Thursday, December 27, 2012

Ensuring Patient ID Online

Although patient identification has long been an issue within the hospital community, a new push in the conversion to electronic health records (EHRs) has added new challenges and solutions. Some organizations, like the Department of Defense (DoD) are already verifying the identity of their patients and other authorized users of their online system, MyHealtheVet. The DoD, however, has the luxury of a Veterans Administration database that includes all military personnel that would be accessing the system.

What health systems without pre-existing user databases should do is still up in the air. Privacy and security experts have not yet decided which methods of ensuring patient identity online are most effective and easiest to use. No matter the conclusion, however, most agree that it will still be necessary to verify patient credentials like a driver’s license, passport, or biometric identifier before allowing that patient to access their records online. 

Some states are implementing programs allowing access to partial records. Indiana’s State Department of Health, for example, has an online vaccination portal which allows parents to verify their children and view online immunization records. A parent must be registered by their child’s healthcare provider, and all access requests are monitored by a separate system.

Other businesses, such as identity card company Gemalto, are suggesting the use of SmartCards for patients. These cards, similar to the federal government’s Common Access or “CAC” cards, will contain a chip with biometric information about the user.

A federal policy committee has provided three guidelines that should be followed when thinking about enabling online access. The access should require a username and password at the minimum, with the option for additional security if the user chooses. The protection should not be so difficult that it discourages patients from participating, and providers should look to the Office of the National Coordinator for Health Information Technology (ONC) for guidance on identification methods. While this guidance has not yet been provided, a team within the National Institute of Standards and Technology has directed the agency to work with the ONC in setting up best practices.

You may find the original article from the Government Health IT website here

Hospitals Get Creative to Limit Medicare Readmissions

Since October, Medicare has been calculating the number of Medicare patients readmitted to hospitals within 30 days of their discharge. This data is kept for the new Value Based Purchasing Program, a part of health care reform (HCR) that penalizes hospitals with high rates of readmission by withholding a part of their reimbursement money.

The program has begun to change the payment structure of Medicaid away from government payments to hospitals per procedure, and towards payments for the overall wellness of the patients. These changes are a welcomed change by many patients, and even by some health care professionals who believe that this is the way hospitals will be paid in the future.

As a result, some hospitals have been employing new techniques to ensure that patients are able to care for themselves at home. According to an article in the Waco (TX) Tribune, some hospitals in Texas will have a nurse call the patient at home to follow up on their recovery and ask if there is anything the patient needs. Others will automatically schedule a follow up appointment with the patient’s doctor. Still others may send health care professionals to the patient’s home to ensure a smooth transition.

Many hospitals employ a discharge questionnaire that asks questions such as “will there be a friend or family member to assist you at home,” “Are you able to get to the pharmacy,” and “do you understand any changes in medication?” While these questionnaires have been in place for a while in many hospitals, some have tweaked the questions in an effort to prevent readmissions.

The program, combined with the resulting changes in hospital procedure, mark a significant change in hospital culture. This change will be important over time, as penalties for readmissions only escalate in the coming years. 

Thursday, December 20, 2012

CDC Predicts a Bad Flu Season

The Centers for Disease Control and Prevention (CDC) warned the public earlier this month to be prepared for a bad year of the flu. The CDC found that this year’s flu season got underway in late November, the earliest start since 2003. The CDC also warns that the strain being seen this year tends to be more severe than in the past.

Normally, a spike in flu like symptoms is not expected until late December, but the CDC reported that the season kicked off the week of November 24th. During that week, about 2.2% of doctor visits were for flu-like symptoms.

The flu is expected to be especially bad in the south, where five states are seeing outbreaks. These states include Tennessee, Mississippi, Alabama, Louisiana, and Texas. Meanwhile, Georgia and Missouri are reporting moderate levels of this year’s strain.

The best tool against infection is still vaccination. The vaccine that is available this year is well equipped to handle the flu, according to the CDC, and officials there believe the vaccine will be effective. So far, 123 million doses of the vaccine have been distributed, and 112 million of those have been administered.

This year, unlike past years, there is not expected to be any shortage of vaccines, so everyone should be able to get a vaccine if they want one. The CDC especially recommends vaccinating vulnerable groups including children, pregnant women, and healthcare workers.

You can view the Denver Post article here, and the CDC report here

OIG Report finds that More Oversight is Needed in EHR Incentive Program

More oversight is needed for the new Medicare Electronic Health Record (EHR) program, according to a report from the Health and Human Services’ (HHS) Office of the Inspector General (OIG).

The program started in 2011 under Center for Medicare and Medicaid (CMS) studies and disbursed about $1.7 billion in its first year. CMS estimates that they will pay a total of $6.6 billion in incentive payments throughout the life of the program, which goes through 2016. More information on the program can be found here.

The report found that, while cursory checks were done to ensure eligibility in the program, the program mostly operates by applicants self-reporting. The model can work, but there was not enough verification done to ensure that the self-reported data was correct. The report stated that CMS “does not verify that… percentage-based measures [reported] reflect the actual number of patients for a given measure, or that professionals and hospitals possess certified EHR technology.”

