[Editor's note: the following blog post was written by Bonnie Cassidy, senior director of health information management (HIM) innovation for Nuance.]
Much has been said about the politics and jockeying of groups behind the scenes, lobbying either for or against ICD-10. That's not going to change. Healthcare providers must be proactive and plan for ICD-10 compliance, while also being agile enough in their planning to realize that another course correction may lie ahead.
In its latest news, CMS announced that Oct. 1, 2015 is the ‘new' final ICD-10 compliance date. "ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics," argues CMS in its July 31 announcement. I could not agree more!
My advice is stay positive, nimble and be wise by reading between the lines. Much has been said about the politics and jockeying of groups behind the scenes, lobbying either for or against ICD-10. That's not going to change. Our current administration in Washington, DC has been riddled with constant criticism and commentary scandals and may view the transition to ICD-10 as risky. All healthcare providers must be proactive and plan for ICD-10 compliance, while also being agile enough in their planning to realize that another course correction may lie ahead.
What steps do you do now to ramp up readiness efforts?
- Stay the course! You have an ICD-10 transition plan at hand; move forward with it. Update your ICD-10 project plans with dates and deliverables, built for an October 1, 2015 compliance date.
- Be nimble. Don't ever find yourself thinking ‘black and white.' We must expect the unexpected. If the government changes the deadline again, you adjust and do a course correction, but you don't stop and never blow up your plan.
- Focus on improving clinical documentation integrity throughout the patient stay. Be the champion for clinical documentation improvement (CDI) and focus on getting the right information into the right medical record at the right time because this will have a positive impact on quality, reimbursement, and coding regardless of shifting dates.
- Leverage technology to enhance your clinical documentation and coding workflow. Many providers use many manual processes, for instance,, Spreadsheets and sticky notes, for clarifications and queries in medical records and emails to physicians. Take this opportunity to assess your workflow and plan for technology-enabled solutions for assisting your medical staff and clinical documentation specialists with your CDI program and coding/compliance.
- Now you have 14 months to develop a customized dual coding program plan for your organization.
- Know your own data! Identify your high impact surgical procedures in various clinical specialties and train your coders the nuances of coding in ICD-10-PCS.
Stay positive, plan for success and always be willing to course correct should there be a shift in the ICD-10 compliance date.
Bonnie Cassidy is the senior director of health information management (HIM) innovation for Nuance, where she oversees the development and implementation of HIM strategies. She currently serves on the Commission on Accreditation for Health Informatics and Information Management (CAHIIM) Board of Directors, is a Fellow of AHIMA, an AHIMA Academy ICD-10-CM/PCS Certificate Holder and ICD-10 Ambassador, and a Fellow of HIMSS. Prior to joining Nuance, Bonnie served as the vice president of HIM product management & innovation at QuadraMed, and served as an executive with the Certification Commission for Healthcare Information Technology (CCHIT), Ernst & Young and the Cleveland Clinic Foundation. She was the 2011 President/Chair of AHIMA.
[Editor's note: the following blog post was written by Toby Samo, M.D., chief medical officer, Allscripts. This is the first installment in our 5-part series focusing on Global Healthcare Megatrends]
There are more than 7 billion people on the planet today. Our growing global population has triggered some of the biggest healthcare challenges we'll ever face. Listening to clients in Australia, Canada, Singapore, United Kingdom and United States, I believe many of these issues are universal. This post is one of a five-part series that explores the clinical, population health, financial, regulatory and technical challenges we share as a global healthcare community.
Caring for more patients than ever before
Worldwide healthcare providers are seeing more patients than ever before. In part, because we're living longer. In developed nations, there has been a huge increase in life expectancy over the last 50 years, and experts believe the trend will continue.
For example, U.S. citizens had a life expectancy of 68.2 years in 1950, which jumped to 76.6 years in 2000, and is expected to reach 83.9 years by 2050. Not only does that mean caregivers have more patients overall, but these patients are aging and require more health care.
Other cultural and economic factors contribute to an increasing number of patients. As middle classes expand in some nations, they seek more health care, more often. Countries that adopt universal health care models will also increase the patient population.
This growing number of patients heightens another global challenge: a shortage of primary care providers.
Providing the right caregiver at the right time
With more patients, the healthcare industry needs more caregivers. Several countries are employing "physician extender" positions to handle and coordinate routine care. These staff additions free the physician to provide expert care. Physicians can then practice at the top of their licensure, which is a better use of resources.
It also helps with clinician satisfaction as they are focusing their time on the patients that need their help the most. However, in some cultures this approach is more of a challenge, as patients may insist on seeing only the physician.
There is also an increasing types of sites of care. No longer will a patient only be seen in the physician's office. They may also receive care in pharmacies, schools, offices and grocery stores.
We must remember that quality clinical care is not just that patients can see any caregiver. It's that people receive the right level of care, no matter where they are.
Driving towards a single patient record
Most countries we work in are all large enough that choosing a single electronic medical record (EMR)* to facilitate data sharing is simply not an option. So everyone in the world is looking for ways to connect a virtual single patient record.
Even as EMRs gain traction in developed countries, we still struggle to communicate between organizations. Patient data does not easily flow among caregivers. New technologies are now appearing in the realm of Healthcare Information Technology to standardize and connect various systems. This technology will be at the hub of future healthcare delivery facilitating the movement of information between the many stakeholders of healthcare at the point of care.
Many cultural factors affect healthcare communications worldwide, including language. There are more than 6,900 languages spoken on this planet. Roughly 5% of the world's population speaks English as a first language, which takes third place to Mandarin and Spanish. This variety affects the single patient record on a most basic level: How do we manage patient data in different languages?
Measuring to ensure best practices
Many countries have identified important clinical measures. For example, it might be simple rates of immunization among children and influenza vaccine among adults. Or it could be more complicated measures of chronic diseases, such as regular Hba1c evaluations for diabetic patients.
Some countries are ahead in this process. Most developed countries have reporting requirements aims at improving quality of care. These is a movement towards setting up parameters that result in rewards, similar to Meaningful Use in the United States. Because it's not just about "checking the box" by ordering a certain test - it's about improving outcomes.
As we look at all of these clinical requirements, it's clear that proper use of EMRs can make a difference. There is still a lot of work to be done, and specific challenges to address in each region. But I'm encouraged by the progress I see globally.
Do these clinical challenges resonate in your part of the world? What other aspects would you add?
* Electronic Patient Record (EPR) is another term for Electronic Medical Record (EMR) or Electronic Health Record (EHR).
Please check back on Executive Insight for the rest of our Global Healthcare Megatrends series. We will highlight Population Health, Regulatory requirements, Technical landscape, and Financial models.
[Editor's note: the following blog post was written by Neil Pithadia, founder and CEO, I Will Change Healthcare]
Moe, the Two-Star Motel Repairman
I arrive at my motel on a road aptly named Motel Circle. As I approach my accommodation in my rental car, a man in a blue shirt that looks of Middle-eastern descent greets me. As he approaches me, I see his name, "Moe" sewn into his shirt I figure likely shortened for Mohamed. His sleeves are rolled up, he is carrying a paint bucket in his left hand and his pants are well worn with paint stains. I quickly deduce that Moe is the motel's repairman. He asks my name and we make small talk. We depart as I park my car and walk to the front office to check in.
