
  2. Outcomes reflects gains and losses
  3. Physicians can self-assemble the best possible teams to manage a patient’s condition, illness, or injury
  4. Encouragement of teamwork across all involved physician disciplines
  5. Encourages physicians to find the most efficient and effective course of treatment and service setting for the patient

These are important factors that need to be properly incorporated into bundled payments. Of particular concern going forward, is that modifications need to be made, many along the above lines. However, the present administration in Washington has a penchant for declaring anything that preceded them as garbage. Hopefully, less polemically-oriented leaders will prevail, and an “improving/amending” approach will be adopted to make these changes.

We don’t need more confusion and discord in healthcare. We need continuing improvement.

March 31, 2014

The NIST Folks Chime-In on EHR Workflow and Usability

Filed under: CMS,EHR Incentive,Meaningful Use — Tags: , , — HankMayers @ 10:27 am

The National Institute of Standards and Technology (NIST) was directed by Congress to work with the ONC on the CHERT certification process as well as generally advise on the EHR effort. Given their background on the application of advanced technology, it is good to hear from them. Their findings reinforce much of what EHR implementers experience every day. One only hopes that the ONC can help champion this work in some fashion, and that the vendor community does not miss these considerations as they scramble to meet 2014 and 2015 CHERT changes.

While it is great to have the NIST credibility behind this topic, I have only one beef with their work; An organization with as broad a scope as they have, isn’t it about time that this analysis include a strong focus on mid-levels and other practitioners, who also must make considerable use of the EHR? With the advent of the PCMH, the significance of their use of the EHR is continuing to rise, and how the EHR enhances the staff integration of knowledge and activity is a key consideration.

If the NIST folks elect to perform a similar analysis of the INPATIENT world (which I hope they do), nurses, techs, and other classes of patient-serving folks are heavy users of EHRs in their own right.

One final observation: CMS’ ambulatory workflow in their DOCIT effort should have been included in the NIST research.

Thoughts anyone??

July 9, 2013

The EHR Auditors Are Coming??

Filed under: CMS,EHR Audits,EHR Incentive,HIPAA,Meaningful Use — HankMayers @ 11:15 am

Some of you may have heard that the CMS EHR Incentive program (for both Medicaid and Medicare) has begun the process of conducting audits of providers who have applied for, or have received their EHR incentive payment. There has been a lot of chatter as of late on this event, and not all of it accurate.

I can share with you the following facts and feedback that we are getting from CMS, HIMSS, and those being audited.

1. This does not represent some kind of negative political turn of events for the program. Yes there has been a number of congressional hearings on how the incentive program is doing. But these audits were always part of the regulations on the incentive program.

2. All providers are not being audited. Generally, the selections are made on a random basis

3. It is true that some providers are being audited before they receive their incentive. This is the case for providers seeking a Medicaid incentive. These pre-payment audits are apparently only focused on validating that the applicant has met the minimum threshold of Medicaid or “needy” patients (20%+ for pediatricians, or 30%+ for all other practitioners).

4. Medicare audits are conducted subsequent to the provider receiving his/her/its incentive payment.

5. One of the complicating factors is that the auditors’ requests are not consistent, but are changing, as the CMS auditing contractor, Figliozzi, gets clarifications from CMS on the way the regulations should be interpreted.

6. Your audit will require that you provide documentation to validate the data that you submitted in your attestation to CMS or your state Medicaid agency. The best strategy is to use the exact documents you used to construct your attestation – just like you would with your tax return. This would include:

a. Reports and/or screen shots from your EHR containing the data you submitted
b. If your attestation was for implementing, not using, your EHR (Medicaid only), the best proof is a confirmation letter from your vendor that their product was fully installed and available to you for implementation.

c. Copies of any patient lists you generated

d. Copy of your Risk Audit
……………1. Remember that it is possible that you could ALSO get selected for a HIPAA Security & Privacy Audit.
………………….This is an entirely unrelated audit process
……………2. Your EHR Risk Audit requires that you follow the HIPAA guidelines
………………….The HIPAA Audit will require that you ALSO be implementing remediation efforts on discovered short-falls in your current security & privacy practices
……………………….The EHR regulations do NOT require (at the present) that you be engaged in remediation efforts

7. If you fail the audit, you will be directed to refund your incentive back to CMS

8. There is a formal appeal process that is part of the EHR audit program.

9. CMS has published the following document on this audit program:

We are very interested in learning more from healthcare entities on their experiences with these audits. Please share your experiences by commenting on this blog.

