Incorporate patient-generated health data into the EMR

ISRAEL GREEN-HOPKINS, MD | TECH | MARCH 2, 2014

A few months ago, I spent 15 minutes filling out a detailed health data form at the doctor’s office. The paper form contained multiple questions about my health, family history, medications and basic demographic information. I assumed that an administrative specialist would code it into the practice’s electronic medical record (EMR) to be put to use. So it came as a surprise when I spent another 5 minutes reviewing the form with my physician, who then proceeded to type this information into the EMR herself. I’m confident neither my physician nor I felt enabled by the experience.

Countless people have had a similar experience — or worse, filled out a form with no sign that any clinician ever saw the information. Though the industry has made outstanding progress in adopting EMRs, the practice of data acquisition from patients remains cloudy. Patient-generated health data (PGHD), a term encompassing all forms of data that patients provide on their own, is a relatively new concept in health care. It falls into two broad groups: historical data and biometric data.

Historical data is the type that clinicians are familiar with obtaining from patients: It includes the patient’s medical history, allergies, medications, family history and lifestyle features. Biometric data, little used at present, are health data gathered by consumer medical devices, such as blood glucose meters and fitness trackers.

Scenarios like mine above underscore how ill-prepared the health care infrastructure is for the sharp rise in both opportunities and requirements for PGHD, and the challenges of wrestling these data into the workflow of clinicians. Now, however, an important milestone is on the horizon. A recommendation from the HITSC Meaningful Use Workgroup would require practices with electronic health records (EHRs) to allow 10 percent of patients to report PGHD electronically. If approved in meaningful use stage 3, the final stage of HealthIT.gov’s EHR incentive program, it could push hospitals to incorporate patient-generated data.

This requirement may seem like a relatively simple intervention, but the ramifications are quite significant. If clinical decision-making is made on the basis of data supplied by patients and documented in the EMR, how can clinicians be sure that such data is complete, correct and valid? And will clinicians like me learn to rely on it, or will we disregard it due to concerns about its validity or barriers to integrating it into care flow? Furthermore, if a patient is in control of her health data entry, who is ultimately responsible for its completeness and accuracy — the patient or the clinician?

Incorporating biometric data into the EMR, an exciting prospect, is even more complex. Though clinicians are quite familiar with data entry from FDA-approved medical devices such as blood glucose meters, pacemakers and pulmonary function units, data from a myriad of consumer-driven health devices (Fitbit and others) will soon seek to flex their way into EMRs. Patients clearly value these data; a recent Pew Research report noted that 60 percent of adults claim to track their exercise routine, weight or diet, meaning providers have some catch-up to do in order to meet patients halfway. Some health systems, such as Partners HealthCare, have already been experimenting with the incorporation of PGHD from remote devices into the EMR, and other institutions should follow. Consumer health data devices are moving ahead at a staggering pace, and while the health care system can’t quite keep up, strategic planning should be happening now.

Meanwhile, patients are flocking to sites like PatientsLikeMe and 23andMe to compare and track health data, symptoms and treatment results. Though the connection between clinical medicine and these services is still quite murky, the data show that large contingents of our patients value the notion of comparing and visualizing their health data.

Despite the challenges, incorporating PGHD is a necessary evolutionary step for health care. Intelligently designed, well-executed systems that fully incorporate and display PGHD in a meaningful way will improve shared decision-making and enable patients as active care partners. Keen clinicians and patients will stay closely tuned to the numerous transformations to come.

Israel Green-Hopkins is a pediatric emergency medicine fellow who blogs at Vector, the Boston Children’s Hospital science and clinical innovation blog.

http://www.kevinmd.com/blog/2014/03/incorporate-patientgenerated-health-data-emr.html

Faxing error causes United Healthcare breach

A Portland, Oregon man has been receiving erroneous faxes containing protected health information (PHI) from Community Memorial Hospital patients through an apparent error with United Healthcare, an insurance company, according to a report from 620WTMJ.com.

The initial fax, which included patient names, dates of birth, patient ID numbers, admission dates, and discharge dates, was sent to Stephen Butler’s home about a year ago. After tracing the number to Community Memorial Hospital in Menomonee Falls, Wisconsin, Butler called the hospital to inform them of the error.

Froedtert Health, which runs Community Memorial Hospital, was alerted of the breach through a patient of the hospital who had been contacted by Butler. After an investigation, the breach was determined to be caused by United Healthcare.

While United has not yet been able to determine if the breach was a result of human error or a glitch in their system, a representative issued 602WTMJ a statement saying, “We were alerted by Froedtert Health about this issue earlier today, and we are working closely with them to investigate and determine the facts. We take very seriously the privacy and personal information of our members.”

http://healthitsecurity.com/2014/02/28/faxing-error-causes-united-healthcare-breach/

Viewpoint: Dr John Ribchester: Why I support the King's Fund's primary care plans

By Dr John Ribchester, 28 February 2014

I am sorry to say that I have read BMA deputy chairman Dr Kailash Chand's critique of the King's Fund's report on commissioning and funding general practice with increasing concern and frustration, writes Kent GP Dr John Ribchester.

Dr Ribchester: 'The King’s Fund’s report advocates changing the commissioning landscape to enable family care networks.'

