Is the “Online Health Clinic” the Wave of the Future?

HealthPartners argues that the answer is yes. In a 2013 Health Affairs article, they argue the following:

HealthPartners in Minnesota launched an online clinic called virtuwell in late 2010. After more than 40,000 cases, we report an average $88 lower cost per episode compared with care received in traditional settings, strong indicators of clinical effectiveness, and a 98 percent “would recommend” rating from customers. The possibility of extrapolating such savings to larger volumes of cases is compelling.

Although I believe that there will be some savings from online health clinics, I believe that much of this perceived savings is due to patients sorting. If relatively healthier patients use the online health clinic, then it could be the case that average costs will be lower for those who use the online services simply due to patient sorting. The report does risk adjust for patient comorbidities and other factors.

Risk adjustment, however, is always imperfect. Thus, three confounding factors could bias these estiamtes.

Individuals who are more educated, wealthier, more technologically savvy are more likely to use the online health clinic, but are also more likely to be relatively healthy conditional on observables.
Individuals who use the online clinics may be more likely to seek treatment for less severe cases. If this is the case, then the treatment received during the online clinic may appear cheaper than is really the case since treating this same people in the clinic may have been cheaper than the average patient. Thus, there would still be cost savingings but the magnitude would not be as large.
Whereas the points above mention that there could be differences in the types of patients that use the online services, within each individual preferences for online treatment may vary. The less serious an illness appears to be (i.e., the lower the likelihood urgent care is needed from the patient’s perspective) the more likely individuals will seek online care.
Thus, although online health clinics may save money, extrapolating these savings over the entire population is likely to produce an overestimate.

The demand side of the equation–that patients will demand online access to around the clock medical care–may drive the market (especially for young adults and families) in the future.

Source:

Patrick T. Courneya, Kevin J. Palattao and Jason M. Gallagher. HealthPartners’ Online Clinic For Simple Conditions Delivers Savings Of $88 Per Episode And High Patient Approval. Health Aff February 2013 vol. 32 no. 2 385-392.

Advancing Reform: Medicare Physicians Payments

U.S. Senate Committee on Finance

Testimony | May 14, 2013

By: Kavita Patel

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Chairman Baucus, Ranking Member Hatch and members of the Committee, thank you for this opportunity to highlight ways to advance physician payment reforms in Medicare. The Medicare program retains a strong commitment to provide care to approximately 50 million beneficiaries across the country; a key partner in the provision of this care are the 900,000 healthcare providers who see beneficiaries in medical offices, hospitals, skilled nursing facilities and other settings.[1] Each day, providers work hard to deliver the best care for their patients yet our current payment system falls short time and time again, with financing mechanisms that perpetuate fragmented care and volume over coordination and value. Fortunately, there are better ways to pay physicians that can enable them to improve care, enhance the patient experience and potentially achieve greater savings for the Medicare system overall. I am honored to present some solutions from my work at the Engelberg Center for Health Care Reform at the Brookings Institution and our Merkin Initiative on Clinical Leadership, as a Commissioner on the National Commission on Physician Payment Reform and perhaps most importantly, as a practicing internal medicine physician.[2]

Current Payment Policies in Medicare

Currently, Medicare pays physicians primarily by a fee-for-service (FFS) schedule that is informed by relative value units (RVUs). Relative value units are determined from the Resource Based Relative Value Scale (RBRVS) which defines the value of a service through a calculation of physician work, practice expense and practice liability.[3] A relative value unit is assigned to every medical service that physicians carry out during a clinical visit. [4] The RVU is then adjusted by geographic region (so a procedure performed in Miami, Florida is worth more than a procedure performed in Salem, Oregon). This value is then multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment to the physician. As the number of billable service codes have grown over time, an extensive regulatory process was enacted to develop RVU weights and update them year over year.

Over time, the RVU updating system has placed an increasing importance, evidenced by RVU weights, on procedures, scans, and other technical services that fix certain ailments or problems. Emphasis on technologies and interventions have resulted in a marked disparity between reimbursement for specialties which emphasize procedures such as cardiology and gastroenterology and those that do not such as primary care, endocrinology or infectious diseases, thus exacerbating shortages and the hierarchical culture within medicine.

