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The Politics of Health Care

Hillary Clinton’s Healthcare Plan
May 9, 2016 12:58 PM by Monique Barrett

[Editor's note: Kirsten Malenke, on staff at ADVANCE, originally wrote this blog.]

Hillary Clinton has been working to expand healthcare coverage since 1979, when she chaired the Arkansas Rural Health Advisory Committee and focused on increasing healthcare access to rural parts of the state. Since then, Clinton has continued the fight by establishing the Children's Health Insurance Program, introducing legislation to reduce the cost of health insurance expenses, and, following 9/11, fighting to fund the recovery of first responders at Ground Zero.

Now, as a Democratic presidential candidate for the 2016 election, Clinton has proposed that she will increase access to affordable healthcare for everyone, primarily by defending and building upon the Affordable Care Act (ACA). During the Democratic presidential debate April 14 in Brooklyn, Clinton said, "So rather than letting the Republicans repeal it or rather than starting all over again, trying to throw the country into another really contentious debate, let's make the Affordable Care Act work for everybody... let's get to 100 percent coverage, let's get the cost down, and let's guarantee healthcare."1

The Affordable Care Act, also known as Obamacare, was passed by Congress and signed by President Obama in 2010 in an effort to increase universal healthcare coverage. Since then, more than 17 million Americans have been able to acquire health insurance, though over 30 million remain uninsured. In addition to expanding healthcare coverage through the ACA, Clinton also plans to cut the costs of prescription drugs and defend Planned Parenthood in an effort to provide all women access to reproductive healthcare.

Expanding the ACA

Clinton plans to expand upon the Affordable Care Act by making premiums more affordable and cutting out-of-pocket costs for consumers acquiring health insurance. Her plan proposes a tax credit of up to $5,000 per family to offset a portion of excessive out-of-pocket and premium costs above 5 percent of their income. She proposes enhancing current premium tax credits available through the exchanges, so that those eligible will pay a smaller percentage of their income. Families purchasing on the exchanges will not have to spend more than 8.5 percent of their income for premiums.

In addition, Clinton plans to broaden the scope of Medicaid coverage across the nation to enhance relief for the lowest-income residents. Following President Obama's proposal, Clinton intends to allow any state adhering to the Medicaid expansion to benefit from a 100 percent match for the first three years. At least 16 million people, or half of all those uninsured, are eligible for essentially free Medicaid coverage or exchange coverage for as little as $100 a month or less. Clinton plans to invest $500 million per year in a campaign to simplify the enrollment process and ensure that more people are aware of their enrollment options.2

Clinton also intends to extend healthcare access through the Affordable Care Act exchanges to all families, regardless of their immigration status. This largely differs from Donald Trump's view, who aims to reduce the amount of foreign employees in the U.S. workforce and repatriate foreign migrants if elected president. Trump asserts that U.S. veterans should be a priority, and was quick to criticize Clinton's plan.3

According to the Center for Immigration Studies, about 14 million illegal immigrants are living in the United States. American taxpayers pay about $5,000 per year for every person enrolled in Obamacare. The addition of just 10 million current illegal immigrants to Obamacare would cost taxpayers at least $50 billion per year. This means that American taxpayers may have to divert funding from their relatives to pay for the healthcare of increasingly more foreign workers.

According to a 2012 study by Gallup, at least 150 million foreigners would like to migrate to the United States. If one-seventh of the estimated 150 million foreigners end up immigrating to the United States, the 10-year bill would increase to $1.5 trillion.3

Differing Perspectives

"Clinton's plan may not be as ambitious as Sanders'," stated an April 15 article on "She's not trying to spend an additional $28 to $36 trillion. But that obscures a more important fact: that when it comes to Obamacare, Clinton has boxed herself in with a series of toothless and contradictory proposals." The Forbes article argued that in order for Clinton to make the ACA work, she will need to increase President Obama's fines for those failing to buy Obamacare-based plans, but she knows that doing so will be detrimental in a general election. Forbes added that as a result, Clinton has proposed incremental half-measures that will have no meaningful impact on the cost of Obamacare-sponsored health coverage.

On the other hand, a Feb. 12 U.S. News & World Report article noted, "In addition to the political reality is the policy reality that the country does not need to go through another overhaul of its healthcare system. The Affordable Care Act is still in its infancy. Although the law passed in 2010, the mandates that are key to its reforms only went into effect within the last two years. It was also severely hampered when the Supreme Court ruled against the mandatory Medicaid expansion in 2012. However, even with all the mistakes the administration committed during the law's implementation and the other setbacks and delays it has faced, it has succeeded in decreasing the numbers of the uninsured. Gaps in coverage remain, but as Clinton suggests, the successes of the law can be built upon to shrink those gaps. There is no need to dismantle what is already working."5

Ultimately, the polls will indicate whether or not Americans are satisfied with Clinton's proposed changes to the Affordable Care Act and believe in her ability to ensure universal healthcare coverage.

Kirsten Malenke is a staff writer at ADVANCE.


1. The Washington Post. The Brooklyn Democratic Debate Transcript, Annotated.  

2. Hillary for America. Health Care.

3. Breitbart. Hillary Clinton Wants to Give Americans' Healthcare to Millions of Illegals, Says Chelsea Clinton.

4. Forbes. Hillary Clinton's Healthcare Plan Is Just as Impractical as Bernie Sanders'.

5. U.S. News & World Report. Clinton Gets It on Health Care.

Medicare's Best Program: Chronic Care Management
April 26, 2016 11:51 AM by Monique Barrett

[Editor's note: Nat Findlay, CEO, Hello Health, originally wrote this blog.]

Medicare in 2016
Medicare has existed in many forms since its inception under LBJ over 50 years ago, but it's safe to say the program has certainly grown in complexity and range since its humble beginnings in 1965.

Today, an estimated 44 million patients are currently enrolled in Medicare, with this number estimated to balloon to 79 million by 2020. With the move to value-based care (VBC) in full swing, it's expected that Center for Medicare & Medicaid Services (CMS) will continue to expand its services to better treat the costly and at-risk patient populations who make up a large chunk of eligible Medicare beneficiaries.

