Senators Sympathetic to Medicare Audit Burden

At a Tuesday hearing at the Capitol, Senators on both sides of the aisle expressed understanding of the administrative burden that CMS audits place on hospitals. The Senate Finance Committee held the hearing on oversight and integrity of the Recovery Audit Contractor program that works with Medicare to audit provider reimbursement claims.

Chairman Max Baucus (D-MT) and Ranking Member Orrin Hatch (R-UT) both voiced that audits should be a balancing act between weeding out fraud and abuse, and creating an administrative headache. Baucus said that the committee will look at the program “seriously.” He said the “goal should be to lower the amount [of incorrect Medicare payments] to zero, but we can’t overburden legitimate providers who play by the rules.” According to CQ, Hatch also expressed concern. He noted that the RAC contractor is coming up for renewal in the near future, and that Medicare should use the renewal to ensure the right balance between protecting Medicare’s finances and avoiding undue administrative burdens on providers.

The RAC program was started as a six-state pilot program under the Medicare prescription drug law in 2003, and it was made permanent by Congress in 2006 after it found $1 billion in improper payments. The program was then expanded under the 2010 healthcare reform law, when Medicare managed care and Medicaid were placed under RAC contractors.

Audits found $29 billion in 2011 payments that were d

eemed to be “improper”, but there are many critics of the program. One representative of a large healthcare resource company testified at the hearing that the company has had to hire 22 full-time employees to handle all the documents requested by RAC. Other providers complain that RAC auditors use information obtained after the a patient is admitted to a hospital to determine that the admitted patient should have been treated as an outpatient.

Panelists all agreed that RAC audits could be improved with a redesigned appeals process, but that doing that alone would not make the process less time consuming. Committee Chairman Baucus recommended that Medicare should also give the contractors incentives to focus on the most “at-risk” providers, and that CMS should make existing regulations clearer.

No Facial Recognition Apps for Google Glass

By now most everyone has heard of Google glass, the glasses that are technologically advanced enough for hands-free pictures, video recording, Google searching, and streaming. Just like with Apple’s iPhone and Google’s Droid phones, the user will be able to download applications to the device from an app store. Already available are apps that allow the user to use Twitter, Facebook, or read the New York Times hands free. What will not be available in the store, however, are any apps that use real time facial recognition technology.

Google made a decision to ban both facial recognition and voiceprint technology apps from the store earlier this month, according to the MIT Technology Review. The decision is a blow to app developers who were planning on using that technology for different purposes, such as helping medical staff pull up health records and charts simply by looking at a patient.

The Review reports that at a recent conference, developer Lance Nanek showed off a medical facial-recognition Glass app he built that could—for a set of patient faces entered into the system—allow Glass-wearing clinicians to verify someone’s identity and instantly bring up records on allergies or existing prescriptions, without ever turning to a cumbersome PC or mobile handset. In an era where patient identity is key, facial recognition could provide crucial biometric confirmation before treating a patient.

The decision to ban facial recognition apps came after concerns from some consumers, and even Congress, that such apps would impose on privacy and be a tool for “creeps.” Members of Congress wrote a letter to Google CEO Larry Page in late May to ask whether the company would prevent “unintentional” collection of data and whether it would allow facial recognition—demanding a response by June 14. The ban came after the congressional letter.

Medical staff can still use technology and facial recognition, but they cannot do so instantly. As of now, staff can snap a photograph, open an app to compare the photo against a database, and refer to the screen to see the resulting data. Any further advancements will have to wait until privacy concerns subside. 

House Members look at Higher Medicaid Reimbursement

The Affordable Care Act, also known as “Obamacare,” increased Medicaid reimbursement rates through 2013 and 2014, but these federal rates expire after 2014, leaving the future of reimbursement up to the states. States control the provider payment rates; 45 states froze provider reimbursement rates in 2012, casting doubt that they will match the 2013-2014 rates that bring Medicaid rates on par with Medicare. Currently, Medicaid pays on average only 66 percent of Medicare rates. The federal government has only been able to provide the payment bump by subsidizing the difference between state rates and Medicare rates. The federal payments to doctors, even though they are retroactive to January 1^st, have been slow to take effect this year due to late rules published by the Centers for Medicare and Medicaid Services (CMS).

At a Congressional hearing earlier this month entitled “The Need for Medicaid Reform”, House Republicans and Democrats didn't see eye to eye about what to do with the future of the program. As reported by MedPageToday, the popular Republican plan has been to transform Medicaid into a block grant program, whereby the federal government gives states a set amount of money per beneficiary and allows them to run the program as they see fit. Democrats have opposed such a measure, saying the low-income elderly and disabled will be most at risk.