The 1997 Balanced Budget Act exacerbated the problem with the introduction of the sustainable growth rate or SGR. The SGR was intended to keep the growth in Medicare physician-related spending per beneficiary in line with growth in the nation’s gross domestic product (GDP). In the early years of the SGR, this worked fine, as spending growth was lower than the calculated GDP target and payment rates for physician services increased. But starting with the recession in 2002, spending growth per beneficiary began to exceed GDP growth. In 2002, payment rates were reduced accordingly, by 4.8 percent.

Every year since then, the scheduled SGR payment rate reductions have not taken full effect. Instead, because of concerns about access to care and the sufficiency of payments, Congress has headed off the full payment reductions on a short-term basis. Typically, this has involved offsetting at least some of the budgetary costs with payment reductions affecting other Medicare providers. As Figure 1 illustrates, actual updates as well as the SGR formula update still grow at rates far below input costs (MEI) and payment rates for other providers, thus exacerbating systemic flaws. In short, our system is broken.

Payment Reforms in the Affordable Care Act

The Affordable Care Act included over 100 policy changes in Medicare provider payments, many of which are currently being phased into the current delivery system and affect physicians directly. [5] These reforms include Medicare Accountable Care Organizations (ACOs), Value-based payment modifiers, the Bundled Payments for Care Improvement initiative as well a number of broader efforts for statewide level innovation, multipayer efforts to promote primary care and alignment of payments for Medicare-Medicaid beneficiaries (dual eligibles). These reforms are incredibly effective at encouraging providers to delivery high-quality, coordinated care at a lower cost and enable Medicare to pay for value. As Jonathan Blum, Acting Deputy Administrator and Director of the Center for Medicare recently pointed out in his testimony before this committee, “the Medicare program has been transformed from a passive payer of services into an active purchaser of high-quality, affordable care.” [6] While these reforms will offer a great deal of insight into how we can improve Medicare physician payment through authorities granted in the Patient Protection and Affordable Care Act, they are still largely based on a fee-for-service payment system. We must acknowledge the limitations in implementing payment reforms in the face of a dominant fee-for-service system. One early large-scale Medicare pilot implemented in oncology in 2006 serves as a good example: in conjunction with reductions in Part B drug payments, oncologists received an additional payment to report on whether the chemotherapy care provided by them adhered to certain evidence-based guidelines. This promoted comparisons to the published guidelines and also supported the development of evidence on how widely published guidelines were being followed in practice. [7] However this pilot did not make any changes in the underlying structure of fee-for-service payments and did not explicitly tie payments to measured improvements in performance, resulting in limited feasibility and adoption. In order to move away from our current system and build on the promise of ongoing efforts we must remove the SGR as a constant impediment to true systemic change.

Recommendations of the National Commission on Physician Payment Reform

In an effort to explore new ways that to pay for care that can yield better results for both payers and patients, the Society of General Internal Medicine convened the National Commission on Physician Payment Reform in 2012. Our commission, composed of a broad range of leadership and expertise spanning the public and private sectors, adopted twelve specific recommendations for reforming physician payment:

1. The SGR adjustment should be eliminated
2. The transition to an approach based on quality and value should start with the testing of new models of care over a 5-year time period and incorporating them into increasing numbers of practices, with the goal of broad adoption by the end of the decade.
3. Cost-savings should come from within the Medicare program as a whole. Medicare should where possible, avoid cutting just physician payments to offset the cost of SGR repeal, but should also look for savings from reductions in inappropriate utilization of Medicare services.
4. The Relative Value Scale Update Committee (RUC) should continue to make changes to become more representative of the medical profession as a whole and to make its decision-making more transparent. CMS has a statutory responsibility to ensure that the relative values it adopts are accurate and appropriate, and therefore it should develop alternative open, evidence-based, and expert processes beyond the recommendations of the RUC to validate the data and methods it uses to establish and update relative values.
5. For both Medicare and private insurers, annual updates should be increased for evaluation and management codes, which are currently undervalued, and updates for procedural diagnosis codes, which are generally overvalued and thus create incentives for overuse, should be frozen for a period of three years. During this time period, efforts should continue to improve the accuracy of relative values, which may result in some increases as well as some decreases in payments for specific services.
6. Fee-for-service contracts should always include a component of quality or outcome-based performance reimbursement.
7. Higher payment for facility-based services that can be performed in a lower cost setting should be eliminated. Additionally, the payment mechanism for physicians should be transparent, and should reimburse physicians roughly equally for equivalent services.
8. In practices having fewer than five providers, changes in fee-for-service reimbursement should encourage methods for the practices to form virtual relationships and thereby share resources to achieve higher quality care.
9. Over time, payers should largely eliminate stand-alone fee-for-service payment to physicians because of its inherent inefficiencies and problematic financial incentives.