In the past few decades, CMS has greatly improved the care of Medicare patients, paying for mammograms, bone density testing, colonoscopies, etc., all of which have had a direct impact on patients' care and outcomes. Further, initiatives encouraging individuals to be vaccinated against flu and pneumonia have made large strides in ensuring an emphasis on preventative treatments and a stronger care continuum overall.

Despite its successes, one particular thorn to CMS has been the continued trend of readmissions and unnecessary ED visits. No patient population is more susceptible than Medicare beneficiaries with multiple chronic conditions such as Alzheimer's, Diabetes, CODP, and Cancer, to name a few.

Consider this: In 2010 alone, among the 14% of Medicare beneficiaries with six or more chronic conditions, over 60% were hospitalized at least once, accounting for 55% of total Medicare spending on hospitalizations. Further, beneficiaries with six or more chronic conditions also had hospital readmission rates that were 30% higher than the national average.1

In 2014, the estimated annual cost of total readmissions for Medicare was $26 billion, with $17 billion considered "avoidable."2

Obviously, these statistics represent a huge hurdle, as all healthcare stakeholders look to cut costs and emphasize a "lean" mindset in the shift to VBC. This came to a head as we entered 2015, when a new message from the CMS became abundantly clear: Something must be done to stave off readmissions and improve the care of our most at-risk patients.

Chronic Care Management
The solution was Chronic Care Management (CCM), a program that went into effect on Jan. 1, 2015. For the past 15 months, the CMS has been using Medicare CPT Code 99490 to reimburse physician practices for providing monthly telehealth calls to patients with multiple chronic conditions.

In essence, CCM tasks PCPs with improving the care continuum via telehealth services, with the ultimate goal of keeping chronic condition patients from re-entering the hospital or ED, and incurring high healthcare costs.

To bill for CCM, a practice must have designated medical professionals call the patient for a non face-to-face encounter, with each call lasting 20 minutes and covering a range of issues specific to the patient's condition and symptoms.

Further, each CCM call must have the following elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • A comprehensive care plan established, implemented, revised, or monitored.

While CCM is a telehealth service (a fairly new term), it is one that many doctors have been providing to their patients since the days of Dr. Welby's black bag. Telephone follow-ups are a natural part of a primary-care office's workflow, and with a few tweaks, the CMS is now reimbursing doctors for running a program they have long offered at their own expense.3

For many Medicare patients, the usual schedule of four in-person visits per year is not adequate to sufficiently manage their complex care routines. Often, the patient's multitude of medications and treatment instructions require numerous clarifications--the CCM call represents a crucial touch point for both the patient and provider.

Prior to CCM, patients with questions and/or concerns about their care would have to travel to the doctor's office or leave a voicemail to receive feedback. When one considers the limited mobility that affects a large portion of elderly patients, it is easy to see how ignoring seemingly benign symptoms could be the more appealing option. However, as those familiar with chronic conditions know, often simple and untreated symptoms can become complex and potentially deadly in a short amount of time.

To remedy this, CCM requires a dedicated medical professional is always available for patient requests, and supplemented by the monthly telehealth calls, ensure that no patient is left out in the proverbial cold. That is not to say CCM patients should not utilize emergency services - rather the program gives physicians a chance to identify potential problems early, using the CCM insights to better inform treatment decisions and ensure the patient is on the proper path towards a healthy outcome.

A Win-Win for Patients and Providers
The advent of CCM represents a tremendous opportunity for both patients and providers as we move further into 2016. As more reimbursements are tied to risk-sharing agreements such as ACOs, the ability to provide a fuller patient picture will be invaluable for healthcare decision-makers looking to ensure the most cost-effective treatment path.

For primary-care physicians with a large number of Medicare patients, the decision to participate in CCM should be an easy one. At last estimate the national average monthly reimbursement for a CCM patient was $42.91. If primary-care physicians can sign up a majority of their Medicare patients­, then there is a large financial opportunity to not only improve care, but also get paid commensurately for these services as well.

According to a study from the Annals of Internal Medicine, a "typical" practice with about 2,000 Medicare patients could generate more than $75,000 net revenue per full-time physician if half of their eligible patients enroll in CCM.1

Beyond potential ROI, the most encouraging example of the CCM's effectiveness has been the overwhelmingly positive response we've received from patients who have been in the program for the past year or so. In my role as CEO of Hello Health, I've had the pleasure of speaking with numerous CCM patients to hear their experience with telehealth and our specific services.

Many of these individuals have serious medical issues, often lacking mobility, full eyesight and suffering from a number of painful symptoms that need constant medication and monitoring. In many cases, telehealth is the only viable way for them to receive care that makes an actionable difference in their day-to-day health.

Despite this promising feedback, Managed Care Magazine reports last year CMS officials said they paid for about 275,000 Medicare beneficiaries who received CCM on average of three times; paying out a total amount of $12 million to participating doctors. When one considers that there are currently 35 million Medicare patients eligible for CCM, this means that only a small portion of patients have been able to benefit since Jan 1, 2015.

In other words, CCM is making strides, but is nowhere close to reaching its full potential in terms of patient enrollment and additional revenue generated for PCPs. With these statistics and the continued push for value-based care, the message to primary-care physicians and their patients is clear: These are the five most important numbers for a Medicare patient and their physician- 99490.

Nathanial Findlay has held executive positions in the healthcare industry for more than 20 years. A veteran of successful start-ups as well as the Fortune 21 company Cardinal Health, Nat's experience honed an entrepreneurial perspective and enthusiasm that inspired him to start Hello Health in 2008. With a background also including accounting and law, Nat continues to work at the forefront of the evolution of modern primary healthcare. Nat's mission is to use the Internet and mobile technology to redefine how patients interact with their physicians and manage their own health.