"Good afternoon, Mr. Pithadia. I hope your journey from Texas was well." Perplexed, I ask the front desk person how he knew my name and furthermore how did he know I was coming from Texas. "Well, Mr. Pithadia I would like to say I have special powers, but you see Moe let me know that you had arrived and as per Texas, when booking with our agent, she made a note in our system that you were coming from Texas. So would you like to see my next trick?" Astonished, I nodded like a child. "Very good, you see this contraption to my right, I will now press this button and it will produce a document. This document is very important, so please focus." He pulled the document from the laser printer and flipped it so that I could read it, "you see that line [I nodded again], I need you to sign it should you incur any incremental charges." I chuckled as I signed and left the front office.
I booked the motel online two months ago getting a 15% discount. I thoroughly read the reviews online which were positive so I already knew I was getting good value in pricing. I was looking for an adequate no-frills budget motel to sleep for the night. However, the experience with Moe and the front desk was the type of welcoming you expect at a four or five-star hotel, but not the $58-a-night two-star Vagabond motel. Yup, that's right, Vagabond motel. The check-in experience was not expected and I wanted to know why Moe did what he did. I caught up with Moe working on some fencing and asked him if he did this for all customers. He chuckled with a genuine smile. He mentioned that even though this was a budget motel chain, the manager of the motel was a really good guy. "My family went through a rough patch with illness and the manager and owner helped me financially and allowed me to keep my job after being away for an extended time. It is the least I can do for them." In the scheme of things, any capable and competent handy person could do Moe's job. He, however, approached his job from a different angle. Moe was generating value for this motel all because Moe had a sense of purpose. His loyalty to the motel and manager was genuine. In his book, Drive, Daniel Pink points out that employees like Moe outperform once they are given two things: financial security and a sense of purpose.
All afternoon, I thought about Moe's situation. I was not asked nor given a survey to fill out, but instead I had a genuine desire to find a way to rave about what had just happened. I ended up spending two hours writing reviews on various websites. Whether the motel realized it or not, they had just generated "thick value." In his book, The New Capitalist Manifesto, author Umair Haque defines "thick value" as value, which is authentic, not created at someone else's expense, and is meaningful on human terms. According to Haque, organizations in the 21st century need to generate "thick value" to remain viable and that the era of "thin value" where organizations are shifting societal benefits to shareholder benefits is not viable.
Treat the Employee Right in Order to Treat the Patient Right.
If we treat our employees with the same level of care, we get those outcomes we so badly desire. A great example of a large organization that has embedded this mantra is the Ritz-Carlton. This motel group is synonymous with the best customer experience and they are upfront about it; their motto (Fig. 1): "We are ladies and gentleman serving ladies and gentlemen." Every employee carries around a pocket-sized card that describes the motel group's motto.
Be warned, having a flashy motto and forming a policy that all employees carry a card displaying it on their ID badge does not automatically translate into each and every employee indoctrinating the motto. This is where many of us in healthcare fail. We want to be sexy in healthcare: "Patient-first," "Top-tier," "World class," yet this falls short when it comes to translation. Why is that?
Ritz-Carlton knows that in order to translate its motto to a meaningful purpose, they must first empower their employees to do so. Each employee has the ability to spend upwards of a mind-staggering, $2000 a day per guest (1). This level of trust allows this organization to translate and deliver on their motto. What is Ritz-Carlton in essence? It is an experience, where luxury and desire intersect. They have developed a structure capable of providing this and have equipped their employees to deliver this experience. Accountability of delivering this experience lies solely on the employee.
What is healthcare in essence? You may mutter something along the lines of "delivery of quality patient care". Yet, these days we see zoom-creep in Doctors' offices, where we focus too much on an add-on service rather than the essence, itself. Things such as elaborate buildings, "diamond" or "medallion" services and free valet parking do not replace the fundamentals of quality patient care.
Lack of empowerment. How many frontline employees in Providers' offices do you know that are as empowered to take ownership of the patient experience? Most have become robotic "I apologize" machines. "I apologize Mr. Pithadia, the doctor is running late/behind" or one of my favorites, "I apologize Mr. Pithadia for waiting for an hour, but the doctor had to go to the hospital, he's going to have to reschedule your appointment." I have been short-changed many times when it comes to my time vs. their time to which I hear, "I apologize...." Never once has a front-desk employee said, "Mr. Pithadia, the doctor is running 20 minutes late, I'm going to tell him that you are waiting and he will be here in 5 minutes." These individuals are not empowered to make decisions that are best for the patient experience. The sexy motto of "Patient-first," can never translate into fruition because we have neutered our front-line employees.
The Powerless Healthcare Customer.
I knew exactly what type of service I would receive during my stay at the Vagabond motel. I was going to get a two-star motel for $58 a night. I had power as a consumer. By deciding to buy or not buy, consumers have created and decimated businesses-from motels, banking, travel to cellphones, pressure from consumers drive innovation and ultimately shift competition, prices, quality, and value. Yet, here is where healthcare remains unique. Healthcare has little price sensitivity and things such as market forces and consumer pressure do not affect price elasticity, quality or value.
Therefore, healthcare in America represents "thin" value. There are numerous articles getting lots of publicity regarding this. Steven Brill's Time's article, "The Bitter Pill: Why Medical Bills are Killing Us" (2) comes to mind which has stirred much attention. Brill mentions that large healthcare systems are thriving in this market, especially non-profits, terming them "non-profit profitmakers." Yet, it is these profits that are divorced from people being better off. So I ask you, healthcare leaders, what type of value are you creating for your patients?
We can open the discussion of how we got in this mess and how the larger issue is that millions of Americans are insulated from the true cost of healthcare. The point remains, that we are at a critical juncture where the purchasing power of the healthcare customer is becoming more relevant with advances in technology, pressure from government, and increasing transparency into our operations. Just in late April 2014, CMS called for the new P4P (Pay for Performance) measures in its Inpatient Prospective Payment System including requiring hospitals to disclose a standard list price for all medical services they provide. Whether or not this comes to fruition is yet to be determined, nevertheless, the customers are asking, "Where is the value?"
If we stick to the fundamentals of delivering quality patient care while instilling a sense of purpose and empowering our employees to make the best decisions for the patient experience and bring transparency to the consumer, we start to increase perceived benefits of the customer and this generates "thick value." We need a paradigm shift where we change the public's perspective of us. Not as "profit makers," but instead contributors to society, after all this is our distinct advantage.
1. Reiss, Robert. "How Ritz-Carlton stays at the top." http://www.forbes.com/2009/10/30/simon-cooper-ritz-leadership-ceonetwork-hotels.html
2. Brill, Steven. "The Bitter Pill: Why Healthcare Bills are Killing Us." http://www.time.com/time/magazine/article/0,9171,2136864,00.html
Neil Pithadia manages a multidisciplinary surgery group in Dallas, Texas. He is also Founder and CEO of I Will Change Healthcare (www.iwillchangehealthcare.com)
[Editor's note: the following blog post was written by Bonnie Cassidy, senior director of health information management (HIM) innovation, Nuance]
With the ICD-10 transition date now at least 16 months away, we must think about the impact this has on the workforce that was hired or educated with the original date in mind
The American Health Information Management Association (AHIMA) represents 74,000 members who have been preparing for ICD-10 for years. With the transition date now at least 16 months away, we must think about the impact this has on the workforce that was hired or educated with the original date in mind. Across the U.S, ICD-10 transformation teams have been assessing, training and implementing technical changes that were to be in place on October 1, 2014.
