Thursday, January 31, 2013

Colorado Study Suggests HIX Website Design

Health insurance exchanges (HIX) have been in the works for a number of years now. Having survived legislative, legal, and electoral challenges, the part of the Affordable Care Act healthcare reform law that mandates the exchanges remains intact. What has not yet been determined, however, is how the exchanges will look to consumers – how user-friendly on-line sites will be. The Department of Health and Human Services (HHS), the agency responsible for the set up and oversight of the exchanges, has reached out to the public in a number of ways to try to determine how the exchanges should look. This outreach has led HHS to change the branding of the product from “exchanges” to “marketplaces”, and may lead to a change in how the interface will look as well.

Originally, according to this article from Kaiser Health News, the online exchanges where being designed to look like the travel website “Travelocity,” where consumers could pick from a number of different product plans. Now, users who go to select from available insurance options through the online marketplaces could see a website more similar to the tax website TurboTax, where the individual is guided through the process with a series of questions.

The change comes as the result of discussion groups held by three non-profit organizations in Colorado. They found that few of the participants in the groups said that they would feel comfortable choosing a policy on their own. Many worried that they would not understand health insurance jargon enough to make the best decision. Like paying taxes, buying insurance is a complicated proposition, and like doing taxes, buying a policy on the exchange means interfacing with state and federal government agencies. The non-profits also found that a model Colorado program would include a customer care line, where individuals could talk through their insurance options with experts.

As HHS grapples with the fact that it will have to run the exchanges in about half the states, the department will have to figure out the most effective way to do this. This study from Colorado could provide insight into the best type of website to set up, but it could also show that no matter how easy a website it to use, consumers will want to be able to talk to an expert before picking a plan. 

Google Flu Trends Will Not Replace the CDC Flu Model

For the past few years, the CDC has not been the only place to go for tracking incidences of the flu. Google has also been tracking illness trends through identifying key search terms associated with illnesses like the flu, allergies, and sunburns. Google claims to have found a close relationship between the number of people who search for specific flu related topics, and the number of people who actually have flu symptoms. By counting the search queries, including specific terms, Google claims to be able to identify flu trends in real time with good accuracy as compared to CDC data. See Google’s tracking against the CDC data on one graph here.

This year, however, the Google model has varied from the model that the CDC puts out each week. Both models can be seen in the National Journal article here. The Google model shows that the U.S. is undergoing the most severe season in years, while the CDC model shows that the severity of this year’s season is still less than the H1N1 pandemic in 2009. So which model should be trusted? Even though the Google model tracks in real time, a week ahead of the CDC model, the National Journal suggests that the CDC is more accurate.

The CDC model can control more factors than the Google model. For example, if the CDC sees an increase in people going to their doctors for flu-like illness without an increase in lab samples testing positive for flu, it can look for signs of other respiratory viruses. The CDC will also call the state labs or individual physicians to try to get to the bottom of the discrepancy.  Google, without these resources, may be tracking other illnesses with symptoms similar to the flu.

Still, the fact that the Google Trends model has been commonly accepted as reliable has the CDC thinking. In the future, the CDC hopes to get more information electronically and in real time. As more doctors get Electronic Health Records, more information can be shared faster, without taking up the valuable time of office workers. Electronic death certificates may also work to improve the accuracy of the CDC’s flu mortality rate. No matter how the information is transmitted, however, the CDC does not want to give up the personal phone calls and conversations with state labs and local physicians that help it identify odd or unusual patterns. 

Tuesday, January 29, 2013

Medicaid Coverage Expansion a State Decision

When the Supreme Court ruled on the Affordable Care Act last year, it was widely hailed as a win for the healthcare reform law.  While the Court upheld the law’s core provision establishing health insurance exchanges, it found that the federal government could not force states to expand their existing Medicaid programs.   The expansion was one of the several means established by the law to ensure that every American will be covered by health insurance. 

As the Medicaid program stands now, children, pregnant women, the disabled, and the elderly can receive assistance through Medicaid if they are at, or below 133 percent of the federal poverty line. That qualification breaks down to about $31,000 for a family of four and $15,000 for an individual.  The Court struck down the provision that would have forced states to extend the program to any adult or family that is below 133 percent of the poverty line, regardless of their age or physical condition. That decision is left to each individual state.