1. "A Pathway To Improving Care For Medicare Patients with Chronic Conditions." Available at:

2. Center for Health Information and Analysis. "Performance of the Massachusetts Health Care System Series: A Focus on Provider Quality." Available at:

3. "Chronic Care Management Services." Available at:

Lessons Learned
March 7, 2016 6:23 PM by Michael Jones

[Editor’s note: this article was contributed by Mike Baker, senior vice president and GM of commercial products, and Maydad Cohen, senior vice president and GM of government solutions, at hCentive (]

Now that the annual open enrollment period is in the rearview mirror, what are the key takeaways from 2016? Here are five lessons learned:

1. ACA health insurance marketplaces aren’t going away.
Exchanges successfully connected people to health insurance in both the public and private marketplaces. More than 12 million people enrolled in the federal and state marketplaces during open enrollment 2016, and 7 in 10 consumers returned to this year. At the same time, new enrollees increased 42%. This demonstrates need for the marketplaces as well as its value.

2. The tech hurdle has been cleared.
Thanks to more mature technology delivered via off-the-shelf software, states are learning that custom-built systems aren’t necessary. As a result, they’ve shifted focus to providing a better customer experience and adding new benefits products, including dental. With smarter decision tools (like provider and prescription medication lookup), private exchange-inspired innovations and more effective contact center support, states are now able to enroll more members and turn their attention to eliminate waste and fraud.

3. Marketplaces are still evolving.
The recent open enrollment period prompted many states to actively explore private sector technology options to or the federally facilitated marketplace, which is a one-size-fits-all solution that is expected to cost more to states with looming federal fees. As states seek more control, they’ll explore proven, financially sustainable alternatives that cost less and have the flexibility to manage state specific policies and complexities.

4. Private health insurance exchanges are growing rapidly.
Public marketplaces got the most media attention, but private exchanges are growing quickly with 6 million enrollees in 2015 and a growth rate of 100% annually, according to Accenture. Employers value private exchanges for their superior cost management, benefits choice and user experience. Brokers are also using some private exchange “web broker” platforms to more efficiently enroll subsidy-eligible consumers.

5. Small and mid-sized companies are looking for new alternatives.
As they seek benefits to attract and retain the best and brightest, small and mid-sized employers are taking a fresh look at private exchanges. These employers are looking for ways to expand choices, simplify administration and make costs more predictable. Brokers who recognize the market potential are adopting technology platforms that allow them to serve this underserved but growing sector.

The health insurance marketplaces still have plenty of room for improvement, particularly on the cost and convenience side. But the recently concluded enrollment season revealed that exchanges are here to stay and that opportunities abound as the marketplaces evolve. 

Trump’s 7-point Healthcare Plan, Part 2
March 7, 2016 2:55 PM by Michael Jones

[Editor’s Note: This blog was originally contributed by ADVANCE staffer Valerie Neff Newitt.]

Major news organizations have been quick to examine and critique the policy, and have noted that requests for further details from Trump headquarters have so far gone unanswered.

The Los Angeles Times reported March 3 that, to date, the ACA “has expanded coverage to about 20 million Americans, driving the largest decline in the uninsured in at least half a century. It is unclear what would happen to these people if Obamacare were repealed. …Trump has not specified how he would help these people, beyond promising that his plans would make healthcare substantially more affordable. That is disputed by many experts. Interstate sale of health insurance, for example, might slightly lower premiums, but would not address the much larger issue of high prices by hospitals and other medical providers, which are increasing their market power by consolidating in communities across the country.” also picked up on the lack of language pertaining to universal coverage. The news outlet reported, “Trump called in his healthcare plan for eliminating the individual mandate, which under Obamacare requires all Americans to have health insurance and which Trump suggested he was in favor of less than two weeks ago.” CNN quoted Trump’s words from a Feb. 20 interview with Anderson Cooper during a televised town hall event: “I like the [individual] mandate. Here's where I'm a little bit different. I don't want people dying in the streets.”

Trump’s earlier, more liberal, stance on healthcare raised the ire of the GOP when he told the CBS program “60 Minutes,” “…everybody's got to be covered. …the government's gonna pay for it.” CNN made the point that Trump's plan now makes no such promise that every American will be insured.

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More than just "big data", while not opposed to some of the planks of Trump’s plan, also noted the inconsistency in Trump’s changing position, “The Donald has previously insisted that he likes the individual mandate, and that he is opposed to Medicaid reform. If he has changed his mind in the last week, great, but we have no assurance that he won’t change his mind again.” Forbes also pointed out that the plan does not deal with pre-existing conditions, a concept that was central to the ACA and generally heralded as one of its better tenets.

One New York Times commentator noted that the plan, overall, is sketchy: “It is possible that Mr. Trump’s document, now a sketch, will be filled in later with a plan to help people with pre-existing conditions, or with some new financing system to provide health insurance for poor Americans. But, for now, the policies he has chosen to highlight won’t help them. He may describe himself as more compassionate and generous on healthcare than his rivals, but there’s a huge gulf between that rhetoric and the practical consequences of his policies.”

The most meaningful assessment of Trump’s healthcare reform plan ultimately will be revealed at the polls, as voters determine if his proposals reflect their best interests and warrant his selection as the next Republican presidential candidate.





Trump’s 7-point Healthcare Plan, Part 1
March 4, 2016 2:14 PM by Michael Jones

[Editor’s Note: This blog was originally contributed by ADVANCE staffer Valerie Neff Newitt.]

GOP frontrunner Donald Trump wants to dump Obamacare on day one of his intended presidential administration. It is one strategy, he says, to “make America great again.” On March 2, Trump released his 7-point plan to repeal the Affordable Care Act (ACA), also known as “Obamacare,” and redesign American healthcare should he succeed in his bid for the White House.

The plan, not surprisingly called “Healthcare Reform to Make America Great Again,” is available in its entirety on Trump’s campaign website.1 In it, he rails against the ACA, stating, in excerpt, “This legislation… has tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices. Obamacare has raised the economic uncertainty of every single person residing in this country. …The damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next president and a Republican Congress lead the effort to bring much-needed free market reforms to the healthcare industry. But none of these positive reforms can be accomplished without Obamacare repeal. On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.”

Trump’s position is one based on free market principles which, when implemented “with sound public policy,” will “broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans,” according to the Republican presidential hopeful.

The 7-Point Plan
Trump puts responsibility squarely on the shoulders of Congress to repeal the ACA, and to consider and enact healthcare reform based on his following published policy points. (The italicized opinions within these points are Trump’s alone and do not reflect any approval or disapproval from ADVANCE):

“1. Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.