"This frustrates me. For the last 4 years of my career I have prepared for this transition, passed the AAPC ICD-10 Proficiency Assessment, and our government once again decides THEY aren't ready. How am I supposed to convince my surgeons that they have to work on this when it keeps getting delayed?" certified coder/auditor
Hospitals and provider offices in the U.S. hired skilled HIM coding professionals to prepare for the transition to ICD-10. Some were consultants, coders, and project managers while others supported revenue cycle and HIT initiatives. What are these organizations going to do now with these highly-skilled members of the workforce? There are concerns that smaller hospitals and health systems may be forced to have layoffs, while others may redirect these resources to Meaningful Use initiatives or stay the course while being champions for ‘No ICD-10 Delay'!
As a past president of AHIMA, I have been meeting daily with HIM colleagues across the country as they rethink their strategies for ICD-10 implementation. The ripple effect of this latest delay has been devastating for some, particularly new graduates. There are still so many refinements that must be addressed for ICD-9 and ICD-10 coding workflow redesign, that HIM resources are critical for the much needed fine tuning of clinical documentation to ensure the highest level of accuracy for both financial and clinical success - not to mention optimizing the use of new technologies tied to the current and future state of the healthcare coding system.
"We are going to find ways to use these employees we hired to do I-10 coding. There seems like there is so much need for documentation, classification and informatics in healthcare we will make sure to find use for these folks in the interim," reports Todd Strumwasser, CEO of Swedish Seattle.
The Impact of the Delay on Resources
- New grads and new hires - They expected their coding skills would be in high demand and now find that some of the anticipated vacant positions have vanished. This delay casts a cloud on the employment prospects of more than 25,000 students who have learned to code exclusively in ICD-10 in HIM associate and baccalaureate educational programs. We must ‘stay the course' and hire these precious resources.
- Physicians and practices - Some fell behind on their ICD-10 implementation and rejoiced at the delay news, but professional practices should use the time to prepare their clinical documentation for improved ICD-9 coding while they implement CDI programs.
- Coding educators - Coding education programs and educators had switched to teaching only ICD-10 codes to students, but now are reevaluating their educational plans and transition timelines, and are putting ICD-9 back into the curriculum and certification exams because new graduates need both ICD-9 and ICD-10 to work. This is a costly effort, as it requires re-training as well as redesigning coursework to appropriately prepare students.
- Tax payers - CMS estimated that another one-year delay of ICD-10 would cost the industry an additional $1 - $6.6 billion on top of the costs already incurred. This does not include the lost opportunity costs of failing to move to a more modern and specific code set, which better supports population health and data analytics to identify optimum clinical treatments on different types of patients. Don't kid yourself. We are all paying for the delay in some way.
The ICD-10 delay has been devastating to some and costly to all. My advice to healthcare executives and clinicians is do not stop your ICD-10 transition planning. Stay the course and use the time for testing and auditing so you will be prepared for success.
[Editor's note: this blog post was written by Michael Murphy, MD, founder of ScribeAmerica]
Medical scribes and medical scribe vendors are riding a new wave of change in the American healthcare system where doctors and hospitals are being consistently called upon to do more with less. But if there's one thing to remember in medicine it's that there's not always a one size fits all solution for every problem.
Medical scribes work hard to master the complexities of various EHR systems to help doctor's focus on medical decision making rather than being highly paid data entry specialists. As scribes continue to become the standard practice in emergency departments from coast to coast some groups are critically evaluating their provider to patient staffing ratios and whom they use to work those provider hours.
But when is it the right time to add medical scribes? No doubt the simplistic mind looks at scribes as a line item, but are they really an added cost or if implemented correctly a net revenue item? Would it be a better investment to hire a nurse practitioner (NP), or physician assistant (PA) who potentially can do more within the organization than just document on EHRs?
That answer historically depends on the needs and size of your organization, but I would argue it depends more on the provider to patient staffing ratios, which really should drive decisions about additional coverage. Most large emergency departments with more than 20,000 annual visits likely have the resources and needs to bring on both scribes and PAs/NPs. What if your hospital is smaller than that? Does it make more sense for you to bring on a PA/NP rather than a medical scribe or vice versa?
Looking at the numbers
For many hospitals PAs and NPs have proven to be an effective means of dealing with the demand for more doctors without having to pay the full salary of a doctor. Nationally, the average salary for a Emergency Medicine doctor is about $250,000 per year, versus $87,000 for nurse practitioners, and $79,634 for physician assistants.
However, for an average of $20-$23 per hour you are able to hire a medical scribe with the ability to customize their hours to fit the needs of your organization. So taking an 18k volume ED where you see on average 2 patients per hour but experiences boluses of up to 5 patients per hour. The department may want a PA/NP for about 6 hours per day to cover those busy hours, however cannot hire someone for 6 hours and are forced to pay for a 10 or 12 hour shift and thus significantly affecting the revenue flow. Replacing the PA/NP with a medical scribe will put a spring back in your provider coil and allow you to see those large volumes of patients that you once could not, without one. At the end of the day, you have a net revenue positive of $200,000 annually while not compromising patient care. In today's Healthcare environment, this is a significant impact on the bottom line.
Medical scribes enable a physician to see and treat more patients. Whereas a PA or NP can help divert patients with smaller problems away from a doctor to allow them to focus on the most serious cases. A study by medical system reviewer Software Advice found that NPs and PAs on average can perform about 80 percent of the same tasks that a doctor can.
When is a right time to add PA/NP? Well let's look at a 60k volume ED with an average provider to patient ratio of 2.08. This site has 56 physician hours and 24 PA/NP coverage daily. Due to decreased reimbursement and a new lower payer mix, the emergency department now requires a subsidy from the hospital to keep its doors open. Instead of taking this subsidy why not consider changes to the staffing model to increase your PA/NP utilization and reduce your physician hours? If you were to go to 36 physician hours and increase your PA/NP coverage to 48 hours you could even add 60 hours of medical scribe coverage and be budget positive roughly $320,000.
The above approach reduces the provider to patient ratios to 1.98 and emphasizes the physician as the quarterback, assisting the PA/NP with most cases.
Consult the budget
With those numbers in mind the next step in your decision-making is to consult the budget. Can you really afford to hire, a PA/NP or a medical scribe, considering that reimbursements cuts are a common theme in government discussions.
If the answer is no, you might consider looking at it in another way. Will your organization in its current form be able to effectively weather the big changes taking place in the American healthcare system over the next year? Between the ICD-10 implementation, the Two-Midnight Rule, and the major provisions of the Affordable Care Act taking effect it's likely you need to be preparing either through hiring additional staff, training existing staff, but more likely, both.
Assess EHR comfort levels
The next step is to assess your physicians' comfort level with EHR's. Many physicians find them challenging and get in the way of patient care. National data on EMR implementation has shown, that physician productivity decreases and persists 6 months after implementation. A medical scribe solution could be the best answer and most cost effective.
Consult your Press Ganey and HCAPS scores
Next you can consult your Press Ganey and HCAPS scores to see where there is room for improvement, regardless of whether your scores are high or low overall. For example if patients are complaining about long wait times to see a doctor, more than their quality of interaction with the doctor then either a scribe or mid-level provider solution will reduce the door to provider times.
Making your decision
The prevalence of both medical scribes and PAs/NPs are the result of the changing landscape of healthcare in America. Your critical analysis should consider the cost benefit of a scribe or PA/NP, take into account how your physicians are incentivized, and the overall provider and patient satisfaction. It's important to be prepared for the big changes ahead, but it's also important to consider other options when increased coverage is demanded.