Specifically, CMS has not yet done any post-payment audits, and they do not have a system in place to assess a potential recipient before a payment is made. Part of the issue may be the limited information that is included in reports that are collected by the Office of the National Coordinator for Health Information Technology (ONC) and shared with CMS.

As a result, the OIG report suggested that CMS set up a pre-payment verification system, where they obtain supporting documentation from applicants, and that they provide guidance and specific examples of what would represent acceptable supporting documents from applicants.

The CMS Acting Administrator Marilyn Tavenner responded to the report, saying that pre-payment audits were not necessary. She contends that these audits would only slow down the process and delay incentive payments, but she agreed with the need for CMS to provide more guidance on documentation.

The report also suggested that ONC improve their reporting and certification programs for EHR technology so they can verify information that CMS is getting from applicants.

You can find the full OIG report here, and the Modern Healthcare article on the report here

More States Opt for Federal Health Exchanges than Expected

An important state health insurance exchange (HIX) deadline has come and gone, and it seems that more states will be opting for the federal option than experts originally thought.

In line with implementation of the exchanges under the Affordable Care Act, states had three options to choose between. There was the state-based exchange, in which a state would run its own HIX, the federal-exchange which ceded control of the HIX to the federal government, and a partnership option where the state and federal governments work together.

The Department of Health and Human Services (HHS) set a deadline of December 14th for states to report their decision.  States that opted to run their own exchanges were also required to submit blueprints of the HIX plans for approval. This deadline was moved from November at the request of the Republican Governors Association. NAHAM News previously reported the shift on November 16th (States Given More Time to Work on Health Exchanges).

The deadline has come and gone, with 18 states and the District of Columbia opting for their own exchanges. An additional 7 states have indicated that they will partner with the federal government, and the remaining 25 states default to the federal exchange. These partnership numbers may change slightly, however, because states that are not running their own exchanges have until by February 15, 2013 to partner with HHS.

State run exchanges will be put in place by California, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Kentucky, Maryland, Massachusetts, Minnesota, Mississippi, Nevada, New Mexico, New York, Oregon, Rhode Island, Utah, Vermont, and Washington.

Partnership exchanges will be put in place by Arkansas, Delaware, Illinois, Iowa, Michigan, North Carolina, and West Virginia.

These numbers are interesting for a number of reasons. First of all, many of the states that defaulted to the federal system have Republican governors who emphasize the importance of the state government. Some of those governors have supported their decision to default to the federal option by calling a state HIX, “state run in name only.”

Secondly, most experts expected the number of states that opted for the federal option to be much lower.  Mostly, only small states were supposed to default to the federal system. While states can switch to their own health exchanges in future years, the logistics of the first year are going to be a challenge for HHS.

See the Kaiser Family Foundation map of States decisions here. This article was written with research from and NPR article, and a Healthcare IT News article

Joint Commission Releases 2013 Survey

The Joint Commission has released its 2013 Survey Activity Guide for Health Care Organizations.

You may find it here, and it is also posted on NAHAM’s Joint Commission Toolkit, available to NAHAM members online.

The Joint Commission’s 2013 Survey Activity Guide (released December 18, 2012) has replaced the 2012 guide. The guide provides detailed information to help an organization prepare for an accreditation on-site survey. Included is a description of each activity that takes place during an accreditation on-site survey including logistical needs, session objectives, suggested participants and an overview of the session.
Also available online to NAHAM members is an archived webinar that introduces the toolkit and discusses Joint Commission surveys, the toolkit, Tracer Methodology, and other special considerations for your next Joint Commission Survey.  The webinar is presented by Michael Sciarabba, CHAM, Director of Patient Access Services, Advocate Illinois Masonic Medical Center and the chair of the NAHAM Policy Development/Government Relations Committee and Brenda Sauer, RN, MA CHAM, Director, New York Presbyterian Hospital and NAHAM’s current Vice President.

EHRs May turn Small Errors into Big Ones

A new review of electronic health records (EHRs) by the Pennsylvania Patient Safety Authority found that mistakes made in EHRs can be farther reaching than errors using traditional paper records.

The study examined over 3,000 incidents over the course of 8 years that stemmed from EHR errors. In about 80% of the cases, the results were errors with medication, and many of the rest involved incorrect or unnecessary lab tests. In the medication errors, about half of the patients were prescribed the wrong medication, and another quarter were under medicated.

So why are mistakes traveling farther? Electronic systems are becoming increasingly networked to things like the hospital pharmacy or other health information exchanges. This means that an error that may have previously been caught before it was replicated may now cascade to other systems before being caught. The scale and amplification of mistakes has increased.

The article, published here, also points out that in the short run, more mistakes are being made. One cause of this could be the lack of training that users of the systems have received. Federal programs that incentivize the implementation of electronic systems, and deadlines that came with the 2009 stimulus funds may have caused a quick rollout of systems to staff members who did not yet know how to use them. Additionally, some facilities may be using EHRs in addition to paper records, producing incomplete information entered into the system.

In some systems, information that is typed into the wrong box is not recognized. In others, system glitches can cause issues, like random medication orders appearing in some patients records.