“2. Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.

“3. Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.

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“4. Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate.

“5. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.

“6. Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources.

“7. Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.”




Why Cures for Childhood Cancers Must Take Flight
February 8, 2016 9:16 AM by Silas Gossman

[Editor’s Note: this blog was originally written by Kristin Connor]

Since President Obama announced last month that he wants to "make America the country that cures cancer once and for all," the White House has convened the first meeting of the National Cancer Moonshot Task Force which is chaired by Vice President Biden. The proposed funding includes $195 million this year and $755 million in the 2017 budget for the National Institute of Health (“NIH”) and the FDA. According to the fact sheet, the $1 billion budget will be directed to genetic analysis of cancers, the development of treatments such as vaccines and immunotherapies, which harnesses the immune system to attack tumors, and better data sharing among researchers.1 In addition to government and academia, the Task Force is calling for a collaboration of philanthropies, patient-advocate organizations, and biotech and pharmaceutical companies. For the childhood cancer community, the new focus on pediatric cancer which will include analyzing rare cancer tumors and studying how cancer progresses in order to develop better treatments, can’t happen fast enough.  Here’s why. 

Each year, nearly 16,000 children2 are diagnosed with cancer, with 40,000 children3 already suffering through ravaging treatments (not to mention the hundreds of thousands of survivors who spend a lifetime struggling with the side effects of toxic, life-saving drugs). Cancer is the second leading cause of death in children and the leading cause of death due to disease.4 Even though childhood cancer represents a real crisis for children, families and communities in the United States, cancers affecting children have never ranked high enough to get more than 4% of the federal cancer research budget. Why is research funding so low? Because allocation of cancer research funds are driven by the number of people who have the disease, and so adults, with decades of exposures and behaviors, get the funds since they experience cancer in much greater numbers than children. With the anticipated keen focus on pediatric cancers by the National Cancer Moonshot Task Force, will anything change? It must if we are going to improve outcomes and protect the lifetimes of children with cancer.

Because while incidences of childhood cancer rise, the 4% research funding allocation has remained flat.5 And this lack of funding has had tragic consequences, yielding 35 years of an unacceptable lack of progress in drug development for childhood cancers. Since 1980, only three drugs have been developed specifically for use in children with cancer.6 Equally disturbing, for many types of childhood cancers, the same treatments which existed in the 1970’s continue to be used without change today. Three and a half decades have come and gone and pediatric cancer treatments have remained stagnant. This is shocking and unacceptable, especially considering the last 40 years have seen a 24% increase in incidences of childhood cancers.2

With current treatments, more than 95% of childhood cancer survivors will have significant health related issues by the time they reach the age of 45 years—nearly all of them.7 We must increase funding for research that will lead to treatments which will not compromise a child’s quality of life for her lifetime. Targeted therapies, those which target the cancer cells and leave surrounding cells and organs unharmed, and immunotherapies, using the body’s own immune system to fight cancer, are extremely promising and with proper investment, offer hope of a cure without the same negative health effects today’s survivor’s face.

It is imperative we shift the mindset from only considering the number of annual cancer diagnoses to considering the number of life years potentially saved.  For a child with cancer, on average, 71 potential life years can be saved.2 The potential to save entire lifetimes should be a driving factor in funding allocation decisions but, to date, has not been considered.

We hope childhood cancer will be highly prioritized in the $1 billion dollar budget because no segment of our population is more important than our children.   

Kristin Connor is Executive Director of CURE Childhood Cancer, an Atlanta-based non-profit dedicated to conquering childhood cancer through funding targeted research and through support of patients and their families. She can be reached at



2.            American Cancer Society, Childhood and Adolescent Cancer Statistics, 2014

3.   Get Informed Childhood Cancer Facts

4.            National Vital Statistics Report, vol. 62.6, December 20, 2013

5.            National Cancer Institute

6.            The

7.            St. Jude Children’s Research Hospital, (JAMA 2013:309 {22}:2371-2381)

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The Mainstream Media’s Uneven Treatment of U.S. Healthcare System Performance
August 17, 2015 9:25 AM by Silas Gossman

[Editor’s Note: this blog was originally written by Ken Perez, vice president of healthcare policy, Omnicell, Inc.]

With the U.S. presidential election campaign season in full swing and a number of polarizing candidates apparently gaining traction among sizable portions of the electorate, the longstanding issue of media bias has arisen once again. One need only watch the two leading cable news networks to wonder if they are covering developments on two different planets!

Media bias certainly exists in the political realm, but is it also at play in the coverage of the financial and clinical performance of the U.S. healthcare system?

In the March 4, 2013 issue of Time, Steven Brill, founder of Court TV and the American Lawyer, delivered a withering critique of America’s healthcare system in an article entitled, “Bitter Pill: How outrageous pricing and egregious profits are destroying our healthcare.” It was the cover article of the issue, and with more than 42,000 words, it was the longest in the history of the magazine. Brill reported, “In the U.S. people spend almost 20% of the gross domestic product on healthcare, compared with about half that in most developed countries. Yet in every measurable way, the results our healthcare system produces are no better and often worse than the outcomes in those countries.” In a subsequent article in the Jan. 19, 2015 issue of Time, Brill went on to describe the U.S. as having “a broken-down jalopy of a healthcare system.”

Brill’s “Bitter Pill” article garnered generous, positive coverage by CBS, the Commonwealth Club, the Huffington Post, the Los Angeles Times, National Public Radio, the New Yorker, the New York Times, and even Jon Stewart’s “The Daily Show.”

But how do the mainstream media cover good news about the U.S. healthcare system?

There is a recent case that answers that question. The July 28, 2015 issue of the Journal of the American Medical Association (JAMA) included an article, “Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013,” that shared the findings of a study of over 68 million Medicare fee-for-service and Medicare Advantage beneficiaries by a team of well-respected medical researchers from Yale and Harvard.