[Editor's note: this blog post was written by Jackie Griffin, associate vice president of client services at TriZetto Provider Solutions]
It's less than 10 months until the ICD-10 deadline, but many providers are finding it difficult to get started with their ICD-10 planning. Others have started their efforts, but a transition of this magnitude can be overwhelming, and many don't know what the next step should be.
Whether you're stuck in the middle of planning or still trying to get started, here are five steps to help make your ICD-10 plan more manageable:
Identify all the places where your practice uses ICD-9 in current workflow. Some examples of areas where ICD-10 will impact are clinical documentation, EHRs, superbills, paper claims, electronic claims and reporting for government agencies. Wherever ICD-9 is used, there will be an ICD-10 impact, so identifying these areas now will help you plan how to transition them.
Conduct a gap analysis to understand where you need to be by October 1, 2014. The results of the analysis will help identify any gaps within your workflows, documents and technology systems that will make it difficult to transition to ICD-10. You'll need to focus your preparations here to avoid any negative impacts to your practice, such as delays in reimbursement or inefficient use of staff time.
Identify solutions that can help your practice transition in these areas, such as new coding books, new superbills and new paper claim forms. For nearly every practice, these solutions should include updating your existing software to accommodate ICD-10 codes. Your practice management software vendor and your clearinghouse may have already notified you about how they are updating their systems for ICD-10. If you haven't done so, contact your vendors to learn whether you need to install new upgrades for ICD-10.
In addition, you need to think about how you will train your clinical and front office staff for ICD-10. Some industry associations, such as AAPC, offer training boot camps to get your staff up to speed. Other organizations, including CMS
, offer ICD-10 resources on their websites for you to use to help prepare staff.
Outline your ICD-10 plan. Start by listing the solutions you plan to pursue, steps needed to implement them, expected cost for each step and timeline for completion. This will help you budget your time and resources appropriately.
Industry research estimates that transitioning to ICD-10 will cost the average 10 physician practice more than $200,000. In addition to the costs associated with preparation, many practices will experience delayed reimbursements and decreased productivity once ICD-10 takes place. It's recommended that you secure a line of credit at least six months prior to the ICD-10 deadline so you can keep your practice afloat.
Implement your ICD-10 plan. This will include training your staff, learning how to use new versions of your EHRs, installing software upgrades, adjusting internal processes, testing your claims with your clearinghouse or payers, and establishing a line of credit.
In addition to these steps, this ICD-10 Planning Worksheet is a helpful tool to guide your practice through each part of your ICD-10 transition.
Planning for ICD-10 is overwhelming, but attempting the transition without a well-organized plan could be catastrophic for your practice. I encourage you to take the time now to organize your efforts, one step at a time, to ensure you are ready for the deadline.
Editor's note: This blog post is written by Alex Tolbert, founder of Bernard Health.
Our healthcare system is broken partly because consumers don't
know what anything costs. As patients become more proactive in making informed
healthcare decisions, we all agree this should be fixed. But why is it so hard?
Achieving price transparency in healthcare is difficult because healthcare
business models rely heavily on a lack of transparency.
Insurers, hospitals and providers want a better healthcare
system as much as anyone, but can't afford to inflict damage on their businesses
by making prices transparent overnight.
To better understand how transparency affects healthcare, let's
take a look at the business models for insurers and hospitals.
Insurer Business Model
If prices were completely transparent, then insurance companies
who had negotiated the lowest prices would begin to lose their primary
advantage. This is because that pricing information would give medical
providers and other insurance companies more power when negotiating and
competing with them.
An insurer's business model can be boiled down to this:
- Negotiate discounted prices with providers.
- Insure people, collect premiums.
- Pay claims to providers at discounted prices.
- Keep the difference.
Since that is the business, here is how you win financially:
- Negotiate the lowest prices with
- Offer the lowest premiums so you can attract
the most insured people.
- Enjoy the virtuous cycle that ensues.
What virtuous cycle?
The more people you insure, the lower the prices you can get
from providers. If you can get the lowest prices, you can offer the lowest
premiums. Offering the lowest premiums will win you the most insured people,
and so you can continue to negotiate the lowest prices from providers. And so
Hospital System Business
If prices were completely transparent, then it would be
difficult for the hospitals to justify the high prices they charge for things
available elsewhere for a fraction of the price. In other words, if everyone
knew that "Procedure ABC" costs $3,800 at the hospital and $600 for the same
quality at a standalone facility next door, the hospital would lose a lot of
The typical hospital system business model can be boiled down to
- Negotiate prices with insurers to be
- Get paid at those prices on patient claims
submitted to insurers.
- Pay your doctors, "midlevel" providers, nurses
and facility/equipment costs.
- Keep the difference.
Since this is the business, here is how you win financially:
- Negotiate the highest prices with insurers.
- See as many patients as possible.
- Submit as many claims as possible for each
It's a lot easier to do more tests/procedures per patient than
to attract more patients. As such, your contracted prices for tests and
procedures are really important.
Fortunately, as a hospital system, your size gives you leverage
when negotiating with insurers. The insurers need you in their network more
than they need a given imaging center. As a result, you're able to negotiate prices that are a lot higher and still be in-network.
Fueling the Movement Toward
Creating a better healthcare system starts with price
transparency. The growth of health savings accounts and transparency start-ups,
like Healthcare Blue Book and Change:Healthcare have fueled the movement toward
In addition, insurers and hospitals are working hard to provide
transparency. To offset the damage transparency will inflict on their business
models, they're working to develop other competitive advantages.
As consumers continue to share the burden of ever-increasing
healthcare costs, it's only fair that they be armed with the information needed
to make informed decisions about their healthcare. This transparency will lead
to a better-functioning and lower-cost system with happier providers and
Editor's note: This article was posted with permission from its author, Christine Gondos, Igloo Software. She can be reached at email@example.com.
The fastpaced healthcare industry is continuously evolving --
whether it be newly released studies, new best practices or new techniques, the
healthcare community thrives off of innovation.
annual conferences provide the opportunity for healthcare professionals to
connect, the majority of professionals rely on email to exchange new findings.
Healthcare professionals have recently placed an importance on social media
networks (such as Twitter) as an additional outlet to exchange ideas. While
social media provides an opportunity for medical professionals to connect and
discuss best practices, this ultimately becomes problematic due to the
confidential nature of the discussions.
how can healthcare professionals network, engage in conversations about practice and
share knowledge while maintaining confidentiality and ethical standards?
Software's Senior Vice President of Marketing & Operations, Andrew
recently presented at the CIO Healthcare Summit where he discussed "How
Healthcare Organizations are Moving from Social Media Marketing to
Business Strategy." Instead of connecting on public social networks,
more healthcare organizations are creating a social business strategy so
can collaborate on their own private network.
Secure enterprise social platform
organizations like Igloo
unite healthcare professionals, practitioners and
patients so they can collaborate on ideas and keep information in one
area. After a patient leaves the office, you no longer need to feel that
sense of ambiguity questioning if you remembered everything he or she
longer does a conversation need to live in the room you had it; nor your
inbox, nor your notebook.
Enterprise social software erases ambiguity and allows information to be
accessible yet secure. Here are four use cases of how enterprise
social software enables healthcare professionals to stay connected outside the office.
- Kimberly-Clark Clinical Solutions
is a health division of a large consumer goods company that has a very large
health product portfolio including medical devices & infection prevention.