Most experts believe, however, that these are temporary setbacks. As time progresses, EHR systems will become smarter, and staffs will become accustomed to using them. Long term, most still agree that EHRs serve as an investment that will yield future gains. 

Thursday, December 6, 2012

Public Hospitals Seek Patient Input for new Approach

A growing number of public hospitals are engaging their patients in a conversation on how to improve service. New committees and boards have been set up across the country, with membership comprised of patients or patients’ families. These committees seek the voice and the view of the patient as it relates to how care is delivered within the hospital.  The timing for this is not by accident.

Patient input and satisfaction have come back into the spotlight due to incentive programs recently put in place by the federal government. The Affordable Care Act carried with it both stick and carrot approaches to encourage hospitals and other patient care facilities to place patient care first.

The new Medicare Value Based Purchasing Program serves as the stick. The program focuses on the whole of patient care, including patient readmissions, shifting away from the traditional fee for service reimbursement model. Hospitals can lose from one to three percent of federal reimbursements for high readmission numbers. NAHAM News previously reported on this program here (Medicare’s new Value Based Purchasing program: Enough to inspire hospital change?)

The carrot, on the other hand, comes in the form of an Electronic Health Record (EHR) incentive program that rewards hospitals for utilizing the new technology. The program is still in its first stage, focusing on raw implementation of EHR systems, but the second stage will focus on meaningful use of the records. The program mandates that EHR technology must provide patients with an online means to view, download, and transmit selected data. More information on the EHR Incentive Program can be found here.

The Gordon and Berry Moore Foundation is also providing a carrot with their Patient Care Program. The program works towards eliminating patient harm with a two pronged approach. They emphasize meaningful patient and family engagement, and a reengineering of hospital processes. In turn, they believe that healthcare will become more cost effective and be more respectful to the patients and families they serve. To work toward the goal, they are planning to give out $500 million in grants to hospitals willing to alter their patient care model.

Ideas that come from these patient committees or boards can provide simple and effective ideas for hospitals. A hospital in northern California had a logical policy that all emergency patients had to be funneled through the emergency room. This included psychiatric patients who would be forced to have psychiatric episodes in the general ER. It was not until the hospital listened to advocacy from the mother of a mental health patient that the policy was changed to allow direct access to the psychiatric emergency department. This simple shift restored a sense of dignity and respect to an entire group of patients.

Another hospital in Oakland, California was shocked to hear about issues that patients experience when working with multiple hospital units. In this instance, physician rounds at 2pm meant that a nurse wouldn’t order a prescription until 2:30, which left little time for a patient to fill it in the discharge pharmacy before it closed at 3pm. This may delay a discharge and prevent another patient from getting an inpatient bed.
Still, other hospitals are requiring staff to attend patient care events that include patient panels and best practice discussions.

You can find the original article from here, but it requires a free subscription.

Changing Health Technology Challenges Traditional Privacy Laws

An improvement in health technology and the use of electronic health records (EHRs) is often touted as a movement that will improve communication between physician and patient. EHRs have enabled patients to access their records online, doctors to easily access patient history remotely, and hospitals to improve patient care.

Some new devices, however, have been testing the gray area left by patient privacy and patient access laws. Under the spotlight in a recent Wall Street Journal article were new implantable defibrillators. These devices serve a dual purpose, while they can correct an irregular heartbeat in patients, new models also collect information about the patient’s heart beat for the maker of the defibrillator. This information is collected and stored onboard the implant, while wireless monitors in the patient’shome download the information and send it to the parent company for the device. The information is provided to doctors and hospitals, but not patients directly. Medical device companies are also contemplating selling the collected information to health systems or insurers so they can use it to predict diseases and lower costs.

These types of records are not covered under the 1996 federal Health Insurance Portability and Accountability Act (HIPPA), because that law only gives patients the right to access information held by hospitals and doctors. The law, which some now claim is outdated, does not cover information collected by medical device companies. In fact, one company claims that federal laws prohibit giving the data collected back to the patient, since the customers of medical device companies are doctors and hospitals.

Another privacy concern involves new smartphone health apps that have also risen in use.  These apps have been praised for allowing users to do anything from collect their medical images to manage their incontinence. However, since the programs do not require FDA approval or doctor supervision, they are also not subject to HIPPA privacy or disclosure requirements.

Device and app companies contend that even if they voluntarily gave information directly to patients, the patient would likely not understand it. Implantable defibrillators collect raw data about heart rhythms, other devices or apps may report raw data to suggest a change in medication. Data of this type are typically not understood by those who have not had medical training.

This fact does not deter some patients who feel that they are within their rights to request information that is collected form their devices. Especially since as of now they are required to pay a copay and see their doctor if they want the information.

Regardless of your stance on the issues, the advice seems consistent. Be aware of what you are agreeing to when downloading smartphone apps, and work with your doctor of obtain and interpret medical device data.  

Changes to Medicare Looming

It is extremely likely that changes to Medicare are coming. The fiscal cliff is looming, the national debt is climbing, and spending on health entitlement programs such as Medicare, Medicaid, and Social Security are only foretasted to increase in the coming years.