Both sides seemed to get together, however, on the need to do something with the program. In Texas, for example, only 31% of doctors accept new Medicaid patients. This poses a threat of access for millions of people starting next year, according to Rep. Mike Burgess (R-TX). Rep. Henry Waxman (D-CA), the top Democrat on the House Energy and Commerce Committee, suggested at the same hearing that Congress should extend the temporary payment increase past 2014.

The hearing also shed light on a cost sharing program in Arkansas that could serve as a potential model for reform. The state started the program in October that determines if a provider reaches quality and cost targets based on historical models for certain episodes. Providers who manage care and costs well compared to historical cost levels receive rewards. Those who don't face losing payments. State Surgeon General Joe Thompson told the committee that the rate of spending growth has shrunk to the lowest in 25 years.

MedPAC Releases Congressional Report

The Medicare Payment Advisory Committee (MedPAC) released their June report to Congress last week, identifying several changes that could be made to the Medicare program. The changes could potentially save over $1.5 billion per year. The report, the second that MedPAC has sent to Congress this year, is less substantive than their first in March, but CQ reports that it reflects an “effort in a variety of areas to identify and eliminate inefficient spending in [Medicare].”

Among the cost saving opportunity that MedPAC identified is a new version of “competitively determined plan contributions”, or what Mitt Romney called “premium support.” MedPAC specifies that the plan may or may not save money depending on how it’s implemented, but they go on to describe a federal contribution toward the coverage of a participant’s Medicare benefit. The contribution would vary based on the cost of competing options for the coverage, including both those offered by private plans and those offered by the traditional Medicare program.

The report also identified significant variations in charges for the same or similar services provided in different settings. Ambulatory services, for example, cost more when provided in hospital outpatient departments than they do when performed in a physician’s office. The report suggested a process where Medicare bases payment rates on the resources needed to treat patients in the most efficient settings, and then adjust for severity of the patient’s condition and locality. Looking at 66 groups of procedures, equalizing rates between the procedure performed in an outpatient department and the procedure performed in a physician’s office could save the program $900 million per year. Stabilizing rates in another 12 groups of procedures performed at ambulatory surgery centers could save an additional $600 million.

An additional way to save money is to equalize costs for post-acute care facilities. The report suggested bundling hospital and post-acute care payments, possibly leading to coordination between the facilities and the physicians. By doing that, MedPAC says, “providers would have an incentive to coordinate care and provide only clinically necessary services, rather than furnishing more services to generate revenue.”

Finally, the report discusses the new hospital readmission policy, part of the value based purchasing program, that curbs reimbursements based partially on readmission. MedPAC suggests re-evaluating the program and taking socioeconomic status into account when adjusting for readmissions, since poorer populations are more likely to use hospitals instead of primary care physicians.

You can view the full MedPAC report here, and the report fact sheet here. 

The Wave of Smartphone EHR Apps

Lots of programs designed to increase communication through the use of electronic health records focus on provider to provider, or hospital to hospital communication. With this mentality comes issues involving the compatibility of different software, secure transfer of data, and the requirement that all providers to have an EHR system. Medicare, however, is shifting the focus from providers to patients with the new Blue Button program.

The program, currently available from the federal government for Medicare beneficiaries and veterans, downloads three years of a patient’s medical history to a smartphone app which translates and displays the information in a simple and easy to understand way, according to Kaiser Health News. Dr. Farzad Mostashari, the coordinator for health information technology with the Department of Health and Human Services (HHS) predicts that if they want it, everyone can get this kind of information within the next year or so. Through smartphone applications and new technologies, patients can have access to the same information that doctors would send to each other.

Technology in the hands of consumers does have its drawbacks. From a logistical perspective, in order for records to be downloaded or pushed to an app, they have to be electronic. According to a 2012 study by the Centers for Disease Control and Prevention, while 72 percent of office based physicians use an EHR system, only 40 percent of practices have a system the meets the definition of at least “basic” requirements.

 There are also obvious security concerns. Apps available would be through third party companies and vendors. This means that another party, or company, could have access to patient records. Additionally, the patient could lose access to their data if the company goes out of business or the app stops working. Patient information also isn’t covered under federal privacy and security rules, meaning that anyone should read the app privacy agreement very carefully. Specific things to look for in the agreement can be found in this article.  Finally, incomplete EHRs on the apps could lead to dangerous situations, since doctors might not get the full picture.