To facilitate research, they launched a social extranet solution to act as a
product evaluation center for open innovation & customer engagement.
- Ontario Health Quality Council,
an independent provincial body for patient care, coordinates a myriad of
stakeholders in a member portal to report on the health system's effectiveness
and opportunities for process improvement.
Are your patients curious about learning more
information about what you said in a recent appointment? While you may question the
validity of checking Wikipedia or the intimidating results Google reports back,
patients often feel alone when they leave their provider's appointment.
Healthcare organizations realize this and have bridged the gap by offering
patients a portal where they can connect.
National Medical Center provides patients with a secure, private virtual
place where they can ask questions, find answers and share experiences around a
specific health condition. Their Emergency Medical Services for Children
Program (EMSC) National Resource Center also provides a secure portal for
grantees to interact and share information with each other in support of EMSC's
national child advocacy programs.
Want to bring together key stakeholders within a healthcare
association to work together and improve healthcare delivery? A
conference may be a great way to get everyone together, but how will you
Enterprise social software platforms provide practitioners a
specific work area where they can collaborate on documents and share best
Drug Information Association uses a social
extranet to connect their 18,000 members in the biopharmaceutical industry for
online learning, collaboration and managing their communities of practice.
Since adopting this new form of technology, their collaboration tools are now
streamlined and this area facilitates knowledge exchange and relationship
building in a private member portal for their 32 special interest groups.
American Academy of Family Physicians (AAFP),
representing more than 100,000 family
physicians and medical students nationwide, improved their collaboration since
launching an online community for peer networking, information sharing and
practice transformation. Members have access to online seminars, practice
tools and the "Ask An Expert" area. Known as Delta Exchange, the award-winning online
network connects physicians, clinical staff, office staff and primary
care-focused residency programs committed to the Patient Centered Medical Home.
wholly-owned subsidiary of the American Academy of Family Physicians (AAFP)
also capitalized on the benefits of social collaboration. In an effort to
improve patient care and assist primary care physicians with medical practice
redesign, over 500 practices and more than 5,000 medical professionals across
the country connect and collaborate using Igloo Software.
External facing communities (extranets) have gained
tremendous momentum for healthcare organizations. Effective collaboration,
improved knowledge sharing, and accessibility anywhere - it is no wonder that
more and more healthcare organizations like The College of Family Physicians of Canada,
are adopting social intranets to collaborate inside their organization.
Bye bye filing cabinets and shared folders.
The organizations mentioned
above stay organized with hierarchical storage of documents with unlimited folders, inline preview
and full version control. Organizations and associations in the
healthcare industry now have the power to stay connected to other healthcare
professionals, practitioners and patients in a secure environment where
confidential information is safe.
For more information, visit http://www.igloosoftware.com/blogs/inside-igloo/continuingtheconversationoutsidethedoctorsoffice4waystostayconnected
(Editor's Note: This guest blog was written by Frankie Rios, CISSP, VP information security and compliance, GNAX.)
Cloud computing and storage is an undeniable migration path and IT strategy.
Overall spending on cloud technology is expected to reach an estimated $150 billion annually by 2014, according to a recent Gartner Group study. And within healthcare, 35 percent of health IT professionals surveyed said their organization was implementing or maintaining cloud computing in 2012, up from 30 percent in 2011, according to a new survey by Vernon Hills, IL, technology vendor CDW.
However, not every software application in healthcare is a candidate for moving to the cloud. And many old myths about cloud computing and cloud storage continue to confuse both covered entities (CEs) and business associates (BAs).
The HIPAA omnibus rule, released in January 2013, basically incorporates the HITECH Act security provisions into HIPAA, confirming the security and privacy requirements in the utilization of technology in healthcare. Below are five key changes under the HIPAA Omnibus Rule:
- BAs of CEs are now directly liable for compliance of certain privacy and security rules.
- The rule strengthens the limitations on the use and disclosure of PHI for marketing and fundraising, and it prohibits the sale of PHI without individual authorization.
- It adopts the increased and tiered civil monetary penalty structured by the HITECH Act.
- It mandates breach notification for unsecured PHI under the HITECH Act.
- It modifies the HIPAA privacy rule as required by the GINA (Genetic Information Nondiscrimination Act), prohibiting health plans from using or disclosing genetic information.
With the increased focus on cloud computing, healthcare organizations should develop a set of criteria that helps evaluate potential cloud vendors and their compliance with these requirements. Here is a list to help healthcare providers get started.
In order to protect themselves, CEs should perform a risk analysis on all potential cloud vendors. The risk assessment should include policies, privacy and security awareness training, account management, physical security, business continuity, incident response, and media disposal. Maintain assessment documents and vendor responses for six years and have them readily accessible should Office of Civil Rights auditors come knocking.
Review your existing Business Associate Agreements (BAAs) with cloud computing partners and ensure they are updated to comply with HIPAA omnibus. For example, contract language should be specific as to the service, usage, and location of the data to be stored in the cloud.
For cloud-based partners using multi-tenant hardware, specific technical and procedural controls for sequestering information by CE or BA should be stated and included in contracts. An indemnity clause must be included stating that the cloud vendor carries enough insurance to cover a breach.
Know if the existing or potential cloud vendor has been audited. Do they have a current SSAE report? If there were findings, is there a documented remediation plan? Are regular, internal audits conducted, and is the cloud vendor willing to share the results?
Does the vendor provide encryption for the communication of information and the data at rest? Encryption is the best way to protect data and prevent breaches. HITECH requires that communication pathways and data storage devices are encrypted. Ask cloud vendors to define their encryption methodologies for both.
Business continuity has always been a must have with cloud-based solutions. Some of the new omnibus requirements make it even more important for CEs and BAs. Questions to answer include:
- How redundant is the vendor's power?
- How many power feeds does the vendor utilize?
- How many Internet feeds?
- How often do they perform tests of their systems?
- Do they keep their equipment sufficiently maintained?
Cloud solutions will keep your PHI private, secure, safe, and in compliance with HIPAA's omnibus rule. Your effective due diligence ensures that they do.
Editor's note: This blog is written by Anthony J. Hall, RN, BSN,
behavioral health charge nurse at Atlanta Medical Center.
The Affordable Care Act (ACA) means major changes in the way
Americans view health issues and treatment options. While there is increased
optimism building around the plan's effect on patient care, healthcare
providers will bear the burden of the plan's negative impacts, such as a
shortage of primary care providers. Though the full impact on the medical
profession has been hard to gauge, providers can be primed for some positive
adjustments as a result of ACA.
It's easy to see the immediate benefits of the ACA for healthcare
recipients - many more families will be able to schedule regular visits to a
general practitioner or family clinic, meaning more check-ups and preventative
For healthcare professionals, this increased patient load means
more providers will be needed; some will gain traction in positions of greater
authority as those with less experience are hired. The shortage of primary care
physicians will mean increased access to nurse practitioners (NPs) and
physician assistants (PAs), allowing localized healthcare to more patients, making
it unnecessary to travel to distant hospitals.
The increased presence of non-physician providers such as
laboratory professionals, respiratory technicians, NPs and PAs in
decision-making positions will bring a heightened awareness and a sense of
respect that has been long overdue. In my work with patients and the general
public, I've encountered many people who are uncertain of the role these
professionals play; by virtue of increased demand, more patients will become
aware of our importance in healthcare.