If his views are representative of the BMA, then I fear that the organisation will be following the ornithomimosaurs (ostrich dinosaurs) into extinction. As a lifelong exponent and supporter of general practice I would like to address his main concerns and explain why I support the tone and content of the report.

Dr Chand states that ‘primary care does not need another reorganisation’. The last major change to the GP contract was in 2004, with small scale changes commencing from this April. The change from PCTs to CCGs which came into force last April was of course a change in commissioning rather than something that had much effect on GPs as providers.

Admittedly, some GPs increased or developed a role in commissioning, but for most it was business as usual. It is surely widely accepted that continuing with GPs doing much the same as ever in an unchanging NHS is not a sustainable option either clinically or financially. A population of increasing size and age and a time of financial austerity is enough of a stimulus to require significant changes.

Recommendations within the King’s Fund’s report to reorganise general practices into large groups which can genuinely perform population healthcare planning and better community healthcare provision seem very logical. The sharing of expertise between the practices, economies of scale in managing fewer, larger practices and the ability to genuinely integrate with secondary care, community care, mental health services and social services can only occur once general practices are larger, whether this be through federations or mergers.

Dr Chand states that we should be focusing on tackling the serious workload and financial challenges faced by GP practices. I completely agree with this statement, but the point is this. Surely general practice would be in a better position to face these challenges once arranged into larger groups.

There is already a trend for CCGs to obtain smaller numbers of larger contracts from larger providers. This means that the small general practice does indeed face a financial challenge by being poorly equipped to attract an AQP or community contract.

I disagree that the model of GP family care networks is totally inappropriate and costly in rural areas. It is certainly true that, given the varying population, density and demographics across the country, one model will not be appropriate for all locations.

One would certainly not advocate siting a large provider unit in a rural area. However, the concept of practices collaborating in some way and sharing clinical and management expertise is equally applicable regardless of location.

I think my largest objection is to the statement that ‘there is a complete lack of evidence for the alternative of moving care closer to home’. There is a growing body of evidence nationally and internationally that this can produce a better experience at less cost.

The King’s Fund’s report itself studies four models and draws from experience of many others. Although not mentioned by name, Whitstable Medical Practice also provided evidence. Our model of community integrated healthcare has been evolving for a number of years.

Currently, 19 GPs look after a locality of 34,000 patients in collaboration with over 20 consultants and other healthcare professionals. Work streams have been developed to innovate in the care of long-term conditions, urgent care and community elective services. The result has been an enhanced patient experience, closer to home, with shorter waits and one-stop care where possible.

This has been delivered at less cost to the system and also to the greater satisfaction of the doctors, nurses and other healthcare professionals involved in delivering the model. Other super partnerships and federations report similar findings.

The evidence is out there and it is growing. One reason that there are not more innovators is that they are trying to develop new and better systems in a bureaucratic environment which is at best unhelpful and at worst oppositional. The King’s Fund’s report advocates changing the commissioning landscape to enable family care networks - otherwise known as community integrated healthcare. This is a concept which has been talked about for many years. Surely there could not be a better time to facilitate progress.

I agree with the statement that conflict of interests for GPs as commissioners and providers needs to be addressed. The report advocates managing this effectively which seems a better alternative than allowing it to block progress, which is all too often the case at present.

Transparency, honesty and scrutiny are the key to success. I find myself agreeing with Dr Chand’s statement that ‘to implement needlessly disruptive policies that focus more on structures than outcomes needs rejecting’.

However, this is not what the report is advocating. Instead it states that the GP contract should focus on outcomes and not inputs.

Finally, Dr Chand makes the point that new investment is required in general practice. I agree that we appear continuously to be asked to do more with less resource, something we all feel pressurised by. However, it is possible that the King’s Fund’s recommendations provide one answer to this. If more clinical activity is occurring in the family care networks then more finance will flow into them.

Economies of scale in running practices and also in providing shorter patient journeys with less duplication, hand-offs and omissions should all have the potential to produce savings which could in turn increase the amount of resource in a new version of general practice which has a leadership role in family care networks.

As the King’s Fund’s report states, simply doing more of the same will not be sufficient and therefore there is a strong argument for a better approach based on innovative ways of providing services.

This debate is advancing in our locality, and others that I have visited. Potential ornithomimosaurs please take note.

* Dr John Ribchester is a Kent GP.

http://www.gponline.com/Opinion/article/1282747/Viewpoint-Dr-John-Ribchester-Why-I-support-Kings-Funds-primary-care-plans/

Tavenner: No ICD-10 Delay, But Expect Some MU Relief

Lena J. Weiner, for HealthLeaders Media , February 27, 2014

CMS Administrator Marilyn Tavenner has announced that the ICD-10 deadline will not be delayed, but she is offering relief to providers, payers, and health information technology vendors struggling to meet Meaningful Use Stage 2 requirements.

Two announcements from Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner at the HIMSS 2014 conference in Orlando Thursday will have wide-ranging implications for healthcare providers, insurers, and vendors.

The deadline for implementing the ICD-10 diagnostic coding set, which had already been delayed one year to October 1, 2014, will not be delayed again, Tavenner said.

And while the Stage 2 Meaningful Use deadline will also not be delayed, Tavenner said that providers and vendors struggling to meet the incentive program's requirements will see some flexibility.