With that in mind, many stakeholders and policymakers have different ideas on what to do with the programs, more especially Medicaid.

An idea that keeps surfacing from both sides of the political aisle is to raise the retirement and Medicare eligibility age from 65 to 67. Republican Senators Lindsey Graham (R-SC) and Bob Corker (R-TN) have both suggested the idea, and President Obama reportedly put the retirement age on the table in fiscal negotiations with Speaker of the House John Boehner (R-OH) last year.

The draw of raising the retirement age would be an immediate reduction in federal spending on Medicare, to the tune of 5% per year. A consequence, however, would likely be increased total spending on health care by consumers, according to a Kaiser Family Foundation (KFF) report.

Raising the retirement age would take 65 and 66 year olds, who are usually the healthiest in the Medicare participant pool, out of that pool. This would raise the risk, and therefore the premiums, for participants who are 67 and older in the program. In turn, the 65 and 66 year olds would be placed into the pool of citizens that can purchase insurance through the health insurance exchanges (HIX). When grouped with 18-64 year olds, these 65 and 66 year olds tend to be “sicker”, so their presence would also raise rates in the HIX pools.

The study from KFF found that federal government savings would be more than offset by costs to states, individuals, and employers with increased premiums.

Another part of Medicaid being considered are the reimbursement rates that doctors receive for the work done on patients. An NPR article explains that, if we go over the fiscal cliff, reimbursement rates would be cut by 30%. This number is the accumulation of annual 4% cuts in reimbursements that have been delayed for several years.

This means that, in an example given by the article, a doctor that treats a Medicare patient with an exam and a cardiogram would see their fees drop from $160 to about $120.

Find the full NPR article here

Thursday, November 29, 2012

Superbugs are invading U.S. healthcare facilities

“Superbugs” are popping up more frequently in hospitals these days, even lasting through drugs of “last resort.” One of these superbugs made headlines this summer after it swept through the National Institute of Health just outside of Washington, DC. NAHAM News reported the story (found here) about staff having to go as far as to rip out plumbing from the walls to stop the spread of bacteria.

These superbugs belong to a string of drug-resistant bacteria known as Carbapenem-Resistant Enterobacteriaceae, or CRE, that has been around in hospitals and nursing homes for almost a decade.

A study by USA Today found that there have been thousands of cases of CRE throughout the country in recent years, affecting 41 states and several cities since the first case was reported in 2001. CRE is not as well-known as other hospital infections such as MRSA or C-Diff, but it is far more deadly. Even worse, there is little chance that an effective treatment for CRE will be developed any time soon.

A challenge for hospitals could be the reporting. There is no Medicare or Medicaid billing code for CRE, and there no reporting requirement so it is impossible to track the superbugs.

The Centers for Disease Control (CDC) has stated that the best way of controlling the spread of CRE may be the old fashioned way. They suggest “rigorous hand cleaning by staff and visitors; isolating infected patients and requiring gowns and gloves for anyone contacting them; cutting antibiotic use to slow the development of resistant bacteria; and limiting use of invasive medical devices, such as catheters, that give bacteria a path into the body.”

In one specific outbreak, a patient was discovered to have two different strains of the CRE bacteria, while other infected patients had a different third strain. All of the patients were linked together, showing that the drug resistant gene could jump between different bacteria, creating new bugs.

In the wake of that news, an important prevention measure because screening patients so that infected individuals can be isolated. However, this poses a challenge to hospitals that may not have the time or resources to screen all of their patients.

Despite the challenges, screening has been proven to work. One Bronx-based medical center started an initiative to cut prevalence rates across its intensive care units.  The initiative tested all intensive-care patients using an experimental, high-speed assay for the bacteria, and carriers were isolated immediately. The initiative eventually grew to all patients in the hospital network. The program controlled the transmission of CRE, but it also found that 40% of infected patients came into the hospital with the superbug already active.

The positive out of all this is that doctors were able to figure out how the drug resistant gene is jumping from strain to strain of the bacteria. Using that as a base, they were able to develop a test that would identify a superbug in days, as opposed to the weeks it was taking before. While this doesn’t help those who are already infected with CRE, it can help stop the spread to new patients.

HHS Press Release on Pre-Existing Conditions and other Affordable Care Act provisions

The Department of Health and Human Services (HHS) issued a press release last week pointing to several new rules proposed by the Obama administration. These rules, three in total, are provisions of the Affordable Care Act designed to make it illegal for insurance companies to discriminate against people with pre-existing conditions.

The Administration proposed a rule that would allow insurance companies to vary premiums based only on age, tobacco use, family size, and geography. The companies would not be allowed to deny coverage or impose higher premiums on individuals with pre-existing or chronic conditions, and would not allow them to consider the individual’s gender, occupation, employer size, or industry
A second rule proposed by the Administration outlined policies and standards for coverage of essential health benefits, while giving states more flexibility to implement the health law.

A third rule proposed implementing and expanding employment-based wellness programs in an effort to promote wellness and control health care spending.