10.  Because fee-for-service will remain an important mode of payment into the future even as the nation shifts to fixed-payment models, future models of physician payment should include appropriate elements of each. Thus, it will be necessary to continue recalibrating fee-for-service payments, even as the nation migrates away from that method of paying physicians.

11.  As the nation moves from a fee-for-service system to one that pays physicians through fixed payments, initial payment reforms should focus on areas where significant potential exists for cost savings and higher quality.

12.  Measures should be put into place to safeguard access to high quality care, assess the adequacy of risk-adjustment indicators, and promote strong physician commitment to patients.

Moving Beyond the SGR

Eliminating the SGR is a principal recommendation of many expert reports, including our Commission’s Report, MEDPAC, The Brookings Institution, Simpson-Bowles and the Bipartisan Policy Center, but the question remains, repeal and replace with what? [8][9]^,[10]As stated above we (and other clinical groups and societies) recommend a five year transition to newer models of payment which move away from FFS as the dominant payer. But the devil is in the details, and proposals to move towards new models over a period of time leaves policymakers and physicians wondering what their practices will look like next month, next year and beyond. In moving from principle to practice, it is also important to acknowledge that while there will be no one payment model that applies to all physicians, payment models must be relevant to primary care physicians and specialists alike. Additionally, given the growing complexity of caring for Medicare beneficiaries, payment models should encourage collaborations between specialists and primary care physicians rather than focus on a model that is suited for one clinical specialty alone.

Short-Term Steps in Advancing Payment Reforms

To facilitate providers’ transition to alternatives to fee-for-service payments, CMS should harmonize current payment adjustments and quality improvement initiatives and apply those funds towards a care coordination payment which could give physicians more support for broader long-term reform pathways. Medicare has implemented quality reporting systems and payment adjustments for physicians, hospitals, and other providers. But these payments are generally administered as either a flat percentage or adjuster to all FFS payments. In contrast, shifting some existing FFS payments into a care coordination payment would give providers more support in moving toward condition-based, episodic payments, or global payments that allow for management of a population of payments that would otherwise be impossible in the current payment setting.

Table One highlights current efforts within the Medicare to increase value in care; each initiative is important but in isolation results in marginal financial gains and at times and each of these initiatives is limited in scope. For example, quality measures for the Physician Quality Reporting System (PQRS) have flexible annual submission options, with qualification through registries, electronic health records etc. However, the program has suffered from criticism that measures are not as relevant to specialists. And at best, providers will gain approximately an average of $1059 for participation per year, which some might say is not worth the effort, even in a penalty phase of the program. With the passage of the American Taxpayer Relief Act of 2013, a mechanism will be in place by 2014 for specialty specific efforts to satisfy CMS’ reporting requirements for PQRS, which will encourage higher specialist participation in quality improvement efforts and help align clinician-developed quality measures with CMS’ mandate to examine quality of patient care. Applying these measures to help physicians understand how registries can not only benefit their patients but lead to better predictability in a changing payment landscape will facilitate entry into pathways of reform.

Meaningful use measures are also quite detailed with important process metrics but physicians will likely also “perform to the measure” and may have difficulty going beyond unless there are linkages to payment reform. This is reflective of the sentiment that many providers express that they are constantly being asked to measure and perform, all while trying to see just as many patients in a day of work with little to no reward for doing less or changing workflows in order to reduce inappropriate utilization of resources. For example, proposed Stage 2 meaningful use measures include 17 core measures and six additional menu objectives from which a physician would choose at least three. This adds up to a total of 20 distinct actions that often involve all office staff. Rather than adding to these measures, CMS should consider how existing measure components could be applied to a payment update overall or a care coordination payment for the care of a patient with a chronic disease.