During the keynote presentation Thursday morning at HIMSS 14 in Orlando, Tavenner announced a partial reprieve for physicians and medical systems finding it difficult to adjust to Meaningful Use guidelines—but urged professionals to come up to speed quickly.

"We have decided to permit flexibility on how hardship exemptions will be granted," Tavenner said. "I must stress we expect all providers to meet requirements in 2015. I urge you to meet the requirements this year." Scattered applause broke from members of the crowd as Tavenner made the announcement.

"We certainly have experienced… difficulties, and I can personally relate to the challenges of new systems, relationships with vendors, and charting a course through previously unnavigated waters," Tavenner said, referring to the well-documented difficulties with thehealthcare.gov website.

When confronted by a question regarding patient safety during the Q & A session after the keynote, National Coordinator for Health Information Technology, Karen DeSalvo, said, "We are exploring our options to help you… we want to make sure you are not penalized for doing the right thing."

These comments come at a time when many within the healthcare industry are expressing concerns regarding the ability to adopt the Meaningful Use standards as specified in the HITECH act. On the Friday before HIMSS, more than 40 healthcare industry groups penned a letter to Health and Human Services Secretary Kathleen Sebelius seeking more time for Meaningful Use attestation, and citing concerns over patient safety and lack of vendor support.

On Thursday, in an exclusive interview with HealthLeaders Media, Intermountain Healthcare CIO Marc Probst disclosed that his organization is unready to seek MU Stage 2 attestation and will forgo incentive payments and trigger penalties.

'It's Time to Move On'While concerns from within the industry are being taken seriously, there will be no turning back. While CMS will be offering exemptions on a case-by-case basis, "Now is not the time for us to stop moving forward," Tavenner said. She was especially unyielding regarding the new ICD-10 coding system.

"Let's face it guys; it's time to move on," Tavenner said. "There will be no change in the deadline for ICD-10. CMS began installing and testing systems for ICD-10 in 2011. All fee for service systems at CMS are ready."

Earlier this month, in response to concerns raised by providers and a group of U.S. senators, CMS agreed to perform end-to-end ICD-10 testing with a small sample group of providers selected to represent "a broad cross-section of provider types, claims types, and submitter types."

The College of Healthcare Information Management Executives (CHIME) responded to Tavenner's comments at HIMSS in a statement released shortly after the keynote speech.

"[CHIME] welcomes CMS Administrator Marilyn Tavenner's announcement this morning, acknowledging the need to provide relief for our nation's providers. Such relief is vitally important for the future success of Meaningful Use, as ICD-10 deadlines and continued shifts in payment policies demand an ever-increasing amount of IT and workforce resources," the statement read.

In the event that expansion of the Hardship Expectations provides the "kind of relief the industry desperately needs," CHIME will pledge to assist CMS "in every way possible," the statement continued. "It will be CHIME's highest policy priority to ensure that providers receive the kind of relief they need in order to deliver quality care."

http://www.healthleadersmedia.com/print/TEC-301496/Tavenner-No-ICD10-Delay-But-Expect-Some-MU-Relief

(CMS) Proposes to Restrict Diagnoses from Home Visits for Medicare Advantage Risk Adjustment

Centers for Medicare and Medicaid Services 

The Centers for Medicare and Medicaid Services has proposed to limit how Medicare Advantage Organizations can use in-home wellness or risk assessment visits of their enrollees to affect the risk adjusted payments they receive.  The proposal could cause a reduction in the number of such visits and lower overall payments to Medicare Advantage Organizations.
The Centers for Medicare and Medicaid Services (CMS) recently proposed to limit Medicare Advantage Organizations’ (MAOs’) ability to use diagnoses obtained from home risk assessments for Medicare Advantage (MA) risk-adjusted payments.  This is among several significant proposals in the Advance Notice of Methodological Changes for Calendar Year (CY) 2015 for MA Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter (the Advance Notice), published on February 21.
The Advance Notice includes other significant provisions affecting the MA and Part D programs, including revised MA payment rates and changes to provider network policies.  Comments from MAOs and other interested parties must be submitted by March 7, 2014.  CMS is expected to issue its final notice on April 7, 2014.

The Proposal and Its Background

The proposal would require that diagnoses from a home visit be excluded from risk adjustment, unless a subsequent clinical encounter confirms such diagnoses.  CMS’ proposal would not affect risk assessments conducted outside the home.
Risk adjustment modifies the capitation payments that MAOs receive to reflect the health status of their enrollees, thereby eliminating incentives for MAOs to avoid enrolling less healthy beneficiaries.  CMS’ risk adjustment methodology identifies enrollees’ health status based on diagnoses for those enrollees.
The present proposal follows a similar one in the 2013 Advance Notice, which was not finalized.  In 2013, CMS initially proposed to eliminate diagnoses identified in all risk assessment visits.  However, in its final notice issued in April 2013, CMS did not implement any such requirement and stated it would further study the issue.
CMS subsequently required that, for all 2014 dates of service, MAOs’ risk-adjustment submissions must code whether the visit was in a clinical setting or in the home.  For home visits, MAOs are additionally required to identify whether the visit is an Annual Wellness Visit, as that term is used in traditional Medicare.  The current proposal would apply to diagnoses from visits performed in 2014, which CMS uses for purposes of CY 2015 payments.

