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 firstname.lastname@example.org.
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 email@example.com.
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."
Editor's note: This blog was written by Molly K. O'Neill, Brian R. Browder and Donald B. Stuart.
With the dust settling on the Supreme Court's Affordable Care Act ruling, the question of whether the decision will lead to increased M&A activity in the hospital and healthcare industry can now be answered with a definitive yes, no and we'll see.
The Supreme Court's ruling left the 2010 healthcare reform legislation largely in place, nullifying only the provisions that would have penalized states choosing not to expand Medicaid eligibility. A legislative repeal of the Affordable Care Act (ACA) would likely require a Republican sweep in the November elections, and despite campaign rhetoric to the contrary, this seems to be highly unlikely (especially to obtain a 60-seat filibuster-proof supermajority in the Senate). It would appear that the ACA, which represented a significant overhaul of the country's health care system and structure, will be with us for at least the near future.
With some measure of certainty now in place, there has been a noticeable increase in interest in deal-making activity in the hospital sector. Hospital systems that adopted a wait-and-see attitude have started to explore acquisitions, partnerships and alliances, and there is no shortage of potential partners who are willing to listen to fresh overtures. Increasingly, these organizations, primarily nonprofit hospitals, recognize that even two- and three-hospital systems will be hard pressed to stand on their own in light of the Medicare reimbursement cuts contained in the ACA and new payment models on the horizon.
For hospitals in states that opt-out of the Medicaid expansion, the need to align with larger systems will be even greater. Several governors have already announced their states would opt out, and hospitals in these states that are already facing a steep uphill climb could have no alternative but to consolidate if there is no increase in the number of insured residents.
Drivers for consolidation in the healthcare industry can be either financial requirements or strategic opportunities. Alignment with larger health systems provides operational savings through group purchasing, back office expenses and other efficiencies and economies of scale. On the acquisition side, distressed hospitals and systems are not the only candidates looking for potential partners. It can also be expected that high-performing, credit-worthy hospitals and health systems will draw significant interest. Investor-owned healthcare providers will be motivated to enhance their cash flow and buoy their stock prices by acquiring these prime facilities and systems. Large tax-exempt health systems, on the other hand, are in a good position to absorb an underperforming asset and improve its margins. This turnaround approach provides return on investment while simultaneously establishing scale.
Increased transactional volume is also likely in vertical markets as hospitals and payors acquire or align with home health agencies, skilled nursing facilities and other providers to position themselves for new delivery and payment models - such as accountable care organizations (ACOs) and bundled payments.
Also likely is increased consolidation among post-acute care providers seeking to gain critical mass. For example, Genesis HealthCare LLC, which operates long-term care, senior living and rehabilitation facilities, recently announced that it had agreed to acquire skilled nursing provider Sun Healthcare Group Inc. With more than 420 facilities nationwide, the combined organization would have the "scale necessary to remain competitive in the post-acute sector," according to a statement released by the two companies following the announcement.
While the Genesis HealthCare-Sun Healthcare transaction involves providers with similar service lines, there have also been announcements of acquisitions and joint ventures involving somewhat strange bedfellows. DaVita, Inc., a Fortune 500 provider of dialysis services, announced plans for a merger with HealthCare Partners, the country's largest operator of medical groups and physician networks. Inova Health System and Aetna announced their strategic partnership to establish a jointly owned health plan to serve the Northern Virginia market.
In addition, with the anticipated increase in the number of Medicaid enrollees, private Medicaid managed care companies and similar players are being sought after, as recently seen in WellPoint's announcement of the proposed acquisition of Amerigroup Corp. It is likely that there will be more announcements involving organizations aligning their interests with partners from different segments of the healthcare industry.
For the reasons outlined above, an increase in healthcare M&A activity seems probable in the wake of the Supreme Court decision. It must be noted, however, that healthcare M&A has been on the rise for the past few years for precisely the same reasons. Many health systems have been gearing up to operate under the ACA's full provisions since the date of its enactment in 2010. Most healthcare providers believed declining Medicare reimbursement rates and the development of new payment and delivery models were here to stay no matter how the Supreme Court ruled. This perspective is underscored by the fact that hospitals and health systems have been actively pursuing the acquisition of physician practices and other healthcare providers in the markets in which they operate since the ACA's enactment.