According to statistics from this Stateline article, 21 states have accepted the expansion so far. That number could increase as well, as the Democratic governors of Arkansas, Missouri, and Montana have all expressed a willingness to expand the program, despite challenges from their state legislatures.  Since there is no deadline associated with this decision, some predict that it could be years before states decide if they will extend their Medicaid programs.

The federal government has pledged to pay all of the costs for the first three years of the program for any state that joins in expanded coverage, and up to 90% of costs after that. Many states, however, worry that the federal government will not be able to make good on its promise. There is also a concern that funding even 10% of the expanded program at the state level could be more than a state would be able to cover.

The decision to expand coverage is something that will likely be discussed in many state legislatures this year. Each state will have to weigh its own costs and benefits in the long run, and deal with conflicting ideas of the role of government in health care.   

Friday, January 25, 2013

Community Efforts Reduce Medicare Readmissions

As a part of the Value Based Purchasing Program that went into effect in 2012, certain hospitals saw their Medicare reimbursement rates cut, due in part to high patient readmission rates. The program, reported by NAHAM News in November (Curbing Medicare Spending Begins with Hospital Readmissions), reduced reimbursement rates up to a 1% this year, but could lose up to 3% in reimbursements in October of 2015.

The focus on readmissions signals a shift in mentality to cost savings, as well as patient wellbeing.  On average, one in five Medicare patients returns to the hospital within 30 days of being discharged, a fact which cost the program $17.4 billion in 2004.

The reimbursement rate penalty sent hospitals looking for ways to reduce readmissions. One popular method was to set up a network of services that Medicare patients could utilize in their community, as opposed to just at the hospital. In a pilot program, the Centers for Medicare and Medicaid Studies (CMS) implemented this approach by contracting with Quality Improvement Organizations, or QIOs. These organizations are private groups in each state ad U.S. territory that are comprised of health care providers and other medical professionals, social service workers, and other community members.

A study on the effectiveness of the QIOs, conducted over the course of 2 years, found that the organizations reduced 30-day hospital readmissions by an average of 5.7%. The study was reported on by Kaiser Health News, and was conducted across 14 economically and demographically diverse communities that used various intervention methods.

At these rates, the average community of 50,000 Medicare beneficiaries could see a savings in $4 million on readmissions alone.  

Groups want a Delay in Meaningful Use Stage 3

The comment period on the Department of Health and Human Services (HHS)’s proposed rule for electronic health record (EHR) “meaningful use” Stage 3 policy closed last Monday with over 500 comments left online.

Stage 3 is the last step in a program designed to give incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way. The program defines “Meaningful Use” as implementing a system that significantly improves clinical care, and was passed into law in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) bill.

Many of the major medical groups that commented on the proposed rule asked for a delay in the implementation of Stage 3. They claim that providers are still trying to implement the first two stages of the program, which aimed to capture, and then share data to advance clinical progress. The third stage aims to improve the clinical outcomes through EHRs. The stage is currently scheduled to begin in 2016.

Providers are currently working towards completion of Stage 2, which needs to be done by October 1st of next year to avoid a 1% Medicare cut penalty.

Organizations such as the American Medical Association (AMA), American College of Physicians, the Association of American Medical Colleges (AAMC) and others all made different arguments for delayed implementation of Stage 3. The AMA argued that more time was needed due to unanticipated challenges in EHR system implementation, while The American College of Physicians objected to the fact that the goals were not tied enough to patient outcomes. AAMC suggested a middle road approach, they suggested putting goals in place as a motivation for physicians, but that the timeline be implemented slowly. They also suggested that HHS exempt physicians from penalties when they meet most of the goals, even if they don’t meet them all.

With the comment period closed, HHS will now develop a final rule governing Stage 3. The rule should be released later this year.

View the whole article from MedPage Today here.

Federal Government Implements Flu Guidance

In light of the flu season, the Washington Post is reporting that the federal government has issued new guidance for their employees.

The Office of Personnel Management (OPM) issued a memo last week providing guidance to employees in the hope of protecting the workforce and ensuring the continuity of operations. Workers were reminded that have the option to telework or alter their schedule to accommodate doctor’s appointments. They were also told to consider other habits, such as washing their hands more often, or social distancing.