While many hospital systems are consolidating, combining forces
and units to avoid producing duplicate services, job cuts in the hospital sector
will provide an upswing in business for small practices, family clinics and
general practitioners. This change is likely to mean an increase in employment
for providers in all areas of specialization.
If you are interested in submitting to the Politics of Healthcare
blog, please contact Kelly Wolfgang at firstname.lastname@example.org.
Editor's note: This blog is written by Miguel
A. Bustillos, department chair and professor at California University of
Management & Sciences in Virginia.
us have heard about the Medicaid expansion and how states like Florida, Texas
and Virginia are against it. Some do not understand why the Medicaid expansion
has become such a big issue or what exactly the Medicaid expansion is.
Medicaid expansion, expected to be fully implemented by 2014, is a plan under the
Patient Protection and Affordable Care Act (PPACA) to expand medical coverage
for a number of people who do not qualify under the current plan. The Medicaid expansion
mandates that a state must meet PPACA standards to receive full federal funding,
which is needed to increase the current plan. The largest problem involving the
mandate is how states will cover the "new eligibles," those patients who are
receiving Medicaid assistance for the first time. It is estimated that 15.9
million new enrollees will participate in the plan by 2019.
federal government currently pays, on average, about 57% of the total cost of
Medicaid enrollees in each state. Of those that qualify for Medicaid, only 62%
have signed up for Medicaid benefits, leaving the remaining 38% without benefits.
Generally, those that are not taking the benefit either don't know that they
qualify or refused the benefit.
were to accept the Medicaid expansion, they would continue to pay for the
benefits of the 62% that are currently covered; in addition, they will have to
cover the 38% that qualified under the previous requirement, but did not take
the benefit. According to the new mandate, states must also provide for the new
the Medicaid expansion mandate, the federal government will continue to pay the
cost for about 57% of the 62% that are currently taking the benefit. With the
new law, the 38% that did not receive benefits will now either take the benefit
or pay a tax penalty. Some states believe that those who are qualified will
take the benefit rather than pay the penalty. Despite the "new enrollee" status
of those patients, the government will not support funding for any persons who
previously qualified but did not receive benefits.
regards to the true new eligible, the states believe that the cost of providing
Medicaid is just too large for any state to handle. To lessen the burden, the federal government has
penned an agreement to cover 93% of the cost of the true "new enrollees" till
the year 2020.
will decline to take on the Medicaid expansion because it's a voluntary program.
The new law can be very taxing to any state's budget and in most cases, there
are not enough incentives for states to adapt the program.
federal government is, however, not worried. When Medicaid was first signed
into law in 1965, only six states agreed to participate. But by 1982, every
state had joined. As 2014 comes along, and the law comes into full effect, it
will be interesting to see what develops and what does not. With the cost of
providing healthcare to so many people being so high, and the fact that
Medicare benefits will be cut to fund the Medicaid expansion, I foresee much
resistance on its implementation.
reported on Newswise, the
following is a statement by Jo Ivey Boufford, MD, president of The New York
Academy of Medicine, one of the nation's oldest and most prestigious medical
academies, on the seriousness of gun violence as a major public health issue.
The statement is in response to deadly incidents of gun violence in Newtown,
CT, Webster, NY, and the shooting of 15 individuals, three of whom died, during
separate acts of gun violence in Chicago, IL on New Year's Day.
"As a nation, we can only improve the health of the
public when we get our priorities straight. Recent acts of gun violence in
Chicago, Webster, NY, and Newtown, CT cannot be ignored. Neither can the 31,000
Americans who die each year at the hands of a gun. This number exceeds the
number of babies who die each year during their first year of life (25,000) or
people who die from AIDS (9,500) or illicit drugs (17,000).
institute protective measures enforcing speed limits and requiring the use of
safety belts; we implement public health measures such as child vaccinations
and regulations around the safety of food, drugs, and products. Yet guns escape
this type of regulation despite their significant contribution to the mortality
rate each year. We must view gun violence as a serious threat to the public's
health if we want to reduce the number of deaths associated with guns.
can start by banning the sale of assault rifles, high-capacity magazines, and
other facilitators of mass murder. And we must allow government agencies like
the Centers for Disease Control and Prevention to fully exercise their duties
in both surveillance of the incidence and impact of gun violence, and in
educating the public on steps for preventing death and injury through the use
evidence is clear, and we must now take action to protect our neighbors and
ourselves from this devastating public health crisis."
the American Nurses Association and the American College of Emergency
Physicians, two prominent and national healthcare organizations, issued calls
for a ban on the sale of assault weapons.
publication ADVANCE for Nurse Practitioners & Physician Assistants
asked its readers, "Do you think it is the responsibility of healthcare provider
organizations to urge this type of action?"
some readers had to say:
- "We can
all do our part. As nurses, as humans." - Teanne
stand in a trauma unit for one night and come back and give me your
answer." - Melissa
Absolutely! It's everyone's responsibility to speak up for what they
believe!" - Kelli
not. I have stood in the trauma unit for 15 years and taking away my legal
guns, which I carry concealed because I am licensed to do so, and taking
away my rifles, which I enjoy shooting responsibly, will do nothing to
stop the common street thug with an illegal weapon, other than allow me no
protection for myself and my property when I'm leaving the trauma unit at
midnight, sitting at a red light, and getting jacked by said thug." -
of our ER staff is armed; we see what's out there. As the Boy Scouts say,
be prepared. The bad guys will always find guns; we need to be able to
defend ourselves." - Diana
Prior trauma nurse here at Miami Dade County. Some individuals have no
business having weapons. Period." - Teresa
is definitely not the responsibility of healthcare provider organizations.
This is a civil liberty. I'm sure many members of the groups do not
support a ban. These groups should focus on healthcare issues." -
mental illness awareness and research would be a wiser choice! Let's be
honest, what health professional has not taken some form of weapon to work
with them?" - Susan
you agree with Boufford's statement and the calls for action by the American
Nurses Association and the American College of Emergency Physicians? Weigh in
on the comments below.
Editor's note: We welcome your comments and
topic suggestions; contact blog author Kelly Wolfgang at
Editor's note: This blog was written by Jodi DeMarco, PhD; she is the interactive solutions advisor for TeleHealth Services.
The controversy around meaningful use options and proposed requirements has morphed from spirited debate to reluctant acceptance. Healthcare providers have weighed in with sometimes varying opinions over the many months since Stage 1 was rolled out. The Centers for Medicare and Medicaid Services (CMS) has reviewed input from all sides and affirmed its intentions for Stage 2 compliance. The resulting mandates reflect compromise in breadth and timing, and the healthcare world now has more clearly defined goals and a timetable for achieving compliance and meeting full reimbursement requirements.
Completing the Transition from Stage1 to Stage 2: Emphasis on Health Information Exchange
In the Stage 1 meaningful use regulations, CMS had established a timeline that required providers to progress to Stage 2 criteria after two program years under the Stage 1 criteria. This original timeline would have required Medicare providers who first demonstrated meaningful use in 2011 to meet the Stage 2 criteria in 2013. However, CMS has delayed the onset of Stage 2 criteria. The earliest that the Stage 2 criteria will be effective for eligible hospitals is in fiscal year 2014.
Providers who were early demonstrators of meaningful use in 2011 will meet three consecutive years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria in 2014. All other providers would meet two years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria in their third year.
Stage 2 retains its core and menu structure for meaningful use objectives, although some Stage 1 objectives were either combined or eliminated. A majority of the Stage 1 objectives are now core objectives under the new criteria.