 If done right, EHR apps have the capability to do a lot of good, but there are a lot of reasons to proceed with caution. 

Noise is an Issue for Hospitals

Hospitals are noisy places. Monitor beeps, staff conversations, medication alarms, and other noises contribute to a constant cacophony of sounds that a patient hears through day and night. Hospitals have previously worked on reducing noise, but the push now comes with added urgency due to new Medicaid policies that allows adjusted or reduced reimbursement rates based on criteria that includes patient ratings on quality of care. According to the Wall Street Journal, “the latest data from [Medicaid] for the year ended in June 2012 shows that only 60% of patients said the area outside their room was quiet at night, representing the lowest satisfaction score among 27 questions about the hospital experience.”

A “State of Patient Experience” report released in April by the Beryl Institute, a nonprofit that helps hospitals improve patient satisfaction, showed that hospital administrators ranked noise reduction as their top priority for the second time since the last report in 2011. While they share a common goal, different hospitals have different methods of working towards it.

Some hospitals are utilizing stoplight like devices that turn yellow and red with elevating noise levels. Other hospitals are expanding the number of private rooms, or providing patients with “quiet kits” that include earplugs, headphones for TVs, and other devices. Doctors and nurses are seeing change as well; some hospitals are switching to wireless headsets instead of loudspeaker pages or walkie –talkies instead of beepers. A lot of hospitals are looking at installing white noise machines to counteract exterior noise, although one study suggested that they have no effect on patient perception of noise levels.

The barrage of noises may not only be a problem for patients. In April, NAHAM News reported a warning from the Joint Commission regarding alarm fatigue, when a doctor of nurse tunes out potentially important patient alarms due to noise overload. That article can be read here.  

OIG Report Shows that CMS can Save on Lab Tests

A new report released this week by HHS’s Office of the Inspector General (OIG) found that Medicare could have saved $910 million in lab test fees in 2011. Medicare is the largest payer of lab services in the nation, according to CQ, but the program paid 18 to 30 percent more than other insurers. The program could have saved almost $1 billion if fees had matched the lowest rate charged to private companies in each geographic area.

OIG officials looked at 2010 claims data for the most frequently ordered and most expensive lab tests under Medicare. They compared Medicare rates for 20 tests representing 56 percent of Medicare costs for lab tests, with the maximum payments for the same tests allowed under each of 50 state Medicaid programs and the Federal Employees Health Benefits Program. They found at least one of the other programs paid a lower rate 94% of the time.

One explanation for the discrepancy is that most private insurance programs use Medicare rates as a starting point before applying their own discounts. State Medicaid programs are also banned from paying more than the Federal Medicare program. Medicare beneficiaries do not pay co-payments or deductibles for lab tests, a factor that decreases costs for private insurers. The report suggested that CMS officials should weigh whether future enrollees should begin to pay deductibles to lower costs.

As a remedy, the OIG suggested that Congress act to alter the fee schedule, since the Centers for Medicare and Medicaid Services (CMS) has a limited capacity to do so.

You can view the full report via the OIG website here. 

EHR Study Reveals Customer Satisfaction

Satisfaction with electronic health records (EHR) systems varies widely, and issues do not always lie with the systems themselves. With only a couple of exceptions, a new report from health information technology market research firm KLAS states that “the greatest frustration that we encountered was about vendor relations, rather than the software itself.” The report, entitled “Ambulatory EMR Usability 2013, More Nurture than Nature”, covers interviews with 163 providers from practices with more than 25 physicians.

According to ModernHealthcare, the study ranked nine vendors in a composite score based on physician responses to questions about how well the typical physician can efficiently and effectively perform on six common EHR tasks or functions. Those tasks were: e-prescribing, medication reconciliation, physician documentation, problem lists, viewing patient information and supporting mobile devices. 

Among the providers, Athenahealth customers rated their experiences the best. The company scored best on getting providers to usability at first use, or “go-live,” and second best in the handholding department—that is, guiding clients who purchased their systems on how to use them.

Runners up include Epic Systems Corp. in second, GE Healthcare and Greenway Medical Technologies tied for third, Allscripts’ in fourth, and McKesson Corp. in fifth.

The Joint Commission celebrates National Time Out Day

NAHAM has long been looking into patient identity integrity issues and advocating for greater consistency in hospital procedure. To that end, a recognized best practice for hospital care is taking Time Outs for Safety. These can be useful at the check in desk to ensure proper patient identification, at the bedside before giving medication, or even in the operating room before making an incision.

