Thursday, May 14, 2015

Legislation to promote interoperability of electronic health records

The U.S. House of Representatives’ Energy and Commerce Committee will consider language designed to ensure that electronic health information systems are interoperable (can talk to each other) as part of its markup of the so-called 21st Century Cures legislation by Chairman Fred Upton, R-Mich., and Diana DeGette, D-Colo.

This reported by Congressional Quarterly.

In an interview last week, Texas Republican Michael C. Burgess told Congressional Quarterly that he has long been concerned about incentive programs to get health care providers to adopt electronic health record systems, which were included in the 2009 stimulus package. In his view, the programs pushed a lot of money out the door without a clear plan for what should be accomplished and the results have been disappointing.

Burgess told Congressional Quarterly that his effort will build on interoperability provisions in a recently-enacted law that changes the way Medicare doctors are paid. The legislation set a national goal of achieving widespread exchange of health information through certified technology by the end of 2018. (NAHAM News will be looking into this.)

The American Hospital Association cited the Medicare law’s new interoperability requirements and maintained that putting additional constraints on providers is unnecessary and could limit flexibility.  AHA recommended that the committee focus on developing policies that ensure vendors are accountable for designing and supporting interoperable products.

Vendor accountability? 
The American Medical Association reportedly favors language that instructs the administration to develop tools to ensure that recipients and patients are accurately identified, among other things.

Accurate patient identification? Wow, but I digress again.

The AMA pointed to the federal incentive program for "meaningful use" in outlining the problems with interoperability.

The existing program gives Medicare or Medicaid bonus payments to physicians, hospitals and other providers who demonstrate that they "meaningfully use" electronic health records and in later stages, penalizes providers who don't comply.

Physicians and the companies that sell the technology are focused on meeting the complex requirements of the existing program "and often do not have the time and resources to focus on actions that fall outside of the numerous MU measures—including interoperability.”

Congressional Quarterly also reports that the Senate Health, Education, Labor and Pensions Chairman Lamar Alexander also wants to address concerns about electronic health records, though his committee is not as far along as the House. From Senator Alexander –

The federal government has spent $28 billion to speed the adoption of electronic health records, and the result is that doctors don’t like the systems and many say they disrupt workflow, interrupt the doctor-patient relationship, and haven’t been worth the effort. We are working in the Senate health committee to identify the five or six things that Congress or the administration can do to help make the failed promise of electronic health records something that physicians and providers look forward to instead of something they endure.

Stay tuned. We’ll keep an eye on this legislation.

Medicare cards will no longer be issued with Social Security Numbers

NAHAM News reported on this on April 23.  The New York Times article, New Cards for Medicare Recipients Will Omit Social Security Numbers (April 20, 2015), gives a good account of the issue as part of a larger bill signed by President Obama recently. 

The two lead paragraphs help with the background -

Concerned about the rising prevalence and sophistication of identity theft, most private health insurance companies have abandoned the use of Social Security numbers to identify individuals. The federal government even forbids private insurers to use the numbers on insurance cards when they provide medical or drug benefits under contract with Medicare.

But Medicare itself has continued the practice, imprinting Social Security numbers on more than 50 million benefit cards despite years of warnings from government watchdogs that it placed millions of people at risk for financial losses from identity theft.

The change, mandated in a larger bill focused primarily on overhauling the way doctors are paid for treating Medicare patients, doesn't come without a cost -

Congress provided $320 million over four years to pay for the change. The money will come from Medicare trust funds that are financed with payroll and other taxes and with beneficiary premiums.

Medicare will have up to four years to start issuing cards with new identifiers and will have four more years to reissue cards held by current beneficiaries. Medicare intends to replace the Social Security number with “a randomly generated Medicare beneficiary identifier,” but the NYT reports that details are still being worked out.

On an interesting side note, the article also points out the long call from within government to discontinue the practice of using SSNs on Medicare cards and the slow response to those calls by the Department of Health and Human Services.

Senator Susan Collins, Republican of Maine and chairwoman of the Senate Special Committee on Aging, said she was puzzled by the delays. “This still does not appear to be a priority” for Medicare administrators, she said.

Medicare officials said their top information technology specialists had been preoccupied with efforts to build and repair, the online system for buying health insurance under the Affordable Care Act, which was overcome by technical problems soon after it began operating 18 months ago.