For more information, please see the HHS press release here

Curbing Medicare Spending begins with Hospital Readmissions

Medicare’s new “Value Based Purchasing Program” levied their first penalties to 2,217 hospitals last month. These hospitals will all receive some form of financial penalty from Medicare, with 307 of them receiving the maximum penalty of a 1% reduction in their Medicare reimbursement rate for the next year.

The program, previously reported by NAHAM News in September (Medicare’s new Value Based Purchasing Program: Enough to Inspire Hospital change?), penalizes hospitals with high readmission rates as part of the Healthcare Reform bill. While a major intent is to get Medicare costs under control (they exceed $550 billion this year), there is also intent to focus more on patient care. The program is expected to save $300 million in reimbursements this year, as well as pressure hospitals to take steps to ensure patient care both before and after they are discharged. Currently, almost 1 in 5 Medicare patients are readmitted to the hospital within a month, costing the government over $17 billion annually.

The previous system paid hospitals a set fee per patient stay, despite the length, so proponents of the new program were concerned that the emphasis was placed more on the number of patients treated, rather than the quality of care. This new system seeks to change that. The penalty is set to double (to 2%) in October of 2013, and will go up to 3% in October 2015.

The program is meeting with resistance from some. Academic medical centers are complaining that the penalties do not take into account the extra challenges posed by extremely sick and low-income patients. This claim is backed up by several studies, including one commissioned by Medicare, that have found that the hospitals with the most poor and African-American patients tended to have higher readmission rates than hospitals with more affluent and Caucasian patients. But these studies also determined that some safety-net hospitals performed better than average, showing that hospitals can overcome the challenges posed by the kinds of patients they treat.

Some researchers also fear that the penalties are too steep. They claim that steep penalties will distract hospitals from other pressing issues, like reducing infections and surgical mistakes, and ensuring patients’ needs are met promptly. There is also a concern that hospitals will try to get around the system, treating patients and sending them home within 24 hours to avoid admission and readmissions.

Overseeing former patients is expensive and time-consuming and many hospitals are relying on financing from community health organizations and foundations. Some may also partner with local organizations to provide follow up care to discharged patients.

No matter the method for reducing readmissions, hospitals will need to adjust to the new system
See the full article from the New York Times and Kaiser Health News here

Tuesday, November 20, 2012

HHS Steps up Role in Health Exchanges

While the Obama administration does not yet know the number states that will opt for the federal health insurance exchange option, the fact remains that it will be more than expected. Every state that decides not to implement their own exchange will be one more state that the federal government has responsibility for. As of now, only 17 states (and the District of Columbia) have signaled that they will set up their own system, leaving the federal Department of Health and Human Services (HHS) to step in and set up a system in the remaining 30 or so.

The main challenge in this role will be setting up a national IT infrastructure that can easily communicate with insurers and Medicaid programs throughout different states. Complicating matters is the fact that many of these systems are old and in the midst of an overhaul. The online systems will have to be operational in time for open enrollment in October of 2013, leaving only 11 months for upgrades, development, and implementation. These online systems, according to the health law, will allow people to enroll in different programs and find out about eligibility for subsidies or public assistance.

HHS stepping in also means that the states will be giving up some of the insurance oversight that they have traditionally had. Tasks such as plan certification, staffing call centers, and overseeing the operations would fall to HHS, at least in part, instead of the state counterparts. This could mean that plans, some of which have long-established relationships with state and local regulators, would find it more difficulty to navigate through the federal regulations.

With this short time frame, everyone is wondering if the exchanges will be ready in time to take effect. While no one knows for sure, most are optimistic the come January 1, 2014, the plans will be in effect.

View the article from Politico here

NFL Medical Records go Electronic

It turns out that hospitals aren't the only ones who are adopting electronic health records to better serve their patients.

According to reports by Kaiser Health News and, the National Football League just signed a deal with Massachusetts based eClinincalWorks to convert the league from paper-based medical records to electronic records.

The records will be completely transportable from hand-held devices to hospitals, and players will also be able to provide the records to their personal physicians. The records will include a player’s medical history, specific injuries, and can even incorporate game footage of specific injuries.  Records will also be able to move with the player, should they be traded.

The system will be phased into use by all 32 teams over a period of 2 seasons. Next season, eight teams (the New England Patriots, New York Jets and Giants, Baltimore Ravens, Pittsburgh Steelers, Houston Texans, San Francisco 49ers and Denver Broncos) will keep their player’s health information electronically. By 2014 the entire league will transition to electronic health records. The NFL estimates that its 10-year contract will cost anywhere between $7 million to $10 million.

The report from KHN can be found here, and the article from can be found here

Friday, November 16, 2012

Why All of the Deadline Changes?

With the last minute deadline changes and states still undecided on whether or not to set up their own exchanges, some may wonder why this is all coming down to the wire.

The explanation lies in the timing. The Affordable Care Act, or ‘Obamacare’, was signed into law two years ago, and set out a specific implementation time table for states to follow, but most don’t see it as that simple. Over the past two years there have been countless political battles over the law, including a supreme court ruling and a presidential election, all of which could have substantially changed the law and it’s implementation.