In the case of a care coordination payment, providers who opt to enter into a care coordination pathway in the first year can receive a lump sum of payment. This payment would be roughly equivalent to the potential bonus payments for all programs in table one. In return they would have to demonstrate that they are improving clinical practice and implementing outcomes-based clinical measures which are germane to their practice. In this example, a cardiologist would receive a population level care coordination payment derived from bonus payments and some FFS payments who does the following:

• Participates in a care coordination pathway for chronic cardiac disease (atrial fibrillation, congestive heart failure, etc)
• Subscribes to a cardiac specific registry (thus meeting PQRS requirements)
• Implements patient engagement tools for electronic care coordination, medication reminders, therapeutic lab monitoring for anticoagulation (meeting requirements for meaningful use, value-based modifier program, e-prescribing)
• Implements a significant practice transformation (potentially a new component which allows for a physician in a small, medium or large practice to individualize their approach to innovation)

The cardiologist would satisfy program requirements and would receive the maximum bonus payments.

Implementing this kind of approach involves potentially supporting CMS and additional entities to provide data on performance measures and quality improvement at more regular intervals along with technical assistance to understand how to translate incoming data into practice transformation. This process can begin in the year following a SGR repeal and can be supported through the assistance of existing clinical societies and quality improvement organizations. In this manner, assumption of clinical and performance risk becomes more commonplace for physicians. Simply put, physicians understand that they need to be held accountable for payment in a standard fashion, but want to feel that they can bring some degree of personalization into their practice in order to meet the needs of their populations.

Finally, I encourage CMS to continue implementing important changes through the Physician Fee Schedule including recent changes for care coordination.[11] These changes are an important acknowledgment that while we migrate from a payment system dominated by fee-for-service, we need to also enhance the existing system to be aligned with the expected outcomes of policy changes. Recent calls for evaluating the distribution of evaluation and management codes and determining the accuracy and appropriate valuation are also an important step in the short term.

Movement from The Short Term to Longer Term Sustainable Payment Reforms

As clinicians of all specialty types realize that there is a viable pathway to care for patients and work across silos. The appetite for a more attractive option is evidenced by the overwhelming response to applications for the CMMI Challenge Grants, BPCI initiative, Medicare Shared Savings Program and other efforts. Clearly, physicians want an alternative.

Through my work at the Brookings Institution’s Engelberg Center for Health Care Reform and the Richard Merkin Initiative on Clinical Leadership, we have been meeting with physicians in primary care and specialties as well as other healthcare stakeholders. With iterative feedback from clinicians in practice, we have proposed a longer term payment model that takes into account the currently uncompensated critical elements of patient care, the need for more flexibility in the way physicians are able to use their time and treatment resources in the best interest of their patients’ individual circumstances, and the need to implement care reforms in a way that recognizes the intense and growing cost pressures in our health care system.

Our model, outlined in Figure 2, would build on the short term payment advances above with incorporation of a payment for care coordination that is derived from the programs in Table One and identify additional opportunities to improve care and lower costs that are not reimbursed well in traditional fee-for-service payment systems. For example, a common procedure in the outpatient cardiac practice is the echocardiogram (echo), or ultrasound of the heart. This procedure is sometimes performed in place of preventive counseling or watchful monitoring of a patient in coordination with a primary care physician, in large part because a hospital-based outpatient cardiology practice receives up to $450 for an echo compared to $53 for a visit without the procedure. Imagine paying both the cardiologist and primary care physician a fixed payment of $400 that allows for longer term communication and conservative monitoring in return for reporting on clinical outcomes at a population level. The clinicians are take the financial risk involved in the clinical care of their patient using the investments previously made by clinically driven pathways, registries and care coordination solutions.

Column A represents total spending on health care and reflects the current state of physician payment: exclusive reliance on the FFS model for physician payments, with waste and inefficiency in the form of redundant and unnecessary care, breakdowns in coordination, escalation of preventable complications etc. This leaves the total cost of physician care high.

Column B illustrates total spending in our alternative payment model. First, a set of services currently reimbursed for a particular episode of care or part of chronic care management are bundled together into a single payment to physicians as a case management payment. For example in clinical oncology a case management payment would include after hours phone care for breast cancer or a palliative care counselor for patients with lung cancer. This enables clinicians to focus less on volume and more on tighter coordination among providers and settings for patients. In addition, we continue the aforementioned care coordination payment paid to physicians, which is built on concepts such as PQRS/ MU and actuallyincreases the current level of physician payment relative to the fee-for-service baseline in Column A. Care coordination payments allow flexibility for physicians to invest in clinical practices and infrastructure through practice transformations that maximizes their ability to treat patients in clinically appropriate ways while not reducing their income due to reductions in billable procedures that would otherwise occur. The investments in clinical practice can include infrastructure/HIT investments or in the case of a small practice, an investment in a shared clinical social worker with other small practices with similar patient populations.