This lengthy, detailed, heavily footnoted and carefully written article reported the following encouraging findings:

-          All-cause mortality for all Medicare beneficiaries decreased from 5.30% in 1999 to 4.45% in 2013

-          The total number of hospitalizations per 100,000 person-years declined from 35,274 to 26,930 (for fee-for-service beneficiaries)

-          Mean inflation-adjusted inpatient expenditures dropped from $3,290 to $2,801

In other words, for the vast majority of American seniors, from 1999 to 2013, the healthcare system saved more lives and did so with fewer hospitalizations and at lower cost — not too shabby for a broken-down jalopy.

The researchers wisely offered a wide variety of possible reasons for these impressive gains, including healthier behaviors (e.g., increases in rates of exercise and decreases in rates of smoking), shifting lifetime exposures (e.g., younger seniors have benefited more from improvements in public health), technological advances (e.g., improved therapies) and other factors. The authors mentioned at the outset national efforts to improve the care of all patients across the study period, citing federal initiatives to improve the quality of healthcare dating from the early 1990s. Like an ocean liner, because of its size and staggering complexity, the U.S. healthcare system requires considerable time for it to change course.

The study’s results do lend support to the belief that the U.S. healthcare system can indeed “bend the cost curve,” even under the frequently criticized fee-for-service model. Interestingly, it should be noted that the biggest drop in the rate of hospitalizations (9%) during the period studied occurred in 2013, the first year of the Hospital Readmissions Reduction Program, which penalizes hospitals for excessive readmissions within 30 days after discharge.

Of course, these gains achieved under the fee-for-service system do not mean that the quality improvement and cost reduction initiatives in Medicare Advantage and Medicare’s accountable care organization programs, respectively, are unneeded — we can and must do better clinically and financially.

So what kind of media coverage has this study with encouraging news received? The last time I checked, while a number of the more serious healthcare industry publications had covered the JAMA article, not a single one of the mainstream media that covered Brill’s article had done so.

So what are we to conclude? Evidently, in the eyes of many mainstream media editors, the improved performance of the nation’s healthcare system doesn’t constitute much of a story and thus doesn’t merit coverage. Such unfair and unbalanced treatment is the bitter pill that good news about the U.S. healthcare system must swallow.    

A Ray of Hope from Washington? Don’t Rush Meaningful Use
July 29, 2015 8:05 AM by Silas Gossman

[Editor’s note: this blog was originally written by Alan Portela, CEO, AirStrip]

I was very pleased to see that U.S. Senator Lamar Alexander is recommending the delay for Stage 31 of Meaningful Use, since it would drive the entire system to its knees. We all agree that the industry needed to change. This has been a bi-partisan initiative that started with President Bush and his appointment of David Brailer as the National Health Information Technology Coordinator back in 2004. For the past decade, this effort has been continued by the Meaningful Use program under the ONC.

I am not criticizing the initial goals of Meaningful Use (Stage 1 – Data Aggregation & Data Access; Stage 2 – Healthcare Information Exchange and Care Coordination; and Stage 3 – Outcomes Improvement). Rather, my extreme disappointment is directed to the fact that we did not pay attention to the first pillar – Data Aggregation and Data Access – to achieve outcomes improvement, which cannot be accomplished without clear and aggressive guidelines on interoperability requirements. Instead, the effort was directed to the implementation of EHRs for data entry, which created silos around few vendors. Of course, the consolidation and collaboration of healthcare providers that resulted from the Affordable Care Act (ACA) exposed the failures of Stages 1 and 2 around interoperability.

If the right level of interoperability is not established early in the program, then the healthcare system cannot easily migrate to Stage 2 – Healthcare Information Exchange and Care Coordination. Why? Because the only data available is now centered around very limited interoperability standards of C-CDA & HL-7 and to the Fast Healthcare Interoperability Resources (FHIR) – which, due to its many shortcomings, should really be called SHIR for Slow Healthcare Interoperability Resources.

Rather than immediately addressing the issue of limited access to clinically relevant data, the ONC came up with a 10-year road mapthat brings the industry to where it needs to be toward the end. To top it off, the push to Stage 3 – Outcomes Improvement – would force a value-based reimbursement model without giving caregivers access to clinically relevant data to make informed decisions – again exposing the limited success of Stage 1.

It seems as if developments are now moving at “Washington Speed” – driven by political elections and not by the original mission and vision of the Meaningful Use program. It is time for the government to start listening to the providers and patients, not the vendors. This could be a win/win situation – providers and patients know what is good for the industry, and can help get the politicians the votes they need.

Achieving the Eight Information Governance (IG) Principles
April 3, 2015 9:56 AM by Robby Chakler

[Editor's note: the following blog post was written by  Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and privacy officer.]

AHIMA's Information Governance Principles for Healthcare (IGPHC) provides a comprehensive framework for managing and governing trusted information. The eight principles form the foundation for a maturity model to help organizations determine how to proceed with an effective IG program.

This article is the first in a series that will discuss key steps to achieve each principle-starting with accountability.  

Viewing Accountability as a Valued Strategic Asset

Accountability in IG means responsibility for establishing stewardship of trusted information. According to AHIMA's principles, an accountable senior leader should be formally designated as responsible for overall IG program development and implementation. The senior leader is accountable for ensuring the IG program is aligned with organizational goals and strategies, and for securing appropriate resources to support the program.

Healthcare executives must understand their responsibility as stewards of information that enables organizational strategies and priorities-quality of care, cost reduction, compliance, improved patient outcomes, risk mitigation, accurate reimbursement. Accountability is central to the business value of IG as a strategic asset-how it helps the organization achieve its goals and strategies.

To realize the full benefits of information governance, AHIMA recommends:

  • An accountability framework and decision rights to ensure the effective use of information, enterprise-wide
  • The essential standards, rules and guidelines for functioning in an increasingly electronic environment
  • The defined processes, skills and tools to manage information throughout its entire lifecycle, as a critical business asset

Achieving Accountability through Collaboration

AHIMA advocates a collaborative, interdisciplinary approach with input from all stakeholders, business process owners and domain experts. Senior leaders can benefit from collaboration with health information management (HIM) directors to assess current policies and procedures, identify gaps and deficiencies, and set priorities.