Even after the Supreme Court upheld the vast majority of the law in a challenge from 26 states, some of those states held out for the presidential election. Governor Romney vowed to delay or altogether stop the implementation of state health insurance exchanges, if he were to be elected.

Obama’s election victory and the continuation of a Democratic Party majority in the Senate guaranteed the survival of his health care law, however, and sent some states scrambling to meet deadlines less than two weeks away. According to the law, states were required to tell the Department of Health and Human Services (HHS) if they intended to operate their own exchanges, and to give specifics on how they would run those exchanges by November 16, 2012.

HHS first issued a letter after the election that maintained the November 16th deadline for states to report their intent, but pushed back the deadline to report specifics .Then, responding to a request from the Republican Governors Association, HHS on Thursday pushed back the deadline for states to report intent to match specific plan deadline on December 14th.

This gives time for the Obama administration to issue details on how a federally run insurance exchange would work before states make up their mind. Those details were also on hold until after the election.

Although the public remains divided about the health care law, the idea of states running the new insurance markets is popular, especially with Republicans and political independents. A recent AP poll found that 63 percent of Americans would prefer states to run the exchanges, with 32 percent favoring federal control.

The breakdown among Republicans was 81 percent to 17 percent in favor of state control, while independents lined up 65-28 percent in favor of states taking the lead. Democrats were almost evenly divided, with a slim majority favoring state control.
This article was written with information from a Washington Post article, found here

States Given More Time to Work on Health Exchanges

In a confusing week for the healthcare industry, the newly re-elected Obama administration has twice changed the insurance exchange deadline, giving states extra time to work on their health insurance exchange plan.

Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS), sent a letter to Governors on November 9th stating that the administration still expected states to declare whether they intend to operate their own exchanges, or opt for the federal government to set up their exchange, by Friday, November 16th.  The letter further stated, however, that states now had until December 14th to file blueprints showing specifically how they would operate the marketplaces. These dates are according to a Reuters report found here.

Sec. Sebelius then sent another letter late on Thursday, the day before the declaration deadline, pushing that deadline back to December 14th as well. The article by Kaiser Health News can be found here.

The decision was in response to the Republican Governors Association (RGA) request Wednesday to extend the deadlines until HHS publishes rules detailing how the exchanges would work. A slew of regulations are expected to be published in the next few weeks. In a statement last night, the RGA thanked the agency for its response.

As previously written by NAHAM News, the health insurance exchanges (known as HIX or HEX) are a key part of the Obama Healthcare Law, also known as Obamacare. The law sets up these exchanges to allow millions of individuals to shop for insurance coverage and find out if they are eligible for government subsidies or Medicaid.

The law allows (and encourages) states to set up their own exchanges, and requires the federal government to step in to build and operate exchanges in states that choose not to set up their own.

As of Thursday, 17 states and the District of Columbia had committed to setting up their own exchanges. Those states are California, Oregon, Minnesota, Washington, Nevada, New Mexico, Utah, Colorado, Kentucky, West Virginia, New York, Vermont, Connecticut, Massachusetts, Mississippi, Rhode Island and Hawaii.

Seven states remain undecided on whether to build state-based exchanges. The undecided states are Tennessee, Pennsylvania, Idaho, New Jersey, Oklahoma, Arizona and Wisconsin.

The remaining states will most likely chose the third option, allowing those states to develop their exchanges in partnership with the federal government. States that chose the partnership option will have until February 15th, 2013 to declare their intentions and prepare the paperwork.

Previous letters have strongly stated that no matter what option states chose, or when they declare their intentions, consumers in all 50 states and the District of Columbia will need to have access to insurance through these new marketplaces on January 1, 2014.

Patient Identification Pitfalls Plague HIE Networks

As NAHAM members well know, managing patient identities is one of the hidden problems of health information exchange (HIE) and electronic health record (EHR) technology.  Every patient needs a single and unique identifier tied to his records, and a simple typo or a misspoken birthday can leave a patient with duplicate records, potentially compromising his care. 

Many hospitals use their own master patient indexes (MPIs) to check if patients have an existing record, but the emergence of HIE means new challenges in ensuring accuracy across multiple providers for millions of new patients. Unique identifiers must be the same across the entire HIE for the network to function, and NAHAM has been working to provide a toolkit to members to assist with that goal.

According to a white paper on EHR Intelligence, establishing a unique identifier can also be accomplished with the help of a system-wide enterprise MPI (EMPI).  An EMPI provides its own identifier that spans the entire network, requiring accurate and complete data across every department or healthcare provider contributing to a patient’s care.

Quality control during the admissions process is the first step towards ensuring accuracy, but staff performing the data entry is often under conditions that require them to be as speedy as possible: mishearing the spelling of a surname or transposing a letter in a street address can accidentally create an entirely new record and identification number for a patient who may have visited the facility before. Without consulting the patient, it’s nearly impossible to tell if the original data is correct or if a mistake was made previously and the new input is the proper information.  Implementing safeguards in patient record software to prevent these small mistakes may seem like an easy task, but human error will always find a way to defy technology. 