Continuous quality improvement resulting from adherence to clinician-driven process and outcomes measures and the increased flexibility in income will push physicians to decrease and ultimately eliminate the waste and inefficiencies that plague the current system. Overall physician payments increases, offset by reductions in total Medicare spending and system wide savings. Care coordination payments that enhance total physician income tied to quality measures would encourage physicians to collaborate and focus on elements of patient care that reduce cost and inefficiencies across the spectrum. In oncology, for example, we do not specify which metrics should be used in which case but comment that target metrics would change over time and as efficiency is maximized in certain areas of care (i.e. ED visit rates) bonus payments would not cease because of lack of room for improvement. Measures would have to be selected with flexibility to accommodate various provider circumstances and changes in the long term improved performance in certain areas.

Physicians who enter into broader accountable care arrangements in which there is a shared savings component will likely find that this model could lead to an increased proportion of shared savings beyond the 2% threshold; therefore our described model would not be mutually exclusive to ACO arrangements, but could enhance them given the decreased reliance on fee-for-service reimbursement.

Tools that Enable Financial, Clinical and Performance Risk

As I have mentioned earlier, physicians will need tools to better understand risk- these are not lessons we had in medical school or in clinical training. Financial metrics (such as those available to ACOs), performance metrics in the form of actionable and regular data feeds as well as peer-led initiatives should be considered essential components of a payment reform package.

Conclusion

Our nation is in a sustained period of constrained finances and while the cost to repeal the SGR has been decreased to $138 billion, finding the offsets and mechanism to pay for such a solution will not be easy. But it is essential that this Committee seize the opportunity to finally dispel the notion that we allow for a system that rewards the balkanization of our patients through a payment mechanism which promotes volume over value. I commend Senators Baucus and Hatch in their recent call for proposals and specific suggestions from the clinical community and look forward to working with the Committee to identify a tangible path forward. Thank you for this opportunity and I look forward to your questions and comments.

Dovetail Health Introduces In-Home Pharmacist Program

Dovetail Health Introduces In-Home Pharmacist Program to help Medicare Advantage Plans Improve Star Ratings

NEEDHAM, Mass. -- 

Dovetail Health is pleased to announce its Star Rating Improvement Program that helps Medicare Advantage health and prescription drug plans enhance their star ratings through an in-home pharmacy solution that targets the closure of key gaps in care for health plan members. With increased financial and quality pressures placed on health plans by CMS, strong star ratings are more important than ever before.

Dovetail’s innovative solutions provide critical support to the highest risk members where they need it most- at home. Dovetail integrates seamlessly with its health plan clients, ensuring the highest quality of care and consistent outcomes. This proactive approach focuses on several of the most heavily weighted star measures for prevalent chronic diseases such as diabetes and hypertension along with a primary focus on pharmacy related measures. And, adherence measures are carefully monitored over time.

Star Rating Improvement Program

Dovetail’s clinical model for its Star Rating Improvement Program involves sending highly trained pharmacists into members’ homes to conduct Comprehensive Medication Reviews, (“CMR”), and generate reports that help members to be compliant with essential quality metrics. Dovetail’s report meets CMS guidelines to ensure that plans receive credit for the CMR’s that Dovetail completes.

The pharmacist provides a written report and telephonic follow up with prescribing physicians to discuss any recommendations for a member’s prescriptions. This information is invaluable to physicians, enabling them to better understand specific factors such as social and financial issues that are impacting their patients at home. Following the initial home visit, the pharmacist will call members to ensure recommendations are followed and any new prescriptions are filled. Dovetail Pharmacists provide more acute members with telephonic and in-home consultations as needed.

To operate efficiently and consistently, Dovetail utilizes a proprietary health management software system exclusively designed to assess members’ gaps in care while managing every facet of program delivery. Furthermore, Dovetail provides plans with data from its system to ensure they receive proper credit for the star measures addressed by Dovetail.

According to Stever Aubrey, CEO of Dovetail Health, "We give our pharmacists the training and tools they need to deliver effective and consistent results with every member they see, and we ensure that the information we collect is shared with all the key stakeholders.”