The reshaping of the healthcare marketplace through innovative partnerships also predates the Supreme Court ruling. Duke LifePoint Healthcare, a joint venture between Duke University Health System and LifePoint Hospitals, and Ascension Health Care Network, a joint venture between Ascension Health Alliance and Oak Hill Capital Partners, were each established in early 2011 to assemble networks of hospitals and healthcare providers. Both joint ventures have been actively seeking and acquiring and partnering with hospitals since their formation despite any perceived uncertainties associated with the Supreme Court ruling.
We'll See . . .
The simple truth is that acquiring a hospital or a health system takes time. If an organization waited until the Supreme Court ruled on the ACA to begin making plans for an acquisition, merger or joint venture, it could very well be the second half of 2013 before the transaction is finalized. In addition, any consolidation within the healthcare industry could be further complicated and delayed by the increasing level of scrutiny the Federal Trade Commission is directing toward healthcare transactions with respect to antitrust issues and state attorneys general challenges to hospital transactions. Between now and then, a number of other factors could come into play that could also impact individual transactions and industry trends, including election results, economic conditions and other market developments.
While the Supreme Court's ruling upholding the ACA may trigger a further rise in healthcare transactional volume, a great deal of activity was already under way. Will these trends continue? We'll see what happens.
Molly K. O'Neill is senior vice president and chief business development officer with Ascension Health Care Network in St. Louis, MO. Brian R. Browder is a partner with Waller in Nashville, TN where he chairs the law firm's healthcare department. Donald B. Stuart is a partner with Waller in Nashville, TN where he advises healthcare providers on tax law and other business issues.
As Meaningful Use criteria push towards required interoperability and changing reimbursement methods necessitate more coordinated care, HIEs are looking more and more appealing to hHealthcare providers. The HIE market practically exploded last year, growing more than 40%, according to a Chilmark Research report.
"As federal incentives drive the adoption of electronic health record (EHR) technology in the U.S., we will quickly move into the post-EHR era where the value of patient data is not what is locked in an EHR data silo, but the cumulative patient data that resides in the community HIE network," said John Moore, founder and managing partner of Chilmark Research.
And those looking to tie their systems together have plenty of options, too, when it comes to the type of HIE. The State Health Information Exchange Cooperative Agreement Program distributed $548 million to states, territories, and state-designated entity HIE startups in 2010, starting the slow creation of public HIEs. But many provider organizations, unwilling to wait for public HIEs to launch, have developed private HIEs — focusing on exchanging data among their own facilities and select outside partners.
While the KLAS report HIE Perception 2011: Public or Private? found that providers were split between selecting a public and private HIE, the tides have turned in favor of private exchanges, according to the Chilmark Research report. Organizations worried about data control or funding sustainability, or looking for a faster implementation time, are opting to create their own, private HIEs rather than wait to join larger, public HIEs. As federal funds dwindle, and state HIEs struggle to implement sustainable business models and develop fee structures through their state legislatures, private HIEs are becoming a more enticing option.
But with private HIE benefits come limitations. The KLAS report listed increased integration and interfacing needs as a possible deterrent, and a recent Journal of the American Medical Informatics Association article took a much closer look at the private vs. public HIE debate. According to the article, private HIEs, which only serve pockets of providers, may be draining resources necessary for public HIEs — which, by mandate, must provide broader services to entire communities and states — to succeed. Public HIEs are designed to connect providers on a grand scale, developing both intra- and inter-state exchanges; if private HIEs corner the market on profitable services, public HIEs have little chance of survival when providing lower ROI services such as connecting rural providers or developing the necessary standards and policies.
But don’t despair, because there may be a way to have it both ways, according to the article. Kentucky, as well as several other states, is working to create a public HIE that operates as an umbrella organization, linking all of the state’s HIEs, including private ones. During a National eHealth Collaborative roundtable, Claudia Williams, director of the State Health Information Exchange Program, recommended that states leverage the burgeoning private HIE development through an umbrella model similar to Kentucky’s, and focus on providing necessary services not met by the private sector.
This approach offers the best of both worlds: private HIEs can link specific provider networks, while the overarching public HIE brings competitors together by connecting all HIEs, as well as private practices not already part of a private HIE. The public HIE would also offer required exchange capabilities with state immunization registries, patient locator services, and new birth and cancer registries.
“In my mind that is a pretty good model. It makes sense to me that some public entity brings all of those [private] entities together, where there really isn’t a motivation otherwise,” said Steven Roth, vice president and CIO of Pinnacle Health System in Harrisburg, Pa, which developed its private HIE in 2009 after failed attempts to create an operable public HIE in 2007.