CMS’ Reasons for the Proposed Change

CMS’ proposal expresses skepticism about the clinical value of in-home risk assessments.  Indeed, CMS states that “to the extent that commenters believe that home assessments improve care, and are not just efforts to increase the diagnoses collected,” CMS would like to receive specific and measurable ways to identify and use certain home risk assessment diagnoses.
CMS notes that in-home risk assessments “are typically conducted by healthcare professionals who are contracted by the vendor and are not part of the plan’s contracted provider network, i.e., are not the beneficiaries’ primary care providers” and do not include treatment.  CMS also states that there is “little evidence that beneficiaries’ primary care providers actually use the information collected in these assessments or that the care subsequently provided to beneficiaries is substantially changed or improved as a result of the assessments.”
CMS suggests that if in-home risk assessments are, in fact, used to guide treatment, then diagnoses should also be documented in a follow-up visit in a clinical setting.  The Advance Notice suggests that the proposal would ensure that in-home risk assessments “serve as an effective vehicle to improve follow-up care and treatment for beneficiaries.”
CMS also expresses concern that diagnoses from risk assessments performed in the home inflate risk scores, without a corresponding increase in MA plan financial liability, and contribute to differences in coding patterns between MA and Fee For Service Medicare.  Although the Advance Notice expresses skepticism about whether risk assessments have real clinical value, it does not expressly state that CMS believes diagnoses obtained through these visits are inaccurate.

Impact of the Proposal

Home risk assessments have been used in MA to enhance the management and coordination of members’ care and are an additional avenue by which members’ conditions are identified and documented in a medical record.
CMS’ proposal to require a subsequent clinical encounter would limit the value of home risk assessment visits for risk-adjustment purposes, since the risk assessment visit by itself would be insufficient to support a diagnosis.  If there is no subsequent clinical encounter or the provider in the subsequent encounter fails to submit the diagnosis or properly record it in their medical records, the diagnosis and documentation from the home risk assessment visit could, apparently, not be used to establish the member’s condition.  The proposal does not define what qualifies as a “subsequent clinical encounter,” nor does it specify whether the subsequent clinical encounter must occur during the same data-collection period as the risk assessment.
The proposal could potentially increase MAOs’ exposure in Risk Adjustment Data Validation Audits, since documentation from risk assessment visits can presently be used to support diagnoses.  The proposal does not directly address whether medical record documentation from a home risk assessment visit could still be used in a Risk Adjustment Data Validation Audit, if medical record documentation from a subsequent visit in a clinical setting is deemed insufficient.

Timing

After allowing for a brief comment period, CMS will issue its final policy for CY 2015 in April 2014.  However, CY 2015 risk adjustment payments are based on diagnosis data from encounters during 2014, including encounters that occur before the final policy is issued in April.  The current proposal does not specify whether it would apply to data from risk assessment visits that occur before any changed policy is finalized or would be limited to risk assessment visits that occur after that date.

Conclusion

CMS’ proposal may have a significant impact on home risk assessment visits in MA.  MAOs should consider commenting on the proposal.  In addition, MAOs should consider what operational adjustments they may need to make with respect to risk assessments performed in 2014.

http://www.natlawreview.com/article/centers-medicare-and-medicaid-services-cms-proposes-to-restrict-diagnoses-home-visit

Fort Drum Regional Health Planning Organization is looking for it's first Executive Director

A six-hospital effort that has been finding ways to work together to reduce unnecessary, repeat Medicaid readmissions and create efficiencies in health care delivery may have its first executive director by April 1.

Operating in partnership with the Fort Drum Regional Health Planning Organization, the North Country Initiative director will oversee the program’s administration and help develop a management services organization and a clinically integrated network.

“As it moves forward, it’ll need staffing in order to meet goals of the organization,” said Denise K. Young, FDRHPO executive director.

River Hospital, Alexandria Bay; Samaritan Medical Center; Carthage Area Hospital; Lewis County General Hospital, Lowville; Clifton-Fine Hospital, Star Lake, and Claxton-Hepburn Medical Center, Ogdensburg, have worked in collaboration throughout the past two years to initiate a plan that could curb costs and create healthier communities.

Through those efforts, hospital administrators determined a management service organization would provide centralized nonphysician services and functions to all participating hospitals. What may be included could be joint purchasing, reference laboratories and synchronized revenue cycles, such as billing, coding, collection and admissions. A clinically integrated system would involve outcome-based measurements and physicians working collaboratively.

Meanwhile, Mrs. Young said, applications for the North Country Initiative’s top post already have come in.

“I think we have a good pool that we’ll get to begin interviewing next week,” she said.

According to a position description, which was posted on FDRHPO’s Facebook page, the director will be responsible for helping to develop the initiative’s business plan and budget and overseeing daily operations.

Up until this point, River Hospital Chief Executive Officer Ben Moore III has served as the group’s spokesman. The position description states that the initiative director will coordinate development and will be responsible for all communication materials. The director will work closely with hospital administrators, community members, community groups and various health organizations.

Once initial steps are complete, the director also will determine the North Country Initiative’s total staffing requirements.

FDRHPO is looking for someone with a master’s degree in health care administration or a related field, and at least five years’ experience in leading or working with independent employed physicians or other professionals. Resumes are due Saturday. For more information, email Mrs. Young at dyoung@fdrhpo.org.