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???

February 16, 2012

Date Changes Could Be Coming For A Number of Federal HIT Initiatives

Filed under: CMS,EHR Incentive,ICD-10,PQRI — HankMayers @ 1:55 pm

As many of my followers probably already know, the AMA recently wrote to HHS Secretary Siebelius and House Speaker John Boehner to complain over the numerous federal HIT expectations (PQRS, E-Prescribing, EHR Incentive, ICD-10 conversion, etc) and how they are cumulatively creating an unmanageable burden for physicians. The AMA was smart enough to not say they object to any of these undertakings. They simply insisted that the government make some choices as to priority, etc.

Even for those of us who are strong supporters of extensive application of HIT to improve the quality and effectivness of health care, it was understood that a great deal was indeed being expected of an a fairly conservative industry. The AMA letter was hardly a surprise, though its timing was a bit later than I expected.

Many of us know that statements made in governmental circles usually require some analysis to be able to undertand what they truly mean. The relevant portion of the official released statement from HHS is as follows:

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

With no disrespect intended, in government-speak, a “re-examination” can mean lots of things. Some adjustment MUST result to at lease confirm that the government was listening. The pressure from the other direction is the oft-referenced need to “bend the cost curve in health care.” The 17% of GDP that is health care, plus the continually growing annual health care cost increases at the federal and state levels are truly unsustainable. HIT is universally seen as a significant factor in costs reduction and care quality improvement. So HIT implementation MUST keep moving, and moving at an agressive pace.

So, it is my view that physicians that are hoping for a major let-up in the pace and expectations for HIT innovation are going to be sorely disappointed. How HHS finally responds here is going to be a very interesting illustration of statesmanship at the national level. And, HHS cannot overlong analyze this. All of us need a fairly quick decision.

September 26, 2011

The CY2011 EHR Incentive Payment Deadline Fast Approaching

Filed under: CMS,EHR Incentive,Meaningful Use — HankMayers @ 10:57 pm

Well, for eligible practitioners (EP) who would like to earn a 2012 EHR Incentive payment, they’d better be meaningfully using their EHR. That’s because starting on October 3, 2011 is the final 90-day window to satisfy the Meaningful Use criteria to earn an incentive payment for 2012 in either the Medicare or Medicaid programs.

If the EP fails to meaningfully use its EHR for all 90 days to 12/31/11, they’ll need to try again. Truth is, if the EP discovers that s/he fails to meet the criteria during part of that window, s/he can start over then – reset the clock. The EP’s 90 window is not limited to any particular window of time. That is, it does not have to neatly fit an annual quarter or whatever. It is 90 days after you set your start day.

So, if a late-starting EP trips during this last quarter of the year, the only loss is the cash flow of the practice. While that can be a serious consideration for the practice, they are not looking at any federal funding loss – just a delay until they get their meaningful use performance nailed down.

By the way, if a Medicare provider waits till 2012 to implement, and waits to start meaningfully using the EHR on 10/1/12 AND then fails to satisfy the Meaningful Use criteria for the entire 90 days to 12/31/12, then his 1st payment will be earned after 2012, and that means he will receive $5,000 less over the 5 year window than if he had met Meaningful Use by 2012. This loss only happens in the Medicare program.

May 21, 2011

EHR Incentive Money Begins to Flow & Adoption Patterns Begin to Emerge

Filed under: CMS,EHR Incentive,EMRs,Meaningful Use — HankMayers @ 9:09 pm

CMS has just released stats on how the EHR Incentive enrollment is going, as well as how the dollars are flowing:

Total Medicare Physicians Registering – 40,379
Total Medicaid Practitioners Registering – 2,014

Medicaid has paid out $5,525,000.00 to 260 practitioners for AIU-level activity
Medicare has not yet paid out any funds to physicians, as we are only now reaching the time window where 90 days of meaningful use could have been achieved in CY2011.

For the skeptics, please take notice that the federal funds are actually being disbursed!

The low rate of enrollment of Medicaid practitioners is probably a confirmation of the market claims that a Medicaid patient load of 30% generally means such a practice is running in the red. Most practitioners I have talked with foresee themselves as only eligible for the Medicare incentive.