While public HIEs struggle to get up and running, private HIEs are popping up all over the country to address the immediate information exchange needs of technologically progressive providers. Although private HIEs have taken the lead, HIEs of both kinds are still in flux, and both have much to offer when it comes to sharing information.
Editor's note: This blog was written by Chelsea Foster, a copywriter at DKI.
Twitter has openly embraced the unimportant. It is the foundation upon which it was built in the first place. We all have that innate desire to inform the online eyes and ears of our friends, families, and perfect strangers, about the most painstakingly trivial personal information.
But Twitter's not all bad (or boring). It also gives us the ability to plug ourselves into the world. Tweet by tweet, we can receive real-time information about anything, from the most absurd to the most important: from what we had for breakfast to what medicine has or hasn't worked for our health condition, everything is on the table online.
Brave New World
The pharmaceuticals industry has a rightful place in this new world. There is a wealth of drug and patient education just waiting to emerge from the industry, but with a skittish FDA leaving blurry if not non-existent lines about what pharmaceutical companies can and cannot do, there is great hesitation to do much of anything at all.
Online, patients are delivering tiny bursts of information about their lives for all to see, including their symptoms, how good their doctors are, what drugs they're taking and offering emotional support. These conversations arise and disappear quickly. And like any social media outlet, the information people are swapping isn't always correct, and can even be misleading, which can be damaging, considering about 60% of Americans turn to the Internet first when they're seeking health information.
This is why the pharmaceutical industry should be involved in these discussions. It borders on having a responsibility to provide patients or potential patients with factual information about their products. It's also helpful to offer the tools and resources that many marketing campaigns provide, like symptom trackers, support and financial resources, and access to patient ambassadors that speak from their personal, verified experience with specific treatments.
What is Pharma Tweeting?
After reviewing pages upon pages of pharmaceutical twitter channels, several themes consistently arose. If pharmaceutical companies can't talk directly about their drugs, they're dead set on trying their best to improve their image and boost awareness about what's to come. The common tweet topics included:
- What companies they're collaborating with (often research oriented)
- The charities and philanthropic endeavors they're donating to or participating in
- Current data and analysis about clinical trial results
- Health tips for various conditions
- Drivers that help flow their followers to their corporate websites
- Re-tweets of patient testimonials regarding their condition, not their treatment
- Links to interesting studies or topics in the healthcare field
Much of the information that the various pharma channels shared was interesting and informative. Surprisingly, one of the more powerful, unexpected tools was the ability to re-tweet. This allows companies to share information about conditions and the personal experiences of others without tweeting it themselves, which may be reviewed more leniently by the FDA (there's no way to be sure). If they're not affiliated or responsible for a given tweet, simply sharing it is a great way to link their followers to information they may not feel comfortable tweeting themselves.
Engagement is a Good Thing
An engaged patient is an empowered patient. This goes for caregivers and HCPs as well. Promoting a drug to boost engagement of any kind in the healthcare arena seems to be a beneficial addition to the twitterverse. It promotes the drug, yes, but it also starts a conversation between patients, a patient and their doctor, or concerned and interested parties. This can lead to a more engaged industry and public, overall. Additionally, these followers are willingly following their chosen channels. As long as the information they are provided with by a corporation is correct, it should be fair game.
We need to catalyze the conversation, not shy away from it. More likely than not, this will entail using the knowledge and understanding we currently have about promoting and marketing drugs, and applying it as seamlessly as we can into the social media abyss. Still, more guidance, if not a green light from the FDA, is needed first.
If you are worried that your organization is falling behind on ICD-10 preparation, you are not alone. Nearly half of the 2,118 providers who participated in the Workgroup for Electronic Data Interchange (WEDI) February 2012 ICD-10 readiness survey said they did not even know when they would be completing their impact assessment — a key milestone that should have been met in 2011. Only a fifth had already completed their assessment.
Health plans are only marginally more prepared, according to the WEDI survey; over one-third of the 242 respondents have completed their assessments, but a quarter are less than halfway there. Most health plans have not slated external testing until 2013.
WEDI notes that historically, their membership and survey respondents tend to be more aware of industry issues and are correspondingly more advanced in addressing them, giving even more weight to ICD-10 preparedness concerns.
In April, the Department of Health and Human Services (HHS), which includes the Centers for Medicare and Medicaid Services (CMS), proposed to postpone the ICD-10 deadline for one year, from Oct. 1, 2013 to Oct. 1, 2014.