Supervisors were ever told that they had the authority to place employees involuntarily on paid, excused leave, forcing them to stay home and out of the workplace.

All of this comes as the Centers for Disease Control and Prevention (CDC) weekly flu reports keep showing widespread flu cases. In their report for the week ending January 12th, 48 states were reporting widespread flu activity, up from 47 in previous weeks. The remaining two states still reported flu activity, but on a regional scale. The only region not showing elevated activity was Guam. The Midwest region, including Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin reported the highest percentage cases that tested positive for flu at 53.9%.

Despite the numbers, however, the CDC is still showing a reduction in the number of positive flu cases. This is consistent with a trend that NAHAM News reported last week (Flu Season Hits Height), and may suggest that the season is in decline after a peak around New Year’s.

The most effective preventative measure is still to get a flu shot. You can find a vaccination opportunity on the CDC’s flue website,

Thursday, January 17, 2013

States Will be Given Extra Time to Set Up Insurance Exchanges

The White House and the Department of Health and Human Services (HHS) have announced that states will have more time to comply with a part of the health care reform law. According to a New York Times article, HHS Secretary Kathleen Sebelius even went so far as to say that she would extend or altogether waive deadlines for states that expressed an interest in setting up their own healthcare insurance exchanges (HIX). She would also extend deadlines for states that were willing to take an active role in setting up a partner exchange with the federal government.

According to the original law, known as the Affordable Care Act (ACA), states were supposed to submit HIX plans to HHS in late 2012. This would ensure that the agency could determine, by January 1, 2013, whether the exchanges were going to be ready to operate in time.  The ACA was passed in 2010, but many states did not start planning. Twenty-six states sued the federal government over the law, and delayed preparations pending the outcome of that case, which went before the Supreme Court. Even after the Court upheld the vast majority of the law, many states held out hope for the 2012 election, thinking that a Republican President would repeal the law.  The President was re-elected, however, and states that were waiting to plan were sent scrambling.

HHS has already delayed the deadlines once at the request of the Republican Governors Association, as NAHAM News has previously reported (Why All the Deadline Changes?), but many states still have yet to file plans. Any state that opts not to run their own HIX would default to a federal government run exchange. While HHS expected to run several, they did not expect to have to step in to run exchanges in over half of the states.

This overwhelming realization could be a main factor in the most recent shift in deadlines. HHS may be trying to cater to the states in an effort to bring more of them into the planning process. HHS has also said that they are willing to work on an individual level with states that gain initial approval to set up their own exchanges. The individual attention could entice states to work with HHS.

Despite the setbacks, there are still a number of firm deadlines that states and the federal government have to stick to. All exchanges, whether they are state or federally run, have to be ready for open enrollment on October 1st of this year. Coverage under those plans will begin on January 1, 2014. 

New Report Shows Fewer Savings from EHRs

In 2005, the RAND Corporation published a report predicting that the U.S. healthcare system could see a savings of $81 billion per year if Electronic Health Records (EHRs) were widely used.

The report was quickly embraced by the health care industry and used to get support from the federal government. It was this report that helped to persuade both Congress and the Obama administration to authorize billions in federal stimulus money to help fund the purchase of EHR systems by doctors and hospitals.

The report was also used by companies selling EHRs to generate business. Cerner Corporation saw their revenue almost triple since the release of the report, increasing from $1 billion in 2005 to a projected $3 billion this year.

Now, eight years later, the New York Times is reporting that a new analysis by RAND shows that the conversion to EHRs has failed to produce the hoped-for savings in health care costs. The new report shows mixed results in the best case scenario, and an overall increase in health care costs in the worst case scenario.

While RAND isn’t taking a shot at estimating savings in their new report, they have acknowledged that their previous one was overly optimistic. Many are blaming the optimism in the original report on the fact that it was funded by companies that had a vested interest in the outcome, including Cerner Corporation. RAND insists that the funding source had nothing to do with the outcome, and that they deliberately publicized the funding sources in the original report.  The new study did not have any corporate funding.