The Stage 2 criteria emphasize health information exchange between providers to improve care coordination for patients. Although clinical quality measure (CQM) reporting has been removed as a core objective for eligible hospitals, all providers are required to report on CQMs in order to demonstrate meaningful use. Beginning in 2014, all providers regardless of their stage of meaningful use will report on CQMs in the same way.
Eligible hospitals must report on 16 out of 29 total CQMs. In addition, all providers must select CQMs from at least three of the six key health care policy domains recommended by the Department of Health and Human Services' National Quality Strategy. These include:
- Patient and Family Engagement
- Patient Safety
- Care Coordination
- Population and Public Health
- Efficient Use of Healthcare Resources
- Clinical Processes/Effectiveness
That the final list includes these six domains is encouraging news. Each domain reflects areas already receiving significant attention and resources. One of the great things about most practitioners is that they don't need mandates to do the right things, especially when it comes to clinical care and working in their patients' best interests. That said, cost plays a huge factor in achieving compliance, especially when regulations require enormous capital outlays to achieve sophisticated electronic milestones, and when goals involving consistency -- though paved with good intentions -- are extremely difficult to achieve.
Although there is consensus in the industry that working toward these CQMs is important and necessary, many go about it in their own way and at their own pace. Some hospitals have made enormous progress, integrating these efforts across multiple disciplines, setting ambitious patient-education goals and dedicating resources to ensure consistent outreach and positive patient, family and caregiver engagement. One shining example is the work being done at University of Arkansas for Medical Sciences (UAMS), a health center with colleges of Medicine, Nursing, Pharmacy, Health Related Professions and Public Health; a graduate school; a hospital; a statewide network of regional centers; and seven institutes.
UAMS is the only adult Level 1 trauma center in the state. It has more than 2,800 students and 775 medical residents, and more than 10,000 employees, including approximately 1,000 physicians and other healthcare professionals. Barbara Brunner, RN, is the director of Patient and Family Centered Care for the hospital at UAMS.
"We have integrated healthcare teams taking care of our patients, essentially a comprehensive nurse/clinician partnership that targets educational planning, implementation and measurement, encompassing all aspects of care, including emergency, inpatient, medication and discharge," Brunner says.
Staff, Brunner explains, practice a "teach back" method to ensure patient understanding of directions and information pertaining to their health and care, particularly involving post-discharge requirements. "Our goal isn't only to determine what they know, but as importantly, what will that patient do when he or she goes home," says Brunner.
Empowered Patients & Caregivers Improve Outcomes & Satisfaction
To that end, UAMS uses a customized interactive patient engagement system with wellness programming that delivers customized, condition-specific education care plans to the bedside television. Following viewing, the patient responds via an automated survey conducted over the telephone to simple "yes/no" questions about their care. This feedback is then reviewed by their care team, who then personally consult with the patient to reinforce care and compliance requirements.
Additionally, families and caregivers are invited to attend classes which teach them how to deal with issues and tasks such as IVs and central line maintenance, pre- and post-natal care, diabetes, wound care, pneumonia, congestive heart failure, stroke care and more.
"Our goal is to integrate the patient, along with his or her family and related caregivers, in the recovery process to plan and adjust to life outside of the hospital," says Jamie Peacock, director of Quality Programs in Nursing. "Additionally, using our patient engagement system we conduct comprehensive satisfaction benchmarking through surveys to ensure that we're hitting our marks and always raising our levels of care. Results vary, based on traumatic versus chronic needs, but we know that empowering patients in their own care is valuable, improves patient satisfaction, and will reduce readmissions. That is a key focus, especially in this era of cost-containment."
The hospital, Peacock adds, is partnering with two outpatient facilities to continue their educational outreach effort after patients go home, focused initially on congestive heart patients, and patients at risk for central line infections.
Maintaining awareness of population-specific tenets and standards plays an important role at UAMS. All communication and information is available in multiple languages, the hospital has certified interpreters, and offers a language line providing translators fluent in dozens of languages. They also have a patient education database, which helps staff deal effectively with cultural differences relating to areas besides language, such as nutrition, family structure, touch and eye contact.
"While we have not yet implemented an online electronic medical record connection integrating patient education, a solution is being planned," says Jerri Garland, director of EMR Services. "Patient education and providing the information patients need at the right time to make informed choices about their health care is a central focus of our initiative. Our interactive patient engagement is one technology that uniquely positions UAMS to extend our health education resources. We'll get there by enabling direct patient interaction and providing proven tools needed to fulfill Stage 2 criteria, while enhancing the patient experience across the care continuum."
Every patient receives an educational assessment within 24 hours of being admitted, Garland says, allowing the hospital to quickly determine the best way to teach each individual. "Through this process we identify potential barriers to learning such as language, cognitive, visual or hearing challenges," Garland explains. "The results of that assessment are documented and available to all staff so it can be used in coordinating care in the hospital, and for subsequent transitional care."
The hospital, Brunner adds, has an extensive medical library, and its video library is accessible to all patients via the televisions in their rooms. They also feature a Department of Patient Education, with dedicated health educators who integrate care across all clinical areas. Their expertise includes training in care planning, formatting, and adult learning. This benefits everyone, Brunner says, and results in patient education being managed by staff beyond just the physicians and nurses, including nutritionists, respiratory therapists, pharmacists and every medical professional that engages the patient. The hospital also is in the process of establishing advisory councils. These will strengthen ties with the community by enhancing outreach, community wellness, and patient education efforts.
"Ours is a far-reaching, education-oriented, multi-dimensional effort," Brunner concludes. "Everyone is involved, and every patient and patient family or caregiver benefits from this comprehensive approach."
Over the coming years, meaningful use will help drive consistency and strengthen links to online record keeping and reporting. That's good, and welcomed. But the road to enhanced patient satisfaction and improved clinical outcomes begins with stronger care coordination and comprehensive and integrated patient engagement, as demonstrated at UAMS and other forward-thinking, technology savvy hospitals across the country.
Editor's note: This blog was written by Michael LaMagna is a partner at Timins & LaMagna, LLP, practicing Health Care Regulatory, Elder /Probate/Disability/Trusts and Estates, Social Security and General Legal practice in both New York and Connecticut.
The Congressional Business Office (CBO) reports that in 2016, which is when the 2010 health care law becomes fully in effect, 2% of Americans, or roughly 6 million individuals, will be subject to the health care penalty tax. This is significantly higher than the estimated 4 million, in large part due to higher than anticipated unemployment, lower wages and salaries as well as changes to the law since its passage in 2010.
The new penalty is the infamous individual mandate upheld by the Supreme Court as a tax, which requires that you either obtain health insurance or pay a penalty, amounting to $695 or 2.5% of your annual household income. The tax is expected to bring in more than $7 billion in 2016 and $8 billion thereafter.
In addition, the CBO projected that the total amount of individuals who will remain uninsured with be 30 million, up from the projected 21 million. The reason why it is projected that 6 million will be subject to the tax is because the other 24 million include: undocumented aliens, Indian tribe members and those with lower incomes.
The CBO has projected that the total cost for the new law will be upward of $2.6 trillion dollars in the next 10 years, which is significantly higher than the first estimates of $900 billion and covers fewer individuals than first thought.
This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna was just appointed to the ACO Task Force of the American Health Lawyers Association. E-mail him at Mlamagna@nyandctlaw.com, call him at 914-819-0663 or visit Attorney LaMagna's website at www.nyandctlaw.com for more information.