Dovetail’s pharmacists coordinate closely with members’ physicians and other caregivers which is critical to the success of the program. Diane Gilworth, NP, Chief Clinical Officer at Dovetail Health adds, "At Dovetail, our pharmacists provide valuable, actionable information to physicians in order to optimize medication regimens, close gaps in care, and ultimately improve Star Ratings.“

Dovetail Health is a leading provider of healthcare solutions, focused on improving quality of care and reducing cost to high risk patients in the place where they need it most - in their own homes. Combining trusted in-home pharmacists with proprietary technology systems, Dovetail delivers significant clinical and financial outcomes for its health plan, provider group, ACO, and hospital partners. For more information, visit www.dovetailhealth.com.

Codesmart(TM) Group's CODESMART(TM) UNIVERSITY Clinician ICD-10 Courses Receive Approval for Continuing Education

Codesmart(TM) University Setting Industry Standards for ICD-10 Accreditation

NEW YORK, May 14, 2013 (GLOBE NEWSWIRE) -- First Independence Corp, with its subsidiary, The Codesmart™ Group, Inc. (OTCQB:FICF) (collectively, "Codesmart™"), a newly publicly traded ICD-10 education and solutions group that offers CODESMART™ UNIVERSITY, its on-line training solution and customizable training solutions, announces today that its CODESMART™ UNIVERSITY programs of study are now eligible for Continuing Education Units ("CEU") for existing coders, as certified by the two major certification bodies for medical coding, the Association of Professional Coders ("APPC") and the American Health Information Management Association ("AHIMA").

"With the two best recognized licensing organizations offering CEU credit, which medical coder members are required to obtain on a yearly basis in order to maintain their certifications, this is an acknowledgement that CODESMART™ UNIVERSITY may be considered the "Gold Standard" of ICD-10 education," said Ira Shapiro, Chairman and CEO of Codesmart™. "Our methodology is integrated and flexible and it allows for any kind of adult learner to succeed in learning this information in any of our programs of study whether they are physicians, nurses, medical coders, or a new student looking to embark on a career in medical coding."

ICD-10, or the tenth revision of the International Classification of Diseases is a World Health Organization-approved designation of the aspects of disease treatment that include categories of diseases and treatment modalities for them, broken down into more than 141,000 designations. The previous ICD had only 17,000 codes, diagnoses and procedures. The United States is among the last countries in the world to adopt these standards, but the Department of Health and Human Services has mandated that all medical practices, hospitals and other medical record keeping organization be trained and ICD-10 compliant by October 1, 2014. This is essential as the Center for Medicare and Medicaid services will also be adopting the ICD-10 standard and will require proper medical coding in order to provide reimbursement.

AAPC was founded in 1988 to provide education and professional certification to physician-based medical coders and to elevate the standards of medical coding by providing student training, certification, ongoing education, networking, and job opportunities. Since then, AAPC has expanded beyond coding to include training and credentials in documentation and coding audits, regulatory compliance, and physician practice management. Currently, AAPC has a membership base of 121,000 worldwide, of which more than 90,000 are certified.

AAPC credentialed coders have proven mastery of all code sets, evaluation and management principles, and documentation guidelines. CPC's and other AAPC credentialed coders represent the best in outpatient coding.

Celebrating its 85th anniversary this year, the AHIMA represents more than 67,000 educated health information management professionals in the United States and around the world. AHIMA is committed to promoting and advocating for high quality research, best practices and effective standards in health information and to actively contributing to the development and advancement of health information professionals worldwide. AHIMA's enduring goal is quality healthcare through quality information.

About First Independence Corp. and The Codesmart Group, Inc.

First Independence Corp, with its subsidiary, The Codesmart™ Group, Inc. (OTCQB:FICF) is a premier national subject matter expert for ICD-10 education and compliance in the United States. Its product, CODESMART™ UNIVERSITY is an on-line program of study for existing coders, new coders, clinicians, and healthcare roles of all types. Created by a combination of a leading panel of ICD-10 subject matter experts and a major four-year accredited University, which contributed the nation's top course designers and a platform that already provides interactive education to more than 60,000 students per year in degree programs. The ICD-10 training also includes live professors who work with and guide students through the programs of study in ICD-10.

CODESMART™ UNIVERSITY is endorsed by over 60 colleges and Universities nationwide for their quality of education. The CODESMART™ Group, Inc. also provides solutions for ICD-10 transitions, outsource coding, coding audits, critical documentation improvement and the revenue cycle continuum. To learn more about CODESMART™ UNIVERSITY's proprietary programs, visit www.codesmartuniversity.org.