Through collaborative leadership, achieving accountability encompasses the following IG directives:

  • Establish an IG structure for program development and implementation.
  • Document and approve policies and procedures to guide its implementation.
  • Remediate identified issues.
  • Enable auditing as a means of demonstrating the organization is meeting its obligations to both internal and external parties.

Accountability depends on clearly defined roles and responsibilities for developing policies, implementing technology, and improving practices that build trust in information. Here are eight steps to help achieve enterprise-wide accountability:

1.       Align strategic planning with IG requirements. Create a multidisciplinary team to guide strategic planning-setting priorities and goals. Make sure all players are represented and know the ultimate goal. Without a strategic plan, achieving goals aligned with IG principles will be difficult.

2.       Identify regulatory and legal requirements and get buy-in. Many stewards must come together to achieve organizational goals. The healthcare environment typically has pockets of stewardship in various departments that manage source systems. Consistent governance is critical.  

3.       Establish relevant standards across systems. Transferring information from one system to another requires standards that support accurate communication across systems. Make sure source documentation definitions are consistent.

4.       Create and implement organizational policies and procedures. Once standards are set, develop and document enterprise-wide policies and procedures to support your decisions. Best practices include consistency around data and collection, use, retention and destruction processes-throughout the information cycle.

5.       Provide multidisciplinary training and education. Secure buy-in regarding all standards, polices and procedures. Changing the way things have always been done can be a challenge. Show benefits for various departments and for the organization as a whole.

6.       Define stewardship roles to achieve common goals. Stewards involved with various source systems should assume a stewardship role for the entire enterprise. Define roles and determine who is responsible for achieving goals for all systems-and ensure consistency in the process.

7.       Perform compliance monitoring, auditing and reporting. Promote program awareness of best practices. Provide ongoing education to ensure information is properly protected, accessed, stored, retained, released and dispositioned. Report audits to appropriate governing bodies.

8.       Invest in IT resources that meet enterprise-wide goals. IT must support established standards, policies and procedures aimed at achieving the organization's accountability goals. A collaborative, centralized approach to IT decisions will serve the needs of all departments.

AHIMA's principles also emphasize the importance of helping the workforce understand how to implement IG practices. Program policies and procedures must be clearly documented, approved and communicated through ongoing training that reinforces compliance with standardized practices.

Assuring Trust in Information

Trust in information is the essence of IG. Accountability builds the trustworthiness required to ensure records are properly governed for auditing and program improvement to support enterprise-wide goals. The future of every healthcare organization depends on it.

Additional IG resources including AHIMA's benchmarking whitepaper, principles document, first IG infographic and more are available at

Rita Bowen is senior vice president of HIM and privacy officer at HealthPort. She can be reached at


Understanding and Addressing Physicians' Barriers to Achieving Better ACO Quality Metrics
March 24, 2015 8:35 AM by Robby Chakler

[Editor's note: the following post was written by Dan Malloy PhD, executive vice president, Quantia, Inc.]

ACOs have long understood that patient engagement is a critical element to keeping individuals healthy and the chronically ill stable. Now ACOs are beginning to appreciate the importance of  physician engagement and alignment around the cost and quality measures that have emerged as the performance threshold for their organizational health. After all, the criteria driving these metrics often lie in the hands of the physicians associated with the organizations.  

However, many ACOs struggle to know for sure that their physicians are aligned in ways that will achieve such metrics. When they're not, it's crucial to understand why. By offering physicians access to web-based, expert-led content on topics that drive these metrics, ACOs and other health systems are helping avoid potential financial penalties associated with these measures, not to mention improve patients' quality of life.

Depression screening

ACOs that fail to reach the quality metric in the area of depression screening may face reduced reimbursement. Yet a recent poll of over 3,500 physicians who participated in an expert-led QuantiaMD content segment on depression screening performance measures found that the majority (61%) only screen patients who present with symptoms. Just 25% say they screen every patient, and 7% say they don't screen any patients at all.

That healthy percentage of physicians who are only screening patients with symptoms may be putting their patients - and their quality metrics - at risk.  As one physician remarked, "Since I've started screening every new patient, I've been astounded at the number of ‘good actors' there are in this world with very high numbers on their PHQ but who I would never have dreamed are depressed by their affect. It's been a very gratifying activity."

As part of this segment, these physicians offered their own reasons for the inconsistency, and opportunities for systems to address these barriers.

Reasons cited for inconsistent depression screening include:

  • Lack of time (63%)
  • Lack of access to mental health services (14%)
  • Uncertainty on how to screen (10%)

Opportunities physicians cited to help increase depression screening include:

  • More time with patients (57%)
  • Better access to mental health services and better screening tools (40%)
  • Staff-assisted onsite care support (27%)
  • More education on depression (20%)

While physicians may always feel strapped for time, their call for increased education and exposure to available screening tools is something that can be addressed through web-based content, including expert advice on how to best manage these screenings. Concise, interactive presentations that are convenient for physicians-along with the ability to ask questions directly of these experts-enable  providers to address the reported  obstacles and help them  to better leverage the resources that are available to help achieve these metrics.

Colorectal cancer screening

Another key ACO quality metric for which physicians have significant potential impact is colorectal cancer screening rates. Thousands of physicians engaged in an expert-led interactive presentation on the topic on QuantiaMD to brush up on best practices for increasing compliance rates. 

Based on a follow-up survey of nearly 300 physicians who interacted with this segment, they appear to have gained a deeper understanding of their influence on increasing screening rates in their practices, and feel greater confidence in their ability to improve screening rates after interacting with the expert led content. For example:

  • 75% of physician respondents say the content influenced how they manage colorectal cancer screening in their practice
  • 68% feel they can increase colorectal cancer screening compliance rates in their practice after interacting with this presentation
  • The number of physicians who say they've initiated a patient activation system since interacting with this content increased by 65%, and the number of those who have since designed a delivery system within their practice to enhance screenings increased by 36%

While many physicians acknowledge that a lack of patient activation is one of the toughest obstacles to overcome, some physicians suggest that we all have a role in helping reverse the major image problem that the preparation for this test has.  