The American Hospital Association (AHA), recognizing that deadline uncertainly is diminishing industry focus on ICD-10 preparation, asked CMS in July to set a firm deadline in order to give providers the time — and motivation — to properly prepare.
“We are in an environment where the demands on providers are really great,” AHA policy director Chantal Worzala told InformationWeek Healthcare. “So there is a natural tendency to prioritize among all the things you have in front of you. We asked CMS to finalize its rule as quickly as possible so we can go back to a state of certainty about the date.”
The AHA has a right to be concerned, as the WEDI survey found that providers, payers, and even vendors have become distracted by a plethora of issues. The survey asked all participants to list the top three obstacles to their ICD-10 preparation progress, and nearly three-quarters responded that competing internal priorities were the biggest obstacle. Other distractions listed included other regulatory mandates, significant IT impacts, staffing, budget and both customer and vendor readiness concerns.
Two-fifths of the providers responded that they were worried about vendor preparedness, and with reason. Vendors are certainly as far behind as providers and payers, with nearly half of the 231 surveyed responding that they are less than halfway complete with their product development. For those organizations ahead of the game and looking for the right vendor, their options may be limited, as only about one-fifth indicated their services or software was already available.
“When CMS puts out a final rule and everybody starts to say ok, ‘this is the date,’ and they get back to the work of preparing, we can take that extra time and use it to ramp up the testing with our trading partners, including the insurers,” Worzala said.
Of course, not everyone agrees with these somewhat worrying results. The 2012 HIMSS Leadership Survey, published at its February conference, found that, for two-thirds of the respondents, ICD-10 was a top focus for their organization. Nearly 90% thought they would be able to complete their ICD-10 conversion by the earlier, October 2013, deadline.
Whether your organization’s preparation timeline supports WEDI’s survey results or HIMSS’s, there is no denying that ICD-10 is a major transition all healthcare leaders must focus on, now or in the immediate future.
If you are looking to motivate your organization to keep its foot on the gas when it comes to ICD-10 preparation, check out a recent Executive Insight article written by Bob Schwyn, principal, Aspen Advisors. He emphasizes that the potential impact of ICD-10 implementation on your organization's financial performance is substantial, so preparedness is essential. He recommends organizations take advantage of the delay to ensure that their efforts do not negatively impact their financial performance as the deadline looms.
For more information, see WEDI’s Survey Results, or check out InformationWeek’s coverage:
For more information from HIMSS, browse through their 2012 Leadership Survey
Editor's note: This blog was written by Karen Hercules-Doerr, a healthcare executive and director of Community-Based Representatives at Allsup. Contact: firstname.lastname@example.org.
It seems reasonable to assume that patients with health insurance are ineligible for Social Security Disability Insurance (SSDI), a program that provides benefits to Americans unable to work because of a disability.
After all, more than 55 percent of Americans aged 26-64 participate in employer-based healthcare coverage, and if they have employer-based insurance, they're able to work, right?
Although working typically disqualifies a patient from SSDI, simply having health insurance does not. Even if patients have health coverage when they are initially treated, that may not be the case in just six months, or later on. When patients have progressive chronic illnesses, they experience increasing difficulty in maintaining work schedules and can lose access to steady income and health insurance. Patients who could be receiving SSDI benefits, but aren't, can become a higher cost patient for the provider.
A 2010 study found that the average SSDI beneficiary visited the doctor seven times per year. That escalated to an average of 22 times per year over the course of three years. As their condition worsens and patients visit healthcare providers more often, they also become increasingly likely to lose employer-based insurance to help pay for care.
Patients with worsening health and rising costs may not be able to pay for their care if they don't file for SSDI in the interim.
However, there is good news for patients: after 24 months on SSDI, patients are eligible for Medicare. The 2-year waiting period underscores the critical importance of identifying at-risk patients and helping them apply for SSDI benefits as early as possible. That's why it's important to look for warning signs with patients who may become SSDI-eligible, so they can begin the process of applying for benefits as soon as they're eligible.
Healthcare professionals find that when their insured patients fully understand the benefits of filing for SSDI with a representative such as Allsup, they are less likely to become uninsured or underinsured later.
It is critically important that hospitals, physician practices and healthcare providers understand that it's never too early to inform their patients that SSDI benefits may be available if they are deemed disabled and cannot work in any capacity for at least 12 months.