CMS and OIG announce plan to exclude “recalcitrant providers”

Faegre Baker Daniels

• Thomas W. Beimers
• USA
• January 31 2014
• 

Author page »

In a move that made little immediate splash, but has since received considerable media attention, including a recent article in the New York Times, the Department of Health & Human Services announced that it will take additional steps against “recalcitrant providers,” including exclusion from participation in federal health care programs. CMS issued a notice, on January 15, stating that it intends to refer recalcitrant providers to the Office of the Inspector General, which will review the cases for potential administrative action.

CMS defines a “recalcitrant provider” as one who is “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” The definition refers to existing procedures whereby a program contractor who identifies improper billing may require the offending provider to obtain education. Contractors sometimes place providers on pre-payment review if their billing practices continue to raise red flags. In the program directive, CMS noted that some providers remain on pre-payment review for years. The new program is intended to provide another level of review for providers who are a drain on CMS contractor resources.

Last year, OIG excluded over 3,000 providers from participation in Federal health care programs. Most of these exclusions are mandatory, and typically are triggered by a violation of the law. The exclusions contemplated by the new CMS initiative will be permissive, meaning that OIG will need to make an affirmative case for exclusion, and the department will provide the physician with an opportunity to have the matter adjudicated by an administrative law judge.

The initiative is reflective of the government’s continued focus on fraud, waste, and abuse in federal health care programs, which many sources estimate at over $10 billion per year.

http://www.lexology.com/library/detail.aspx?g=450e5463-1cad-4b11-b4df-7605cc5069d8

Medical Homes and Quality of Care, Costs

(HealthNewsDigest.com) - Chicago - One of the first, largest, and longest-running multipayer trials of patient-centered medical home medical practices in the United States was associated with limited improvements in quality and was not associated with reductions in use of hospital, emergency department, or ambulatory care services or total costs of care over 3 years, according to a study in the February 26 issue of JAMA.

The patient-centered medical home is a team-based model of primary care practice intended to improve the quality, efficiency, and patient experience of care. Professional associations, payers, policy makers, and other stakeholders have advocated for the patient-centered medical home model. In general, medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options, and other structural changes that might improve patient care in exchange for enhanced payments, according to background information in the article. Dozens of privately and publicly financed trials of the medical home model are under way. "Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear," the authors write.

Mark W. Friedberg, M.D., M.P.P., of the RAND Corporation, Boston, and colleagues measured associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, a multipayer medical home program, and changes in the quality, utilization, and costs of care. Pilot practices could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). Thirty-two volunteering primary care practices participated in the pilot (conducted from June 2008 to May 2011). Using claims data from 4 participating health plans, the researchers compared changes in care (in each year, relative to before the intervention) for 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices. Measured outcomes included performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care.

Pilot practices successfully achieved NCQA recognition and reported structural transformation on a range of capabilities, such as use of registries to identify patients overdue for chronic disease services (increased from 30 percent to 85 percent of pilot practices) and electronic medication prescribing (increased from 38 percent to 86 percent). Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention.
Of the 11 quality measures evaluated, pilot participation was significantly associated with greater performance improvement, relative to comparison practices, on only l measure: monitoring for kidney disease in diabetes. There were no other statistically significant differences in measures of utilization, costs of care, or rates of multiple same-year hospitalizations or emergency department visits.

The authors conclude that "a multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years."
"Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found that transforming primary care practices into medical homes produces measurable improvements in the quality and efficiency of care."

The authors add that their "findings suggest that medical home interventions may need further refinement."
(doi:10.1001/jama.2014.353)

Editor's Note: This study was sponsored by the Commonwealth Fund and Aetna. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.
Editorial: The Patient-Centered Medical Home - One Size Does Not Fit All

"Before confidently promoting the patient-centered medical home (PCMH) as a core component of health care reform, it is necessary to better understand which features and combination of features of the PCMH are most effective for which populations and in what settings," writes Thomas L. Schwenk, M.D., of the University of Nevada School of Medicine, Reno, in an accompanying editorial.

"The identification of specific PCMH features for various risk strata will likely have significant influence on the work patterns of physicians, who may be responsible for a larger panel of patients than currently but for whom only routine care is needed, often by other members of the health care team. The physician's time and expertise will be best focused on a relatively small number of the most complex and expensive patients."
(doi:10.1001/jama.2014.352)

http://www.healthnewsdigest.com/news/Research_270/Medical-Homes-and-Quality-of-Care-Costs.shtml

Norwalk physical therapist charged on 46 counts of fraud, as well as obstruction of an audit.

Written by Aaron Boyd.

A Norwalk physical therapist was arrested Monday on 46 counts of health care fraud and one count of obstruction of a federal audit.

Danielle Faux, 46, of Weston, owns and manages a physical therapy operation, Danielle Faux PT, LLC, and is also part owner in Achieve Rehab and Fitness gym, both on Lois Street in Norwalk.

According to court documents, Faux would refer clients to Achieve Rehab and Fitness for personal training sessions but bill them through Medicare as physical therapy. 

Documents also allege that Faux fabricated and altered patient records before a Medicare audit in August 2009.