Some experts are claiming that healthcare costs have risen $800 billion since the first report, due in part to the fact that the available systems may be aimed more at increasing billing by providers than at improving care or saving money. Others are optimistic that despite the setback, usage of EHRs will normalize and decrease costs in the long run.

Flu Season Hits Height

The Centers for Disease Control and Prevention (CDC) issued their weekly flu report for the week ending January 5th, and the numbers can cause concern at first glance. According to the report, forty-seven states are reporting widespread flu activity, up from forty-one the previous week. At second glance, however, NPR reported that there may be some good news hidden in the statistics. Five states reported less flu activity than the previous week, which is a trend that can suggest that the flu season has peaked in those areas. The flu tends to ebb and flow, according to the CDC, so this could also just be a blip or an anomaly.

Meanwhile, Boston mayor Thomas Menino has declared a public health emergency in the city due to the flu outbreak. According to, there are 700 confirmed cases of the flu, with four flu-related deaths so far. Last year, the city had just 70 confirmed flu cases.

The state of emergency in Boston was declared to raise awareness of the flu, and to provide residents with additional opportunities to get a flu shot. The city is planning multiple clinics in an attempt to reach citizens.

Nationwide, about 3 in 10,000 adults over the age of 65 have been hospitalized with the flu so far this season, compared to an average of 1 in 10,000 at this time last season.

Politico reports that CDC officials are just starting to get word of vaccination shortages. They stress that there are still plenty of vaccinations out there for those who look for them. This year’s vaccine is 62 percent effective, and while that may sound low, it is still the best tool to prevent the flu.

The CDC is optimistic about some of the trends, but stresses that it will take a couple of weeks to know whether we are over the peak of this early flu season. 

Thursday, January 10, 2013

Hospitals Bypass Cuts with Grassroots Lobbying

Hospitals took some hits in the final fiscal cliff deal, as NAHAM News reported last week, but they managed to avoid the worst case scenario.  That scenario included cuts to any one of three key programs, which were all spared despite most health insider’s expectation that at least one would be cut in the deal. None of these three programs, outpatient payment funding, graduate medical education assistance, and Medicare “bad debt” payments, were in the deal when all was said and done.

A Politico article published this week attributes the save to the strong hospital lobby with good ties to members of Congress. The ties are not new, and it is not the first time that evaluation and management (E/M) spending has been spared from cuts. These cuts have been suggested in a number of deficit reduction plan recommendations and even passed the House in 2011. Each time, however, the cuts have been successfully fought back by hospital representatives.

The reasons why the hospital lobby has been so successful may lie in the fact that there is no shortage of congressional allies. Almost every Member of Congress has a hospital in his or her district that not only provides medical care, but also proves to be a large employer of constituents.  When these E/M cuts are proposed, hospitals and hospital groups can quickly organize a grass roots effort and send notes to their Representatives describing how the cuts would be bad.

The news is not all good, though. However strong these efforts may be, healthcare costs are a hot topic now, and cuts can be hidden in new legislation. This fiscal cliff bill included coding updates that would cost hospitals $10.5 billion and reductions in Disproportionate Share Hospital payments — which help facilities that care for a large number of uninsured patients — that would cost an additional $4.2 billion, according to some estimates.

With another fight on the way in the next few months, hospital advocates will go back to work to protect funding during the debt ceiling and sequestration negotiations. It is likely that the three programs will be back on the chopping block, along with additional changes to hospital coding. 

Flu Season Gets Worse, According to CDC Report

It appears that this Flu season may be worse than expected, according to a report from the Centers for Disease Control and Prevention (CDC).

NAHAM News previously reported a CDC warning about an early flu season in November (CDC Predicts a Bad Flu Season), but new data show that the numbers are getting worse. For the fourth week in a row, the share of people seeking treatment from health care providers for flu like symptoms rose. As of the week ending on December 29th, twenty-nine (29) states had reported high levels of flu activity, and two child deaths were linked to the flu.

The CDC weekly flu report, which can be found here, reported that 5.6 percent of all outpatient doctor visits for the last week in December were flu related. This is up from 2.2 percent the previous month, and is well above last year’s season, which peaked at 2.2 percent.

While these numbers can seem troubling, the CDC is assuring citizens that the rates are still below the epidemic threshold, and are still below the 7.7 percent rate that was seen during the 2009 H1N1 flu pandemic.