HIE vendors are trying to work around these problems with a variety of innovative ideas such as biometric data or cloud-base solutions, but patient records are continually developing collections of changeable data.  The goal of HIE and EHR is to manage this data cleanly, effectively, and with the maximum benefit to the patient, but the margin for error only grows wider as more and more providers try to collaborate and share information. 

HIE systems must be capable of preventing mistakes caused by duplication or accidental deletion of records, but healthcare providers themselves are ultimately responsible for being certain that the patient in front of them matches the information on their computer screen.

Thursday, November 8, 2012

The Obama Win and Healthcare Reforms could Benefit Hospitals

Hospital stocks reacted with optimism to the news that President Barack Obama had won a second term, making the fate of the healthcare reform law even more certain – this according to a Bloomberg report.

The Affordable Care Act, or “Obamacare”, is the biggest change to the U.S. health-care system since Medicare and Medicaid began providing taxpayer-funded services in 1965.

That enthusiasm for hospitals seems to be a repeat.  Traders bought hospital stocks and sold off commercial insurers after Obama’s overhaul passed Congress in 2010, and again when the law survived a challenge at the Supreme Court.

Romney said in June that he disagreed with the Supreme Court’s decision to uphold the constitutionality of the plan, and that he would repeal the law on his “first day if elected president.” This caused investors to be unsure as some agencies planning for implementation slowed or even stopped preparation until after the election.

The law’s survival represents the status quo, however, and means that the industry will undergo significant change and new regulations beginning in 2014. With the status quo, comes renewed optimism in hospital stock.

While share prices of the largest insurers declined, shares rose for companies that focus largely on Medicaid.

Preservation of the overhaul helps most hospitals, which had already started moving ahead with implementing aspects of the law despite the election. Romney’s plans would have pressed hospitals to find new ways to deliver care at a lower cost.

Up to now, hospitals have been paid each time they do a procedure, in arrangements known as “fee for service.” This law shifts them to incentive systems where the focus is on more efficient care. They may get a set amount of dollars to spend on a patient, for example, and can keep surplus if they can provide care for less.

While exact implementation plans for healthcare reform remain unclear, confidence in hospital stocks is expected to remain high. 

Obamacare Is Here To Stay – But In What Form?

President Obama's re-election, and the retention of a Democratic majority in the Senate, means that repeal of the Affordable Care Act is not likely, but no one is quite sure what implementation will look like. An NPR article discusses some possibilities.
January 1, 2014, is the date that major parts of the law, like the new insurance policies available to individuals and small businesses, are supposed to become available. The full timeline can be found here.

That doesn’t leave a lot of time to get ready, however. Many states and some key parts of the health care industry delayed gearing up much of this past year. Some say they assumed either the Supreme Court would rule the law unconstitutional, or Mitt Romney and a Republican Congress would be elected and make the law go away. Neither of those options happened.

In fact, there is a key deadline just days away.  By November 14, states must decide whether they want to run their own insurance exchanges, or whether they want to let the federal government do it for them.

Insurance exchanges are where people will go to shop for insurance coverage. They are also where people will get help paying for that coverage if they qualify for subsidies from the federal government. So far, only 13 states and Washington, D.C., have said they plan to set up their own exchange. If states decide not to set up their own exchanges, the federal government will step in and do it instead. But federal officials still haven't spelled out exactly how that will work.

Meanwhile, opponents of the law say that there are some problems with the underlying statute. The problem goes back to those subsidies that will help people afford coverage starting in 2014. The law authorizes subsidies for state-sponsored exchanges, but not for the exchanges picked up by the feds.  This raises concerns in some quarters that the health insurance markets are going to collapse and health insurance premiums are going to skyrocket because the subsidies are available only through state, and not federal, insurance exchanges.

Other experts contend that is not true. They point to cross-references within the statute that make it clear that the subsidies are meant to be available to everyone based on their income. This means the subsidies should be available whether the insurance exchanges are run by states or by the federal government.

With the election over, overturn of the Affordable Healthcare Act is unlikely, and attention now turns to implementation.   The healthcare law is here to stay, but it’s not clear what it will look like.

Hospitals Gamble on Urgent Care Clinics to Keep Patients Healthy

Some doctors are referring patients to urgent care clinics over primary care appointments or emergency room visits, according to an NPR article. The clinics are all about speedy service; some even feature a timer outside of every exam room so the staff knows how long a patient has been waiting. With the expanded use of electronic health records, clinics can pull up electronic health records to determine medicine allergies or if the patient is due for any other care.

Hospitals already own more than a quarter of the nearly 9,000 urgent care clinics in the U.S. that are drawing patients away from emergency rooms.  But this trend is in its “early stages” according to the NPR report.

But industry watchers say it is unclear whether hospitals will actually be successful at managing urgent care centers. They say that hospitals tend to be good at providing high-quality care, but patients may prefer clinics from a customer service perspective.

As an example from the NPR report, within the MedStar Health system, hospitals make money for every patient the clinic refers to a MedStar facility for follow-up care, like a CT scan or an appointment with an orthopedist. Patients who don't yet have a regular source of health care can be referred to a MedStar primary care doctor.

There appears to be a future for this model. Insurers and Medicare are starting to pay providers to keep patients healthy. Providers get a bonus if they manage to lower the cost of the medical services their patients need. These clinics could be a key part of this strategy for hospitals.