In that spirit, the Joint Commission is teaming up with the Association of periOperative nurses to observe National Time Out Day on June 12^th, 2013. The Joint Commission sent out a letter urging healthcare practitioners to recognize National Time Out Day. While their specific focus is on wrong-procedure or wrong-person surgery, the idea of National Time Out Day is something that can be adapted for patient safety by any healthcare professional.

Read more about National Time Out Day on the Joint Commission website here.

Using Soap with all ICU Patients found to Reduce MRSA

A new study, released late last month, tested three different strategies for preventing methicillin-resistant Staphylococcus aureus, or MRSA. Researchers from the University of California, Irvine, Harvard Pilgrim Health Care Institute, Hospital Corporation of America (HCA), and the Centers for Disease Control and Prevention (CDC), all participated in the study. They compared providing routine care to all patients, providing germ-killing soap and ointment only to patients with MRSA, and using germ-killing soap and ointment on all ICU patients.

The study found that with routine care, neither the presence or MRSA or other bloodstream infections were significantly reduced. Method two, bathing and treating only patients who were found to carry MRSA, reduced infections by 23 percent. The best treatment, however, was universal bathing and treatment of all ICU patients, which reduced infections by 44 percent.

A total of 74 adult ICUs and 74,256 patients were part of the study, making it the largest study on this topic, CDC officials said. The study, and a synopsis, can be found on the CDC website here.

How to Choose a Hospital

For most citizens who do not work in the healthcare field, choosing a hospital can be quite difficult. Most have the ability to shop around and decide which hospital they want to go to for non-emergency situations. Despite that, according to the Atlantic, few patients are able or willing to invest the time and effort that would be required to find the best hospital. Even if they did, which healthcare parameters should they track? The factors used in decisions vary from patient to patient, and they can consider factors ranging from procedure success rates to hospital food. Even with research, some of these questions are not so straightforward.

In the case of a specific procedure, for example, patients may be tempted to pick the hospital with the 99 percent success rate over the hospital with the 95 percent success rate, due to a perceived better quality of care. The 95 percent hospital, however, might perform the procedure on the sickest patients in most dire need of the surgery, while the 99 percent hospital may only perform the procedure on relatively young and healthy patients, many of whom do not need it as much.

Patient satisfaction is another factor patients may look at when choosing a hospital. The Centers for Medicare and Medicaid Services and the National Committee on Quality Assurance require participating organizations to publicly report their patient satisfaction data, so rates are easily obtained. This data can also be misleading though, as patients may rate a hospital experience poorly because they had to wait, when in all reality they received excellent care. Alternatively, patients may rate their hospital experience highly because there was ample parking, even though their care was sub-par. These factors may not be the best to determine where to undergo a procedure.

At the end of the day, the Atlantic suggests two key questions in choosing a hospital. First, do the people who work at the hospital, particularly nurses and physicians, seem generally happy and proud of the work they do?  Secondly, if health professionals were going to be hospitalized, which institution would they choose? These questions are good ones to keep in mind for both patients and hospital staff.

Electronic Health Records Prove Useful in a Disaster

The recent disastrous tornadoes in Oklahoma caused people all over the state, and all over the country, to jump into action. Over 40 people were killed in two separate events, and even more required medical attention. In an emergency, everyone expects the hospital to jump into action to help the wounded, but what happens when the hospital is destroyed? That is where electronic health records come into play. In Moore, OK, the site of most severe tornadoes,  the hospital was leveled. Three hundred people including staff, patients, and other community members that were in there at the time waited out the storm in the cafeteria, chapel, and in various stairwells. Luckily, all survived according to AARP.

With Moore Medical Center destroyed, patients had to be moved to other hospitals in the Norman Regional Health System. Within an hour, 30 patients had already been transferred to other hospitals that were able to seamlessly continue treatment prescribed in the patients electronic health records.

If the hospital had been using paper records, the process of finding a patient file to determine a patient’s medical history, medications, current treatment plans, etc. would have been a lot harder. The director of health information technology at the Norman Health System explained that the paper records would have most likely have been destroyed by either the tornado or the rain that followed.

Instead, transitions were easy and patients were taken care of with minimal inconvenience. In this case, the lessons learned by using electronic health records can be applied to any disaster that requires medical attention. The electronic records definitely improved patient care following a disaster, and may have even saved lives.