Giving patients options regarding their future and offering them help from expert representatives can minimize the tremendous losses they face when they can no longer work because of a disabling condition. This step also can expedite access to benefits that patients have paid into and deserve, and helps minimize providers' exposure to the significant cost demands of treating patients who don't have a steady source of income or insurance.
1. Ensuring Patients with Disabilities Can Maintain Care and Coverage." Allsup, 2012.
Editor's note: This blog was written by Jill Glomsted, editor of ADVANCE for Occupational Therapy Practitioners.
In the June 28 Supreme Court ruling, seven of the nine Justices agreed that it would be unconstitutional for the federal government to force states to participate in the Affordable Care Act's expansion of the Medicaid program. The expansion had been expected to cover roughly 17 million uninsured Americans, mostly low-income adults. The federal government will foot the full bill for the expansion for the first three years; after that the federal share will slowly decline, but it would still be 90 percent in 2020.
The Court's decision basically renders the expansion a separate animal from the current Medicaid program. If states don't participate in the expansion, they can keep their existing programs (and existing federal money) without consequence. The question now is, what will the states choose to do?
So far seven states and the District of Columbia are already offering expanded coverage, paying for it with state funds until the federal payments via the ACA kick in in 2014, according to CBS News.
However, 26 were plaintiffs in the case the Court heard; the governors of some of them, including Texas, Mississippi and Wisconsin, have already hinted that they will not implement the expansion, while others have refused to say what they're willing to do. Virginia Governor Bob McDonnell isn't saying, but told Politico.com that the expansion would cost his state $2.2 billion over 10 years, even with the federal funds.
It's unsurprising that few want to commit to a decision, given the political hot potato that the Affordable Care Act has become and the huge financial burdens states are already facing due to Medicaid. But if states opt out of the expansion, what's going to happen to their residents?
If all 26 states who were parties to the suit opt out, that's more than half - roughly 9 million people - of those expected to be covered by the expansion who will still be without insurance. What's more, they will be some of the poorest Americans.
"We will have a really strange doughnut hole in this country," said Kevin Outterson, associate professor of law and associate professor of health law, bioethics and human rights at Boston University, during an Association of Health Care Journalists webcast on the Supreme Court decision today. Individuals making up to the federal poverty level (FPL, currently $15,415 for an individual; $26,344 for a family of three in 2012) will have some level of coverage under existing programs. Those making 133 percent of the FPL or more will be able to participate in the state health insurance exchanges that the ACA established, with subsidies to help them purchase affordable coverage. But the people who fall in between are not eligible to participate in the exchanges - the ACA did not include them because it was assumed they would be covered by the Medicaid expansion.
Public and safety-net hospitals in states that opt out could also suffer. Currently hospitals that treat a large number of low-income, uninsured or vulnerable patients receive "disproportionate share" funding to help pay for that uncompensated care. Under the ACA, those hospitals are scheduled to lose about half that funding, on the premise that the expansion of coverage through both the individual mandate and the Medicaid expansion would offset what hospitals will lose. If a state chooses not to participate in the Medicaid expansion, its hospitals will still have to provide care to those populations but with much less funding than they have now to do so.
Providers could lose out too, though that is uncertain. The ACA raises rates for primary care providers in Medicaid up to Medicare levels. It's unclear, based on the Supreme Court ruling, whether providers in states who don't participate in the expansion will get that increase in payments.
Another issue is that "there is nothing out there to give states any sense of when they have to make a decision, because no one thought they would have to," said Alan Weil, executive director of the National Academy for State Health Policy, during the webcast. In states that don't decide, Medicaid programs could be caught in a holding pattern.
Martin Salo, executive director of the National Association of Medicaid Directors, told the New York Times in an article on June 29 that his initial sense is that many states will participate in the expansion. Many Republican governors may be waiting until after the November election to decide, hoping that Mitt Romney will win and make good on his promise to dismantle the entire law - Wisconsin Governor Scott Walker said on Thursday that was his position, CNBC reported. However, governors don't necessarily hold all the cards here. Much of Medicaid is regulated by the legislature, and when state legislatures come back into session in January they may take some or all of this decision out of the governors' hands, said Weil. It's also possible that Congress or HHS could act in the way of new legislation or new regulations to encourage states to participate.
By way of analogy, several Republican governors initially said they would not take federal stimulus money from the American Recovery and Reinvestment Act of 2009, said webcast moderator AHCJ President Charles Ornstein. Eventually, they all did. Americans - especially the poorest - will just have to wait and see if they do the same with the Medicaid expansion.