Well, generating a random number as an identifier is a not so novel concept.  As Medicare works on replacing the SSN with a new identifier for purposes of beneficiary benefits, it is to be hoped others give thought to the use of viable identifiers to be used for purposes of patient safety, through put and access to health records.  Let us know your thoughts on this.  What would the set of identifiers or unique identifier look like for the purpose of positive patient identity?

Friday, May 8, 2015

When a hospital closes

Kaiser Health News cites a recent study that finds that patients are not hurt when the local hospital closes.  See "Patients Not Hurt When Their Hospital Closes, Study Finds."

Here is a summary statement of the findings -

"While the researchers noted that some people might be inconvenienced by having to travel further for care, they found no significant changes in how often Medicare beneficiaries were admitted to hospitals, how long they stayed or how much their care cost."

One important caveat -

Lead researcher Dr. Karen Joynt said "the researchers had no way of examining whether the health of low-income and uninsured people suffered from the closures, so it was possible those closures did have deleterious effects. The paper looked at Medicare patients because their records are easiest to analyze and compare."

Of particular interest in a map of hospital closures between 2003 and 2011.

Also of interest if the characteristic found by the study -
"The closed hospitals tended to be financially troubled, with revenues averaging 13 percent less than the cost of running the institutions."

Additionally, a third of the closed institutions were safety net hospitals that treated large numbers of the poor and uninsured.
Another finding, keying off another NAHAM News post looking at the closure of Lakewood Hospital in Cleveland - 70 percent of the hospital closures were in urban areas rather than in rural regions, where hospitals have had trouble staying afloat for decades. But the article notes that the impact of a hospital closure in rural areas can be more devasting.

Regarding the findings of the study, Dr. Joynt is quoted by Kaiser Health News -

"It’s possible that we didn’t see any change in outcomes because patients instead went to nearby hospitals that had better finances and may have had more resources to provide care."

Changing suburban demographics impact hospital systems

An article by Kaiser Health News, "Losing A Hospital In The Heart Of A Small City" reveals a growing and challenging trend. 

The trend is one of hospitals closing their doors in communities they have served for years if not generations.  In this case it's the Cleveland suburbs and the hospital is Lakewood, a part of the Cleveland Clinic heralthcare system.  Lakewood Hospital has reportedly lost money since 2005 and the expectation is that it will close within two years.  To be clear, it will be replaced by a small clinic and emergency room that Cleveland Clinic says will make it a sustainable point of care.

Lakewood is experiencing something that is increasingly common across the country -

The hospital, like others, has fewer patients and they aren’t staying as long – which can cut into revenues. Who is using the hospital is also a factor - there are fewer privately insured and more Medicare and many more Medicaid patients.  As many as 16% of Cleveland population live at the poverty level, up from 2% reported in 2002.

The trend of hospitals closing because of the inability to sustain revenues is a particular problem in rural areas.  Kaiser Health News article, "Georgia Weighs Medicaid Experiment (But Not Expansion)," cites a novel yet not guaranteed approach by the State of Georgia to shore up its rural healthcare. 

While to article unfolds within the politics of the Affordable Care Act and a state that has opposed the law's Medicaid expansion, it highlights the same issue of hospitals not able to sustain a presence where populations are withouht private insurance and reliant on Medicaid -

"Dozens of rural hospitals face funding shortfalls so acute that they threaten access to care for tens of thousands of Georgians across the state. Since 2001, eight rural hospitals have closed and more than a dozen are considered financially fragile."

From a related NAHAM News post ("When a hospital closes"), we find one significant difference in the closure of a rural hospital versus the closure of an urban hospital -

"Rural closures can be devastating when the hospital is the only one in the region."  In an urban area, patients arguably have an easier time finding and getting to alternative care settings.

Since 2010, 50 rural hospitals have closed, 16 of them last year, according to the N.C. Rural Health Research Program.


Thursday, April 23, 2015

Disparities among states show weaknesses and strengths of the Affordable Care Act

Four largest states have sharp disparities in access to healthcare



Californians and New Yorkers have better access to healthcare than Floridians and Texans, according to the study from the Commonwealth Fund, a New York foundation that studies health systems domestically and around the world.


The data may reveal the strengths and weaknesses of the Affordable Care Act, or at least the pathways the law affords the states.  The suggestion is that access to medical care and perhaps even ability to pay medical bills is affected by whether a state has expanded insurance coverage under the law.


·         Residents of Florida and Texas, which have resisted expanding insurance coverage through the health law, reported more problems getting needed care than residents of California and New York, which both guarantee coverage to their residents.