Also promising, there has been no shortage of flu vaccinations reported this year. 

Study Shows Copying Common in EHR Notes

Electronic health records (EHRs) have long been touted as a transformative tool in medicine. The data can be shared easily between the patient and medical staff, medications can be automatically screened to ensure safety, and a doctor’s scribbles can be changed to easily read text. All of this good, however, is dependent upon the information in the EHR being accurate.

Many EHR systems allow users to copy and paste information, and according to one study, this can cause information to be incorrect or outdated. The study, done by a team at Case Western Reserve University School of Medicine, examined 2,068 progress reports for 135 patients in the ICU of a Cleveland hospital. The reports were created by 62 residents and 11 attending physicians, and were monitored over the course of five months using plagiarism detection software.

The team found that in 82% of the notes made by the residents and 74% of the notes made by attending physicians, 20% or more of the text was copied and pasted from pre-existing text from the patient’s records. These reports are used by internal hospital staff to monitor patient progress, but text containing a significant amount of pasted information may not be helpful. In one case, doctors of a patient who was released and then readmitted to the ICU couldn’t understand the previous progress reports. The pasted notes gave no clues as to the original diagnosis, and the new doctors had to call the diagnosing physician.

This study could signal that doctors are now using notes as more of a method to document billing then as a method to communicate with other health care staff.

The Reuters article can be found here.  

Thursday, January 3, 2013

Healthcare Changes in the Fiscal Cliff Bill

On Monday night, the New Year came and went with the U.S. Senate still in session, debating a last minute compromise bill to avoid the so called “fiscal cliff.” The Senate ended up approving the bill about two hours later, on a vote of 89 to 9. The bill was then sent to the House of Representatives where members, after a day of party meetings, took up the bill at around 10:30pm eastern on January 1st. The bill passed the House, 257-167, and will be signed into law by President Obama.

The bill, known as the American Taxpayer Relief Act (ATRA), avoided the across-the-board spending cuts and tax hikes that were scheduled to go into effect, among other things.

One of the main provisions of the ATRA was to cancel out the massive automatic spending cuts known as sequestration. By doing this, the bill stops the 27% reduction in doctor Medicare reimbursement rates that would have been included in the sequestration cuts.  The ATRA also extends benefits on some outpatient services, extends the Medicare-Dependent Hospital (MDH) Program through Fiscal Year 2013, and extends the Low Volume Hospital Program through 2013.

The MDH Program provides funding for 200 rural hospitals through special Medicare rates resulting from high populations of Medicare patients. A hospital qualifies for the MDH Program if it is located in a rural area, has 100 beds or fewer, is not a "sole community hospital," and has at least 60 percent of inpatient days or discharges covered by Medicare. The Congressional Budget Office (CBO) estimates that this extension would cost approximately $100 million over 10 years.

The Low Volume Hospital program provides additional Medicare funding to hospitals in rural communities that are more than 15 road miles from another comparable hospital and have fewer than 1,600 Medicare discharges per year.

These extensions are offset by cuts in other healthcare spending. The current reduction in rates paid to hospitals for uncompensated care is extended by the bill, funding for the Medicare Improvement Fund is eliminated, and payments for end-stage renal disease treatments is modified. 

2013 Healthcare Reform Provisions

A new year means new provisions to be put in in place under the Affordable Care Act. There are four provisions slated to go into effect this year, three of them went into effect on January 1st.

The first provision provides new funding to state Medicaid programs that choose to cover preventative services for patients at little or no cost. The program provides states with a 1 percentage point increase in federal matching payments to provide these services.

Another provision requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government, and is a ramp up to Medicaid providers serving more patients in 2014.

The final provision that was effective on New Year’s Day establishes a national pilot program on payment “bundling”.  Under payment bundling, hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a “bundled” payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care.

Under a fourth provision of the Affordable Care Act, effective on October 1, 2013, states will receive two more years of funding to continue coverage for children not eligible for Medicaid. This is provided under the existing Children’s Health Insurance Program, or CHIP, plan.

Also, as NAHAM News has written before, open enrollment for state health insurance exchanges will begin this year for coverage beginning on January 1, 2014.