As one physician remarked, "The procedure is not always the hesitancy...word is out there that the prep is vile. That said, there are MUCH better preps now (bisacodyl + miralax as one example), which makes it way more tolerable. One awful prep, folks tell 10 people, and then 10 do not go. Easy prep, IV sedation, easy procedure...we need to get the word out there."

The good news is that based on this survey population, at least, the majority of physicians are leading by example-less than 10% of those doctors who are eligible for colorectal cancer screenings themselves admit non-compliance. The reasons they cite for avoiding the test are the same ones their patients have - fear, laziness, other medical problems taking a higher priority, and even the self-described "lousy excuse" of not wanting to give up two days in the office to get the procedure. Recognizing these universal barriers to optimal preventive health can help physicians approach their patient conversations with greater empathy.

Key takeaway

The consequences of inconsistent screenings-in terms of undiagnosed medical conditions and reduced reimbursement-are obvious. Gaining a window into physician's attitudes and behaviors around these metrics helps identify and address these issues. 

Do you have the insights and physician buy-in needed to address these and other quality and patient care outcomes? The nation is watching.

A New Perspective on Privacy and Security as Foundational Components of Information Governance (IG)
March 16, 2015 2:01 PM by Robby Chakler

[The following blog post was written by Rita Bowen, MA, RHIA, CHPS, SSGB, Sr. VP of HIM and Privacy Officer, HealthPort] 

Healthcare must move beyond compliance to a greater model of IG.

For the past three years, the Privacy Point column has focused primarily on privacy and security- issues, challenges, priorities along with strategies to promote compliance and mitigate risk. During that time, the HIPAA Omnibus Rule was piloted and refined in 2013 and 2014, with September 23, 2014 as the final date for all business associate agreements to comply with the current regulations. With procedures in place for that phase of compliance, the focus is now shifting to the value of information governance (IG) in healthcare.

Going Beyond Compliance

Despite decades of privacy and security regulations, many organizations lack proper governance and management practices to address ever-increasing risks and threats. According to the Identity Theft Resource Center, approximately 42 percent of major data breaches reported during 2014 were attributed to healthcare organizations. That's a stunning statistic. And security risks may be on the rise for 2015, especially if the HHS Office for Civil Rights (OCR) follows through with its random audit program to assess compliance with HIPAA privacy, security and breach notification rules.

Traditional privacy and security solutions are not sufficient to address rapidly emerging risks and threats. Data and security breaches and compliance penalties point to inadequate control of information. Establishing proper controls requires effective IG that ensures protection of trusted information. Compliance alone is not enough.

AHIMA's IG principles recommend a proactive, collaborative, interdisciplinary approach. Privacy and security must be viewed from a new perspective-as foundational components of an enterprise-wide information governance model.

Former AHIMA CEO, Linda Kloss, MA, RHIA, FAHIMA and author of Implementing Health Information Governance: Lessons from the Field, states: "Leading organizations understand that governance and management of privacy and security must be in full compliance, but must also build trust and transparency through ethical stewardship practices that may go beyond compliance. . . They also understand that a compliance mindset does not fully serve the interests of the patients they serve. . . Their sound governance of privacy and security considers ethical compliance and fiduciary responsibilities."

As the demand for trusted information increases, leading healthcare organizations are moving from a compliance approach to a broader IG perspective aimed at improved quality of care and organizational performance. Fortunately, AHIMA has taken the lead toward a smarter, strategic maturity model. And HIM professionals are best qualified to educate all stakeholders on the value and responsibility of stewardship-privacy and security, risk management, and overall data integrity-critical components of trust in information.

Advancing IG through Collaborative Leadership

While some organizations have taken steps to initiate an IG program, most are still in the infancy stage of implementing consistent and collaborative IG practices. Whether your organization is just beginning or in the process of refining its program, here are four strategies for advancing IG:

  • Assess existing policies, procedures and systems for capturing, processing, delivering and storing data. Set priorities to build a program aligned with your organization's goals.
  • Engage an executive sponsor by showing the business value of IG-quality of care, cost reduction, compliance, improved patient outcomes, risk mitigation, accurate reimbursement.
  • Create an interdisciplinary team including HIM, IT, compliance, C-suite, revenue cycle, legal and risk management.
  • Develop a plan for implementing the AHIMA principles.

HIM professionals already know the value of IG. Their knowledge, skills and experience will advance enterprise-wide information governance through strong collaborative leadership.

Focusing on the Essentials

Once an IG framework is established, organizations should focus more closely on the essential elements of an effective program-privacy and security, quality and integrity, data capture, records management, availability and use of information. While privacy and security concerns continue to occupy center stage, each component is an integral part of a greater IG model. 

In the coming months, IG Matters will delve deeper into the various aspects of each component, including the following:

  • Clean master patient index (MPI)-Ensuring a high level of MPI integrity must be a top priority for enterprise-wide IG programs. Preventing errors and inconsistencies is critical to patient safety.
  • Data dictionary and data map-Both tools are key to understanding the source and meaning of data across systems.
  • Best practices to promote data integrity-Quality and integrity management are the foundation for trust in information.
  • Interdisciplinary education-Ongoing education regarding privacy and security, risk management, and quality of information builds a culture of IG.

In today's evolving regulatory environment, healthcare providers cannot afford the risks of ineffective management and governance of information. That is why 2015 must be the year of IG in healthcare. And HIM is ready to lead the way.

Welcome to the IG Journey

With many thanks to all the dedicated followers of Privacy Point, I now invite you to join the IG journey. Throughout 2015, IG Matters will focus on strategies for building and sustaining a successful program, the essential elements of IG, lessons learned from case study organizations, and more. Your ideas for future topics are most welcome.

Rita Bowen is senior vice president of HIM and privacy officer at HealthPort. She can be reached at

Data Security Dilemma
March 3, 2015 12:09 PM by Robby Chakler
[Editor's note: the following blog post was written by Jeff Margolis, chair and CEO, Welltok]

Data, data, everywhere...the practical dilemma is that even as the increasing threat of data security challenges is hitting the front page, healthcare industry leaders and pundits are in nearly universal agreement that far more - not less - consumer interaction and engagement with meaningful healthcare data is necessary to drive significant improvements in healthcare value. It's perhaps analogous to the notion of a person needing water to drink, but the water around them is either saltwater or it potentially contains harmful bacteria or parasites. Frustrating to say the least! 