CONTACT: Company Contact:
         Ira Shapiro
         CEO and Chairman
         First Independence Corp.The Codesmart Group, Inc.ishapiro@codesmartgroup.com
         646-526-7867

         Investor Contact:
         David Brionesdbriones@briofinancial.com
         908-370-5102

Read more: http://www.nasdaq.com/article/codesmarttm-groups-codesmarttm-university-clinician-icd-10-courses-receive-approval-for-continuing-education-units-by-top-two-medical-coding-associations-20130514-00463#ixzz2TKQwaj8X

U.S. charges 89 people with healthcare fraud

U.S. Attorney General Eric Holder refers to his notes during testimony before the Senate Judiciary Committee on Capitol Hill in Washington, March 6, 2013.

Credit: Reuters/Jonathan Ernst

WASHINGTON | Tue May 14, 2013 4:26pm EDT

(Reuters) - U.S. Attorney General Eric Holder said on Tuesday the Department of Justice had charged 89 defendants in eight cities with healthcare fraud, and warned that budget cuts could limit future efforts to crack down on fraudulent claims.

The government's sixth national crackdown on healthcare fraud since 2010 involved $223 million in fraudulent claims in jurisdictions including Miami, Detroit, Los Angeles and Brooklyn, New York, the Justice Department said.

But Holder said efforts to expand the battle against fraud is being affected by automatic across-the-board federal budget cuts, known as sequestration, which have stripped $1.6 billion in funding from the Justice Department for the fiscal year ending September 30.

"Unless Congress adopts a balanced deficit reduction plan and stops the reductions currently slated for 2014, I fear our capacity to protect the American people from healthcare fraud ... will be further reduced," Holder said.

Since 2007, officials say the government's Medicare Fraud Strike Force has charged more than 1,500 defendants who have falsely billed the Medicare program for the elderly and disabled for $5 billion.

(Reporting By Susan Heavey and David Morgan; Editing by Sandra Maler and John Wallace)

NHS clinicians save up to 45 minutes a day through simplified access to patient data

Even in some of the most digitally advanced hospitals and clinics I visit, I frequently hear clinicians grousing about access to patient care data and systems. It’s not unusual for todays’ healthcare settings to have multiple repositories of patient data in different departmental systems like admissions, lab, radiology, and pharmacy. Doctors and nurses complain about all the time they spend logging into and out of various applications over and over again as they go about their clinical day. Sometimes this involves using different passwords for different applications. Things can get even more complicated as clinicians move from one area of the hospital to another, and especially from one device to another such as moving from a desktop, to a tablet or maybe a smartphone. All of this takes away precious time in caring for their patients. But what if they could avoid all that by using a desktop solution that simplified access to multiple applications and patient records, and was even capable of following the clinician across multiple devices? Even better, what if that solution actually did save time, on average 30 to 45 minutes per day! That is just what has happened  with a solution developed by Microsoft and OCSL, a long term supplier of IT solutions to the healthcare sector, for Luton and Dunstable NHS Foundation Trust Hospital in the UK.

Located in Bedfordshire, Luton and Dunstable Hospital houses 700 beds with over 4,000 members of staff. The solution developed for the hospital by Microsoft andOCSL is called asseSSOnce. It provides users with one clinical desktop solution that layers over all existing applications. It is capable of working across desktop, laptop and tablet devices and creates a virtual desktop that allows session persistence from the office, to the patients’ bedsides, to the outpatients’ clinic. This makes it easier for clinicians to securely access data while making their rounds, confident that the information they are acting on remains consistent across devices. This mobile device-neutral environment also provides a starting platform for the hospital’s Bring Your Own Device (BYOD) scheme and allows it to push ahead with plans to provide clinicians with tablet devices that can provide the interface via Windows 8 to the clinical teams.

Mark England, Director of Information Management and Technology, Luton and Dunstable NHS Hospital, said: “Speaking to staff we found that their biggest frustration was having to enter a password and select the patient for every system. acceSSOnce eliminates this time consuming process and makes it much simpler to securely access information when moving around the hospital. This improves the lives of our clinicians and increases the amount of time they can spend treating patients and providing care. On top of this we can take a stronger line with regard to information security and governance as we now have a much improved audit trail on access to our applications. acceSSOnce has revolutionized how we look at results. Instead of logging onto different systems, we log in once and look at all of the results in one go, saving us time and making us more efficient. Any additional time saved by being able to manage patients more efficiently means we’ll have more time to ensure we’re discharging our patients safely.”