Friday, November 2, 2012

How the Health Law Might be Changed Under the Next President

After reviewing what each candidate has been saying on the campaign trail, Kaiser Health News has published an article on how Obama and Romney might change the health law in the years ahead. The article is based on interviews with health policy experts, and can be found here.
President Barack Obama has asked voters to re-elect him so that he can put the law fully into effect. But some analysts predict the mounting pressures to reduce federal spending will complicate that plan.  And others note that in a second term, Obama may be more open to working with Congress to tweak provisions of the law that have raised concerns. Leading up to this tight election, Obama and Democrats have been reluctant to make modifications to the law, known as the Affordable Care Act (ACA) or Obamacare.
Scale Back Subsidies: As part of that effort to reduce federal spending, there could be pressure to scale back the health law’s subsidies that help low-income residents afford coverage. People who earn up to 400 percent of poverty – currently about $92,000 for a family of four – are eligible to get financial help in purchasing coverage.  Another big-ticket item is the expansion of Medicaid coverage to anyone up to 133 percent of the poverty level, or about $30,656 for a family of four.
Change in Age Rating Bands: The ACA prohibits insurers from charging more than three times as much for a policy sold to an older person than to a younger person. Some say this creates a problem where coverage become more affordable for the elderly but more expensive for the young people – an important demographic that needs to be able to get coverage.
Medical Device Tax Cut: Of the many taxes in the health law, one has come under strong criticism: a 2.3 percent tax on the sale of any taxable medical device. Medical device manufacturers have loudly opposed the tax and won some key congressional support. Legislation to repeal the tax passed the House in June with 37 Democrats joining Republicans to support the measure, although it is unlikely to receive Senate consideration this year. 
Gov. Mitt Romney has promised a full-scale repeal of the ACA.. Short of Republicans controlling both chambers of Congress however, he would have to rely on the federal regulatory process to stop funding and give states wide latitude to implement – or ignore -- the law.
Slowing Down Implementation: The health law gives significant power to the secretary of Health and Human Services to implement the health law, and a Romney administration could use that power to slow the rulemaking process.
If Republicans win control of the Senate, they could also use the reconciliation process—which requires only a majority instead of the 60 votes usually needed to pass a measure -- to strip out sections of the law that relate to the federal budget. Reconciliation can be a cumbersome and difficult process, and it only applies to budget measures, so not all of the law would be subject to Reconciliation. And changes made under the process can’t increase the deficit.
Waivers: Romney has said he would allow states to opt-out of the health law by using a waiver process. He could also use the process to give states wide latitude to implement provisions, like health insurance exchanges, that differ from requirements in the ACA. But there are many rules that govern the waiver process, so there may be limitations on what the president could do through waivers.
If Romney opted not to move forward on the law, the administration could also be sued by individuals and groups. That litigation could take months – maybe years – to be resolved.
What Might Stay: Romney has said that he expects insurers to keep coverage that allows adult children to stay on a parent’s health insurance policy until age 26, although it’s unclear if he would support legislation or regulations to make that happen. He also has expressed support for states to set up health insurance exchanges and high-risk pools to cover the uninsured. 

Insurers nervous over prospect of Romney victory

With the election just around the corner, NAHAM News is taking a look at the healthcare side of the rhetoric. This article from the Associated Press reports that although the insurance industry dislikes parts of President Barack Obama's health care law, major outfits such as UnitedHealth Group and BlueCross Blue Shield also stand to rake in billions of dollars from new customers who'll get health insurance under the law.
The companies already have invested tens of millions to carry it out. Were Romney elected, insurers would be in for months of uncertainty as his administration tries to make good on his promise repeal Obama's law. Simultaneously, federal and state bureaucrats and the health care industry would face a rush of legal deadlines for putting into place the major pieces of "Obamacare."
The Romney campaign has not provided specifics on how the candidate would carry out his repeal promise, other than to say the push would begin on his first day in office. Romney has hinted that he wants to help people with medical conditions, but doesn't say what parts of the health care law he would keep.  Rather than an overall repeal, most assume he will try to reduce scope or coverage.  A lot would depend on what Congress is willing to go along with – if anything.  For its part, the insurance industry has three items in particular it wants stripped out: 1) cuts to Medicare Advantage private insurance plans; 2) a requirement that insurers spend 80 percent of premiums on medical care or rebate the difference to their customers; and 3) new taxes on insurance companies.
There is also no consensus among Republicans in Congress on how to replace Obamacare, much less anything like a bipartisan middle ground on health care. This would be a necessity if the House retains its GOP majority and the Senate remains in Democratic hands.
In contrast, Obamacare is starting to look more and more like a tangible business opportunity. In a little over a year, some 30 million uninsured people will start getting coverage through a mix of subsidized private insurance for middle-class households and expanded Medicaid for low-income people. Many of the new Medicaid recipients would get signed up in commercial managed care companies.
At a time when employer coverage has been eroding, government programs such as Medicare, Medicaid, and now Obamacare are becoming the growth engines for the industry's bottom line.