While all of the facts around the Anthem breach aren't known yet, other health plans and providers are - as any rational person might expect - expressing heightened concern and examining their own vigilance. It's difficult to feel "safe" when you contemplate the awe-inspiring scope and alleged consumer-harming intent of the breach. Although healthcare industry organizations endeavor to follow best practices, even the most prepared organizations can be subject to the challenge of a data breach. And beyond the challenges of Anthem and its members, digital innovations across the industry that can generally benefit consumers will almost certainly face potential delays. 

Allow me to put the healthcare industry data security dilemma into practical terms. First, understand that the HIPAA and HITECH Acts establish minimum requirements for compliance with the Security and Privacy Rules, with the intent of these regulations being to define a common baseline across the healthcare industry. Second, understand that these regulations do not set forth best operational practices for assuring the protection of consumer data, nor do they impart a step-by-step security and privacy framework that establishes best practices for the dizzying array of computers and devices that consumers use today to interact with their health plans, doctors, hospitals and pharmacies.

To be sure, there are excellent and capable people, consultants and security-centric companies to drive and share best practices. However, I feel legacy technologies and existing platforms in healthcare will struggle to apply new security advancements at a sufficient rate to mitigate efforts by the "bad people" who plague multiple industries today.

Today's healthcare consumer-interactive platforms need to be built on the fundamental principle of anonymity with security and privacy engineered into the core design, unlike those based solely on HIPAA. This includes applying the HITRUST CSF security framework and data segregation of PHI/PII from consumer facing capabilities. We began the development of our CaféWell Health Optimization PlatformTM from the perspective that there needs to be a better way to deliver both an engaging, personalized user experience and a safe, secure environment that also mitigates risk.

As my intent is not to be overly technical, I'll conclude with this thought. Figuring out how to help consumers benefit from more data about themselves without increasing the risk of exposing their identity is not easy...but it is possible!

Will 2015 Be The Year Your Watch Teaches You About Your Health?
February 5, 2015 8:57 AM by Robby Chakler
[Editor's note: the following blog post was written by  Dr. van Terheyden, CMIO at Nuance Communications.]

Regardless of which side of the exam table you sit, we're all healthcare consumers. Technology holds the potential to create clinical synergy between patients and caregivers, providing better intelligence about personal health data and outlining proactive measures to take to become better partners in health care.

There is no known medical condition that enables an individual to predict the future.  While such an ability would be extremely useful for myriad reasons, we have, instead, learned to hone and leverage our analytic skills to deduce what might occur, relying on the data we cull and parse to help forecast the future.  So, when it comes to predicting the year ahead, we should consider the one we just had.

Regardless of which side of the exam table you sit, we're all healthcare consumers

Consumer technology is often a good indicator of what type of capabilities and functionalities might be in store for health IT.  This past year, we saw major players in the tech space announce their forays into healthcare.  While this will not be without its challenges, it does not diminish the underlying fact that there is a need and want for better technology in healthcare- regardless of whether you are a patient looking to effectively manage your weight or a physician struggling to juggle patient care and administrative duties.

In the last year, we saw a wave of next-generation wearable devices flood the market, and as a result, we, as patient consumers, now have streamlined access to information such as our daily step count and average heart-rate on our watches.  We know that ease-of-use, understandability, and some level of gameification ("Congratulations! You've reached your target heart rate today!") are vital to maintaining engagement.

I believe this is the beginning of something much larger, a groundswell movement that will result in patients wanting more information about their health data, and, more importantly, craving a better understanding of what all these numbers actually mean and how to positively impact them. Achieving this level of engagement demands a simpler intelligent interface that doesn't require a learning curve, but is one that consumers can just use. Clever user interface designs can only go so far, particularly given the small visual real estate available on wearable devices, and the addition of capabilities such as intelligent voice assistants will be an integral part of this explosion of personal health management.

Having a heart-to-heart about your heart

Technology holds the potential to create clinical synergy, bringing patient consumers (who have become professional health IT consumers, or health prosumers) better intelligence about their personal health data and outlining the proactive measures they can take to become better partners in their own health.  The average patient consumer may not have a reaction to the phrase "Your Protime this week is 3.3," but for someone with a heart condition, this number is very important and indicates how fast her blood is clotting.  The data, while extremely useful to a clinician, is only helpful to the patient if she understands what it means and how she can take the right actions as a result.

The future is about patients managing their own care and working alongside clinicians to drive better outcomes.  To the woman who has a Protime of 3.3, access to these results supplemented with clinical guidelines would mean that she wouldn't need to wait for her physician to call with diet recommendations, she would know her blood is clotting too slowly and that she might have an inadequate protein consumption or might need to increase her vitamin K intake.  If the number required that her Coumadin dosage be adjusted, this would be the point where her physician would reach out to her to discuss.

Although a basic example, it is one that has endless permutations when it comes to building a more engaged patient population.  There is no one more invested in your health than you, and the person who cares the next most about keeping you well, is your physician.  I believe that clinical synergy will be driven by both patients, who want to actively manage their chronic conditions and take meaningful preventative care measures, and physicians who want to empower their patients to better understand how the choices they make have significant health implications.  Technology is the connective fiber that can enable the transmission of this important data, and help translate it into wisdom.  And that truly is the crux-the data flowing between patient and physician must be relevant and meaningful.  That ability for technology to determine the relevancy of health data information is just around the corner and soon our wearables will be able to notify our health information data that deviates from our personal "normal" results.

Approximately 75 percent of U.S. healthcare expenditure is related to chronic care management, imagine the impact this level of clinical synergy will have on driving a healthier population while reducing cost.  I'm ready, are you?

ICD-10: Ready, Set, Code
October 2, 2014 10:10 AM by Robby Chakler

[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?

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Now you have 14 months to develop a customized dual coding program plan for your organization.
  6. 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.

Global Healthcare Megatrends: Clinical Challenges
September 3, 2014 1:36 PM by Robby Chakler
[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.



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