Faux was indicted on Feb. 19 and, if convicted, faces 10 years in prison and fines of up to $250,000 for each count of health care fraud — a total of 460 years and $11.5 million — and 5 years imprisonment and a $250,000 fine for the count of obstruction.

Faux pleaded ‘not guilty’ on all charges Monday and was released on $50,000 bond.

http://greenwich.patch.com/groups/police-and-fire/p/physical-therapist-faces-465-years-12m-fine-for-medicare-fraud_50f896ad

Holder, Sebelius tout billions in healthcare fraud recoveries

The U.S. recovered $4 billion last year through healthcare fraud prevention and enforcement efforts, according to a report released Wednesday by Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius.

The report says that the Health Care Fraud and Abuse Control Act (HCFAC) recovered more than $8 for every $1 it spent on healthcare fraud investigations over the last three years, the best ratio in the 17-year history of the program.

“With these extraordinary recoveries, and the record-high rate of return on investment we’ve achieved on our comprehensive health care fraud enforcement efforts, we’re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs,” Holder said in a statement.

The joint effort between the Department of Justice and HHS has recovered more than $19 billion over the last four years, the agencies said.

In addition, the report said the agency strike forces filed 137 cases, charged 345 individuals, secured 234 guilty please, and won 48 trial convictions. All of these are record highs, according to the DOJ and HHS.

“These impressive recoveries for the American taxpayer are just one aspect of the comprehensive anti-fraud strategy we have implemented since the passage of the Affordable Care Act,” Sebelius said in a statement.

Around the time of the passage of the Affordable Care Act, President Obama launched initiatives aimed at rooting out waste and fraud in Medicare and Medicaid, saying that federal overpayments to doctors and hospitals, and other misallocated funds, should be recovered and redirected to patients.

“We’ve cracked down on tens of thousands health care providers suspected of Medicare fraud,” Sebelius continued. “New enrollment screening techniques are proving effective in preventing high risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results – all of which are adding to savings for the Medicare Trust Fund.”

Still, the FBI says that the U.S. spends at least $80 billion a year in healthcare fraud.

http://thehill.com/blogs/healthwatch/health-reform-implementation/199276-holder-sebelius-tout-billions-in-healthcare

Health Literacy means Better Health! Play "2014 Health-e Olympics" Today!

Join Dr. D and Natalie as they host the 2014 Health-e Olympics!

2014 Health-e Olympics

"Welcome to the Village! Dr. D. and Natalie are so honored to be hosting this year's event. TEAM Health needs your help to reach the top of the mountain first! See you at the top..."

If your up for the challenge click the link to launch the game:

2014 Health-e Olympics

District court blocks hospital acquisition of physician practice

• Hogan Lovells
• Robert F Leibenluft, Leigh L Oliver
• USA
• February 13 2014
• 

Decision
Comment

Decision

In the first ever Federal Trade Commission (FTC)-litigated challenge to a hospital system's acquisition of a physician group, the US District Court for Idaho ruled in favour of the plaintiffs (ie, the FTC, the Idaho attorney general and St Alphonsus, a competing hospital system). The plaintiffs challenged St Luke's Health System's acquisition of the Saltzer Medical Group, a 41-physician multi-specialty group, including 16 adult primary care physicians, located in Nampa, Idaho. Among the key issues in the litigation were:

• geographic market definition;
• the likely impact on reimbursement rates; and
• whether the acquisition would facilitate a more integrated healthcare delivery system that would improve healthcare quality and efficiency.

A more detailed findings of fact and conclusions of law were filed under seal to give the parties and third parties an opportunity to object to the disclosure of any material that they deem to be sensitive and confidential.

In the memorandum decision and order, the court recognised that St Luke's strategy to deliver more integrated care by using primary care physicians as care coordinators would lead to improved care in the Treasure Valley, but the court concluded that this more integrated care could be achieved through means other than acquisition of the Saltzer physicians.

Comment

This ruling is important for stakeholders in the healthcare industry, particularly hospitals, health systems and provider groups that are considering affiliations, mergers or consolidations with other provider groups, as well as health plans. Notably:

• the acquisition was not reportable under the Hart-Scott-Rodino pre-merger notification process because the value of the transaction did not exceed the minimum threshold of $70.9 million;
• the geographic market definition for the provision of adult person-centred planning services was hotly contested; and
• both the plaintiffs and St Luke's presented expert testimony on the issue of whether employing physicians was necessary in order to achieve St Luke's strategy for integrated care.

http://www.lexology.com/library/detail.aspx?g=7811a603-37d7-48cc-a766-1e76b0ced27c

Meaningful use incentive payments top $19 billion, 88% of hospitals included

Nearly 88% of eligible hospitals have received a payment for participating in the EHR incentive program, as noted in data shared at a recent Health IT Policy Committee meeting. The payments were either given to providers who could attest to having fully installed and were using EHRs according to meaningful use criteria, or those who had yet to achieve meaningful use but were in the adopt/implement/upgrade phase with their EHR system. Through 2013, more than $19 billion in meaningful use incentive payments had been distributed to eligible professionals and hospitals.

In a meeting held last April, the Health IT Policy Committee laid down some ideas for the continued development of the meaningful use incentive program. Goals for stage 3 of the program — including whether to shift compliance requirements more toward effective use of data and away from technology adoption — was among the topics covered by the committee. For providers who have attested to previous stages of meaningful use, stage 3 compliance could depend more on patient outcomes and disease prevention.