Editor's note: This blog was written by Jodi DeMarco, interactive brand manager, TeleHealth Services.
With final Stage 2 rules for satisfying meaningful use requirements issued by The Centers for Medicare and Medicare Services (CMS) last week, several of these initiatives focus on the importance of patient education and engagement. The requirements for the adoption of certified technology enable the capture and sharing of health-related information to advance clinical processes and drive improved patient outcomes, and many of these criteria actually are driven by patient engagement initiatives.
Beyond improved clinical outcomes and patient satisfaction, the incentive currently driving meaningful use is government subsidies for implementing the technology and compliance changes. Non-compliance in the future will be penalized through withheld reimbursements for hospitals, healthcare organizations, and physicians who fail to achieve meaningful use in the required timeframe.
Under the rules for Stage 2, all Stage 1 items will become mandatory, the scope of many Stage 1 measures will be increased, and providers will be responsible for meeting a number of new requirements, particularly around care coordination and patient engagement. Under the current Stage 2 rule, providers have more time to meet the Stage 2 criteria. A provider that attested to Stage 1 of meaningful use in 2011 would attest to Stage 2 in 2014, instead of in 2013, as was outlined in the original timeline from CMS. Therefore, providers are not required to meet Stage 2 meaningful use before 2014.
However, in preparation for meeting the rules for Stage 2, hospitals need to prepare for these evolving compliance requirements as soon as possible. Those who resist or do not take quick action face the risk of having only a few months to achieve the deadline by which hospitals are responsible for actually initiating Stage 2 requirements. That makes them vulnerable to penalties for non-compliance if unforeseen issues or delays prevent requirements from being implemented on time.
The Nature of New Requirements for Stage 2
Many of the entirely new measures for Stage 2 put greater emphasis on care coordination. The new measures also require additional capabilities and processes related to patient engagement. For hospitals, Stage 1 measures related to patient engagement were limited to patients who asked for an electronic copy of their health information or discharge instructions. In Stage 2, hospitals are responsible for an entirely new measure requiring that hospitals make electronic access to health information available to more than 50 percent of their patients and that more than 10 percent of patients actually view information about their hospital admission.
Another important aspect of meaningful use involves healthcare IT implementation, which generates useful information and translates that information into knowledge. This, theoretically, leads to improved clinical outcomes that result in reduced readmissions, shortened length of stay, improved patient satisfaction, clinical efficiencies, and other processes that help keep the patient engaged in his or her recovery and continued health and wellness.
Stage 2 quality measurement segments include:
- Population and public health
- Patient safety
- Patient and family engagement
- Care coordination
- Clinical process
According to CMS, providers have earned more than $5 billion in incentive payments for voluntary Stage 1 meaningful use compliance involving electronic health records. Prior to its release of Stage 2 requirements, The American Hospital Association (AHA) warned CMS that the proposed requirements for Stage 2 were not feasible, especially in light of the fact that more than 80 percent of hospitals had not attained Stage 1. The College of Healthcare Information Management Executives (CHIME) also had said the preliminary Stage 2 criteria were "overly ambitious."
Focus On - and Fund - What's Already Working
As the debate continues, many hospitals already are using patient education, engagement, and interactivity tools to increase compliance and understanding, enhance care coordination, measure service responsiveness, and improve clinical outcomes. These outcomes include reduced readmissions, better post-discharge planning, and improved patient satisfaction ratings. However, while these practices are proving beneficial to patients, their families, and hospitals' bottom lines, they often are not properly coordinated or tracked, nor are they provided needed resources.
Diane C. Moyer, MS, RN, is president of the Health Care Education Association (HCEA), a national non-profit, multi-disciplinary professional organization of healthcare educators. She also serves as associate director of Health System Patient Education for The Ohio State University Wexner Medical Center, in Columbus, Ohio. HCEA, she explains, is dedicated to improving healthcare through evidence-based education, resource development, and communication.
"Everyone has similar standards for patient education, but we use a variety of different resources, vendors, customized in-house, and off-the-shelf third-party solutions for educating patients, and different tools for documentation," Moyer says. "Our intentions are good and the information is useful and valued, but this ‘mish mosh' of execution makes it difficult - if not impossible - to measure effectiveness, share best practices, and demonstrate a clear return on investment."
This lack of consistency, Moyer explains, becomes more complex when you consider the assortment of specialists who all share responsibility for patient education. That includes nurses - who, she says, are the primary educators - as well as physicians, dedicated patient educators, therapists, pharmacists, dietitians, social workers, and more.
"In some ways," Moyer reflects, "we have taken a step back because our systems are not flexible enough to capture all the needed data without extensive documentation by clinicians and time to find and review the notes across disciplines. For example, some hospitals capture patient education participation electronically, and even use simple interactive bedside or online tests to verify comprehension. Often this information is not easily or automatically retrievable, is not connected to a primary resource like an electronic medical record, and is not shared among those educating the patients. This disconnection," she adds, "includes gaps involving patient education and discharge information, particularly as they relate to inpatient and outpatient care."
By "patient education participation," Moyer is referring to how hospitals assign specific educational information and on-demand videos or digitized broadcasts to patients, based on their identified learning needs. For instance, a patient who is in the hospital for heart surgery may be assigned videos detailing specific aspects of his or her disease, as well as programming on medications, exercise, nutrition, rehabilitation, relaxation, and related subjects. Both the patient and the family can view this information, which helps them better understand their challenges and plan appropriate post-discharge care. At the same time, these patient engagement efforts support other clinical initiatives and help the organization meet compliance requirements.
Moyer credits these types of tools, as well as follow-up questioning and additional evaluation by nurses, physicians, and other clinicians, as critical for helping patients comprehend their medical issues and take better care of themselves after they have been discharged. Most patients, Moyer stresses, are not "at their best" when in the hospital. They are frightened, anxious, sedated, and often afraid to ask questions or admit they do not understand the complexities of their illness or what is expected of them. The ability to duplicate their curriculum at home, she adds, is a nice advantage to these systems.
But providing the resources is not the same as providing good education, she stresses, and in the rush to get things done, educational materials may be given to patients with little explanation or opportunity to ask questions or practice the care. Health literacy issues also play a big role in patients' understanding of their care, and not all providers simplify the communication or check that the patient really does understand what needs to be done when they go home.
Ensuring that comprehensive print and video materials are available, particularly in languages specific to the community being served, can be expensive and time consuming. Often there are no take-home resources in non-English languages. More worrisome, Moyer points out, is that there are no federal funds for reimbursement of interpretation or translation fees, so these materials and services add significant costs to doing business, even though it is the right - and smart - thing to do for patient safety and quality care.
"Detailed, coordinated patient education involving patients and their families in understanding their roles in recovery and long-term health is essential," Moyer reflects. "Most patient education specialists would advocate for evaluation of patient/family learning. Can they show you how to change the dressing? Can they tell you what they would do if the tube fell out? Who would they call if they had a problem? Do they understand warning signs before it escalates to the point where that patient is back in the emergency room?"
"Interactive learning tools that inform patients and their families on these scenarios or skills and check comprehension are absolutely critical, but they require resources to implement," explains Moyer. "Providers of interactive patient education tools can offer a scalable solution to aid hospitals in their integration, thus providing immediate value, a manageable installation, and a sustained return on investment. As technology improves, enhanced connectivity and better ways to guide patients to credible, plain language health resources outside the hospital will be invaluable. "That," she adds with a smile, "would truly be meaningful use."