·         Floridians and Texans were also significantly more likely to struggle with medical bills and to report that they had medical debt.


·         More than 40% of residents of Florida and Texas reported that they did not go to the doctor when they were sick, didn't fill a prescription, didn't see a needed specialist or skipped a recommended test or treatment in the previous year.


·         The same proportion reported they had been unable to pay a medical bill, had been contacted by a collection agency over a medical bill, had had to change their way of life to pay bills or had medical debt.


"Health policy decisions made by state leaders matter," the study's authors conclude, warning: "Coverage gaps are leaving millions uninsured and without access to affordable coverage."


Some states have expanded Medicaid with federal aid made available by the law; other states — all led by either Republican governors or legislatures, or both — have turned down the assistance, citing concerns about Medicaid's effectiveness and cost.


States that fully implemented the law saw a 4.8 percentage-point improvement in the share of adults with insurance from 2013 to 2014, according to a recent Gallup poll. That was nearly twice the rate of states that have not fully implemented the law.


Just 31% of Californians and 30% of New Yorkers reported the same access problems as found in Florida and Texas. Even fewer said they had the same struggles with medical bills.


What is the situation in your state?  What are you seeing at registration or the back end of the revenue cycle?


Legislation to Remove SSN from Medicare Beneficiary ID cards

A NAHAM member active on our Policy Development and Government Relations Committee send the following -

President Obama has signed a bill<> that provides $320 million in funding to remove Social Security numbers from Medicare beneficiary ID cards within the next four years in an effort to fight identity theft and fraud.

The law calling for removal of Social Security numbers from Medicare beneficiary cards comes after several years of recommendations for such a move by government watchdog agencies, including the Government Accountability Office.
GAO has repeatedly issued reports in recent years recommending eliminating Social Security numbers from Medicare cards to help protect individuals from falling victim to ID theft and fraud, ranging from healthcare-related fraud to thieves opening credit card accounts using those IDs.


Thursday, April 16, 2015

Data Security versus HIT Interoperabilty

The HealthLeaders Media article, "EHR Data 'Blocking' Hobbles HIT, Says ONC", points out a tension between data security concerns and health information technology interoperability.

Find the article here: John Commins, for HealthLeaders Media , April 13, 2015 -

The byline reads: "Technology vendors, hospitals, and health systems restrict data access under the guise of security and confidentiality, but it can be challenging to identify and differentiate information-blocking from more benign impediments"

Highlighting the issue is a report by the Office of the National Coordinator for Health Information Technology.

Part of the problem derives from concerns about competition.  The HealthLeaders Media reports that "The federal government's $28 billion investment in health information technology interoperability is undermined by vendors and providers who don't want to share data with perceived competitors."

The ONC report says that "information blocking" is a problem that will likely get worse.  Technology itself is an enabler, and the ONC finds -

"However, based on the evidence and knowledge available, it is apparent that some healthcare providers and health IT developers are knowingly interfering with the exchange or use of electronic health information in ways that limit its availability and use to improve health and health care."

Here is one source of the problem according to the ONC finding -

"Some EHR developers allegedly charge a substantial per-transaction fee each time a user sends, receives, or searches for (or "queries") a patient's electronic health information. EHR developers may also charge comparatively high prices to establish certain common types of interfaces—such as connections to local labs and hospitals. Many providers also complain about the costs of extracting data from their EHR systems for their own use or to move to a different EHR technology."

But the report finds providers can also share some of the blame, or a misunderstanding by providers of what federal and state law requires of them -

"Such constraints are not information blocking insofar as they are consistent with the requirements and policies established by federal and state law that protect patients' electronic health information," ONC said. "But it has been reported to ONC that privacy and security laws are cited in circumstances in which they do not in fact impose restrictions."

Example: A provider cites HIPPA privacy rules to deny the exchange of electronic protected health information for treatment purposes, even though HIPPA specifically permits such disclosures.

Of particular interest is the question raised: Who Owns the Data?

Health records belong to the patient.  So says Chris Van Gorder, president/CEO of San Diego-based Scripps Health.

And Consider the power of that ownership in this New York Times article: The Healing Power of Your Own Medical Records:

As reported by HealthLeaders Media -

"The only legitimate concern providers have with patient data exchanges is confidentiality, Van Gorder says, because providers are liable for any release of confidential patient data to anyone other than the patient."

What do you think?  When is data blocking legitimate and not contrary to the interests of the patient?  When does data blocking exceed legitimate legal and business concerns and become an impediment to the patient?