CMS continues to adjust their deadlines to allow for greater participation in the meaningful use program. The agency recently extended both the stage 2 deadline and the reporting period for providers to receive incentive payments for 2013. The decision to prolong stage 2 was due to stakeholder concern that insufficient data would be available to fully assess its effectiveness before moving on to the third stage.

Extending stage 2 will not only give more providers a chance to receive incentive payments while transitioning to the ICD-10 codes, but it will also help define the next stage in the meaningful use process. Specifically, it will allow the policymakers more time to determine reasonable benchmarks to set for stage 3. It also grants vendors additional time to create and adjust their products to better suit providers’ needs.

http://searchhealthit.techtarget.com/healthitexchange/healthitpulse/meaningful-use-incentive-payments-top-19-billion-88-of-hospitals-included/

The new cost of ICD-10 Implementation: $225,000 for small practices and up to $8 million for large practices!

Making the switch from the ICD-9 to the ICD-10 diagnosis code set could cost as much as $225,000 for some small practices and up to $8 million in some large practices, according to a study from the American Medical Association.

Physician offices and hospitals must use the ICD-10 code sets beginning Oct. 1, but the preparation for the switch is taking years and involves hours of staff training, the purchase of new hardware and software, and testing with vendors and payers.

A follow-up report prepared for the AMA by Nachimson Advisors found that in certain cases, implementation costs are nearly three times higher than what the firm predicted in 2008.

In their original report, Nachimson Advisors estimated that it would cost more than $83,000 for a typical small practice (3 physicians, 2 administrative staff) to implement ICD-10, rising to $285,000 for a typical medium-size practice (10 physicians, 1 full-time coder, 6 administrative staff), and about $2.7 million for a typical large practice (100 physicians, 10 full-time coders, 64 administrative staff).

Now those costs are estimated to range from $56,000 to $226,000 for small practices and $213,000 to $824,000 for medium-size practices. And for large practices, implementing ICD-10 could cost anywhere from $2 million to $8 million.

About two-thirds of physician practices are expected to have costs in the upper range of those estimates, according to the AMA.

One reason for the increased cost is new requirements related to the adoption of electronic health records (EHRs). Nachimson Advisors also projects a larger potential for payment disruptions, estimating that 2%-6% of claims could be denied after the Oct. 1 implementation date.

"The markedly higher implementation costs for ICD-10 place a crushing burden on physicians, straining vital resources needed to invest in new health care delivery models and well-developed technology that promotes care coordination with real value to patients," Dr. Ardis Dee Hoven, AMA president, said in a statement. "Continuing to compel physicians to adopt this new coding structure threatens to disrupt innovations by diverting resources away from areas that are expected to help lower costs and improve the quality of care."

The AMA is calling on Health & Human Services secretary Kathleen Sebelius to reconsider ICD-10 implementation. But if the agency sticks to its plan, the AMA has requested several changes to mitigate some of the costs.

For example, the AMA recommends that Medicare provide a 2-year implementation period during which the agency would not be allowed to deny payments based on the specificity of the ICD-10 code provided. And the agency would provide feedback on coding to physicians during this time.

The AMA also is asking Medicare to simplify its claims requirements by adopting a policy that when the most specific ICD-10 code is used, no additional information or attachments will be required before paying the claim.

How Can We Properly Prepare for ICD-10?

Begin by assessing your individual situation and creating a plan of action.

• take your top 50 icd-9 codes and map them
• then look at the different documentation requirements
• create simple templates to start changing documentation habits NOW!
• consider dual coding ( I highly suggest this!)

What Else Should I Be Doing

• talk to your vendors
• begin creating new superbills
• review other practice documents that will need to be updated prior to Oct. 1, 2014
• BUY an ICD-10 book and become familiar with it!

These are simple steps that will reduce your "loss of productivity" and protect your cash flow. 

For more ideas, tips and tricks please visit: www.ermconsultinginc.com

Telemedicine Bolsters ICU Care In Rural Maryland Hospitals

By Rita Rubin

FEB 12, 2014

This story was produced in collaboration with 

An intensive care unit nurse in a small-town hospital on Maryland’s scenic Eastern Shore suspected that a patient had necrotizing fasciitis, the so-called “flesh-eating” disease.

The condition is rare. Even experienced intensive care doctors seldom see it, and, since it was nighttime, no such physician was in the ICU. Pinning down the diagnosis was critical—and in this case Berlin, Md.’s Atlantic General Hospital had back-up.

Doctor Marc T. Zubrow, medical director at the University of Maryland Medical System's eCare, says he can use a bank of monitors to care for up to 100 patients in eight different hospitals all over the state of Maryland. Patients can be visually monitored and their lab tests and medical information are contained on the screens (Photo by Barbara Haddock Taylor/Baltimore Sun).

A critical care doctor 125 miles away was monitoring the patient’s health via voice, video and high-speed data lines constantly streaming information about vital signs, medications, test results and X-rays, a telemedicine service known as Maryland eCare. The physician quickly verified that the patient had the deadly infection and arranged immediate transfer to another hospital with a surgeon who could remove the infected tissue.