A further interesting piece of data is that, of the 2,014 incentive registered Medicaid practitioners, only 260 are seeking AIU eligibility. The remaining 1,754 appear to be registering for full Meaningful Use. It would seem to follow that, at least up to April 2011, very few Medicaid practitioners are choosing to launch an EHR initiative as a result of the Medicaid EHR incentive dollars. Rather, the incentive is going to practitioners that already have an EHR. This piece of data warrants very close observation by Medicaid incentive program administrators who are committed to motivating their practitioners into EHR technology.

As the state RECs have generally shifted from marketing to service delivery, as of 1/1/11, it would seem that they could provide additional “pipeline” data on Medicare and Medicaid practitioners launching EHR initiatives. Hopefully, they’ll make such data available on the ONC website soon.

Nonetheless, it is good to see evidence of the EHR Incentive flowing.

Comments anyone?

July 22, 2010

CMS Recognizes That a 30% Medicaid Encounter Rate is a Rarity?

Filed under: CMS,EHR Incentive — Tags: — HankMayers @ 10:22 pm

The 1/13/10 draft Medicaid EHR Incentive required that an eligible practitioner (EP) have atleast 30% of its encounters be “attributable to Medicaid” in any 90 day quarter of the reporting year. Most physicians that I have talked with on this subject say this is a game-killer, as 30% Medicaid is the point where conventional wisdom holds that a practice starts becoming insolvent. This Medicaid EHR incentive requirement has always struck me as a major flaw or hole in the EHR incentive “balloon”.

It would seem, from a reading of the final regs, that CMS has taken a step to reduce the risk from this particular requirement, by adding a 2nd calculation method. The final reg allows a state (such as Michigan), in which Medicaid enrollees are assigned to managed care programs, to allow the EP to count the total assigned Medicaid managed care panel (or from other Medicaid assigned patient programs), PLUS all other Medicaid encounters during the reporting 90 day period. There is an acceptable proxy to this numerator calculation in which “an encounter with any [Medicaid] patient on the panel within the previous calendar year prior to the representative 90-day period when the patient was on the panel.” In all cases, the EP is not allowed to count any Medicaid patient more than once in the reporting quarter.

The intent, apparently, is to allow the EP to count any Medicaid patient in its panel as an encounter, plus any non-panel Medicaid patient encounters. It would seem that this is an advantage IF non-Medicaid patients generate much less frequent encounters.

Regretably, the state Medicaid program offices will not have ready data on this prospect, because indivdual service claims are not filed in managed care programs.

So, I am asking my practitioner friends to comment and let me know if they think this arrangement will help them achieve Medicaid EHR incentive eligibility!.

Thanks, everyone

February 23, 2010

Extra Motivations Needed For HIE Participation by Health Systems?

Filed under: CMS,EMRs,HIEs,Meaningful Use — HankMayers @ 12:29 pm

Now that the federal HIE Planning & Implementation grant awards are behind us, and work gets uderway, I find myself considering the criticality of the active participation by health systems in such HIEs. After all, the hospital usually owns the principal ED, and such central ancillary service providers as the major laboratory and radiology/imaging departments that serve the community. Electronic exchange of orders and results information with these ancillary entities is a major priority in the federal EHR incentive meaningful use criteria for eligible practitioners.

In spite of the fact that HIEs are a linchpin to interoperability, the federal meaningful use criteria for hospitals does not cite any requirement that the hospital EHR incentives require participation in multi-stakeholder HIEs.

Comments anyone?

January 13, 2010

Does The CMS 12/30/09 EHR Incentive Program Require Use of Patient Portals??

Filed under: CMS,EMRs,Meaningful Use,Patient Portals,PHRs — Tags: , , , , , , — HankMayers @ 11:32 am

There are many interesting items in the CMS 12/30/09 EHR document that we’ll be talking about in this blog over the next several weeks. The one I want to touch on today is the material in pp. 92 & 93. This Eligible Practitioner Objective require that “10% of their unique patients are provided timely electronic access to their health information.” The CMS explanation of this requirement on the following page is “…have timely access to their health information (for example, have established a user account and password on a patient portal).”

While the CMS narrative goes on to acknowledge that patient internet access will be a challenge (but believes 10% is reasonable for the present), it fails to acknowledge that patient portals, or Personal Health Record services, are some of the newest and less available features in the EMR market at the present time. There clearly is a lot of effort going on right now to create these features in the EMR product market. But is it really reasonable to make this a 2011 criteria – wouldn’t 2013 be better?

Comments anyone?

Hank Mayers

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