Atlantic General is one of Maryland eCare’s six original community hospital clients, which have a total of 72 ICU beds. By the end of the year, the program will go live in three more Eastern Shore hospitals, adding 18 more ICU beds.

Studies have shown that patients do better and leave sooner from ICUs managed by intensivists, another term for critical care doctors. But intensivists are in short supply nationwide, and small community hospitals like Atlantic General have a difficult time recruiting and retaining them, let alone paying their salaries. Connecting intensivists to small ICUs via telemedicine, proponents say, is the next best thing to hiring them.

Telemedicine, the exchange of medical information between sites via electronic communications, is being used not only by ICUs but also by other hospital departments, home health agencies and private doctors’ offices. But skeptics suggest that small ICUs might be able to improve care with less expensive measures. Telemedicine now costs hospitals roughly $40,000 to $50,000 a year for each covered bed. Initially, adaptation of telemedicine in ICUs nationwide was rapid, but a new study suggests it is slowing.

One of Maryland eCare’s 20 intensivists monitors ICU patients from 7 p.m. to 7 a.m. weeknights and for 24 hours on Saturdays and Sundays.  They’re stationed at computers in Maryland eCare’s COR—Central Operations Room—which last year moved from the Christiana Care Health System in Wilmington, Del., to the University of Maryland Medical Center in Baltimore. On weekdays, when the hospitals’ critical care doctors are at work, eCare critical care nurses staff the COR computers.

Physicians and nurses at the University of Maryland can monitor ICU patients using voice, video and high-speed data lines that constantly stream information about their vital signs using a telemedicine service known as Maryland eCare (Photo by Barbara Haddock Taylor/Baltimore Sun).

Critical care specialist Atif Zeeshan and another intensivist work in Atlantic General’s ICU from 7 a.m. to 7 p.m. on alternating weeks, and they’re on call 24/7. Zeehan said he was at first leery of telemedicine. Four years after his eight-bed ICU hooked up with Maryland eCare, Zeehan is a believer. “There have been cases where lives were saved with eCare intervention,” he says. 

Maryland eCare was established with a $3 million grant from CareFirst BlueCross BlueShield, which helped cover capital expenses, such as computer and video connections. Participating hospitals pay Maryland eCare an annual fee for each ICU bed. Other eCare clients are Peninsula Regional Medical Center in Salisbury, Union Hospital in Elkton, Meritus Medical Center in Hagerstown, Calvert Memorial Hospital in Prince Frederick and MedStar St. Mary’s Hospital in Leonardtown.

Zeeshan’s initial skepticism isn’t unusual. “Nobody wants to be dictated to,” acknowledges Marc Zubrow, a critical care and lung specialist and eCare Maryland’s medical director. “An absolutely huge part of my job,” says Zubrow, is to “convince the local medical community that this will not negatively impact patient care and might possibly improve patient care.”

Hospital representatives routinely visit the Baltimore COR, and Zubrow and members of his team regularly visit the community hospitals and “get very close with the local bedside people.”

And sometimes to patients’ families.  Zubrow shared an eCare doctor’s notes about an interaction with a patient’s daughter (stripped of information that could identify the patient). The woman, who’d flown in to be at her critically ill mother’s bedside, arrived  around 3 a.m. and spent a few minutes video-chatting with the eCare intensivist on duty.

“I told her that nothing we do medically is going to improve her mother’s condition or meaningfully prolong her life,” according to the doctor’s notes. “I urged her to allow us to focus on treating her mother’s pain and suffering…I offered my support and told her I would speak with her again at any point tonight.”

Community hospitals say telemedicine helps critically ill patients be treated close to home and family. Even with extra oversight, however, these hospitals are still not equipped to care for all critically ill patients, so telemedicine intensivists help them decide which patients should be transferred.

Telemedicine has helped improve the care of ICU patients says registered nurse Anne Lockhart, who directs the unit at Calvert Memorial. Lockhart says that includes a reduction in the number of patients contracting pneumonia as a result of being on a ventilator.

Since implementing telemedicine, “we dramatically reduced our ICU mortality rate,” says Ed Grogan, vice president of information services and chief information officer at Calvert Memorial.

But Jeremy Kahn is skeptical. An associate professor of critical care, medicine and health policy at the University of Pittsburgh, he says assessing telemedicine’s effectiveness in the ICU is tricky. Comparing mortality rates before and after implementation of telemedicine doesn’t account for the fact that “outcomes in the ICU get better over time, no matter what,” Kahn says.

A better comparison would be to other, less-expensive, measures, such as using more non-physician providers—physician assistants and nurse practitioners—at ICU patients’ bedsides, Kahn said.

While Maryland eCare is adding hospitals, Kahn says adoption of telemedicine in ICUs nationwide is slowing. In a study published online in October by Critical Care Medicine, Kahn and his colleagues found that the number of U.S. hospitals using telemedicine in ICUs increased from 16, or 0.4 percent, in 2003, to 213, or 4.6 percent, in 2010, with usage doubling in the first four years but dropping to average growth of 8.1 percent in the last four.

 “In an era of cost constraints, I feel we need to be simultaneously exploring cheaper ways to get the same outcome,” Kahn says. “That’s not to say we should not explore telemedicine.”

http://www.kaiserhealthnews.org/Stories/2014/February/12/Some-Maryland-hospitals-use-intensivists-to-improve-healthcare.aspx