Jane Ayres, Director of OCSL, said: “As Luton and Dunstable has shown, acceSSOnce can have a significant impact on the lives of clinicians. Forty-five minutes a day could translate to three additional patient visits. Over the course of a year, that means one clinician could treat roughly 800 more patients. Multiply that across the hospital’s entire clinical staff and that number grows exponentially again. At a time when budgets are being continually squeezed, acceSSOnce offers a simple way to improve productivity and patient care, by alleviating the administrational burden of those on the frontline.”

When it comes to driving adoption of IT solutions that impact clinical workflow, nothing is more important than delighting end-users. Solutions that add work and take away time from patient care will always be unpopular with clinical staff. I’ve always found that giving back time is its own reward—a reward that is always welcomed by busy doctors, nurses and other clinicians.

What are the Financial and Operational Impacts of ICD-10?

Written by Anuja Vaidya  | May 12, 2013

At the Becker's Hospital Review Annual Meeting in Chicago on May 11, Deborah Grider, senior manager of revenue cycle at Blue and Co., and Laura DeBusk, senior director of business development at White Plume Technologies, discussed the financial and operational impact of ICD-10.

According to Ms. Grider, the only way for healthcare organizations to minimize financial losses is to document properly. "Documentation drives everything," she said. Currently, common problems in documentation include lack of specificity and illegible physician handwriting. Physicians need to be trained to be able to document effectively for ICD-10. Clinician documentation improvement programs should include a physician advisor to help train, and education opportunities for ICD-10 should be maximized in those programs. "Ultimately, documentation translates to revenue," she said.

Operationally, the dip in physician productivity is going to be the hardest thing for healthcare organizations to deal with. Ms. DeBusk also warned that clinicians will have to be trained so as to be able to use the new technology and new coding, and the processes that they had been using, that have become almost muscle memory to them, will have to be thrown out the window. Nurses will have to learn how to document with new types of forms, and front desk staff will have to learn how to use new technology. "With ICD-10, for the first time, paper won't be faster than computers," Ms. DeBusk said.

Another operational impact that organizations will face is payor readiness for ICD-10, said Ms. DeBusk. Most payors say they will meet the deadline, but some may not, and organizations need to figure out if their payor will be ready. As payors make changes to their systems, operations will slow down on their end as well, which organizations will have to prepare for. Ensure that your healthcare organization knows how to respond to payor issues with ICD-10, she said.

© Copyright ASC COMMUNICATIONS 2012.

Senators Want Provider Feedback on Medicare Payments

Senators Want Provider Feedback on Medicare Payments

Senators Want Provider Feedback on Medicare Payments

Margaret Dick Tocknell, for HealthLeaders Media , May 14, 2013

Leaders of the Senate Finance Committee are asking doctors to answer questions about the physician fee schedule and changes that would be necessary to accommodate alternative payment models.

In advance of a "doc fix" repeal hearing scheduled for Tuesday, the Senate Finance Committee has reached out to more than 100 healthcare providers for specific recommendations on how to improve Medicare's physician payment system.

In a co-signed letter Sen. Max Baucus (D-MT), committee chair, and Sen. Orrin Hatch (R-UT), ranking member, call for "a permanent solution that will address the SGR and physician payment reform."  

Physicians face a 25% payment reduction in 2014 under the current sustainable growth rate formula. Congress has tried and failed to repeal it for years.

The senators are looking to healthcare providers for help, emphasizing that "comments containing specific suggestions will be the most valuable to the committee." Physicians and other providers are asked to respond to three questions:

1. What specific reforms should be made to the physician fee schedule to ensure that physician services are valued appropriately?
2. What specific policies should be implemented that could co-exist with the current FFS physician payment system and would identify and reduce unnecessary utilization to improve health and reduce Medicare spending growth?
3. Within the context of the current FFS system, how specifically can Medicare most effectively incentivize physician practices to undertake the structural, behavioral and other changes needed to participate in alternative payment models?

Stakeholders have until May 31 to provide responses. What happens after that is anyone's guess. No timetable for future action has been released.

Although there is widespread agreement that the SGR is flawed and needs to be replaced, In a longstanding delay tactic,  Congress has long opted to intervene on an annual basis to prevent physician payment cuts rather than develop a permanent solution. A bipartisan-sponsored  repeal bill introduced in February has the support of  the AMA and the American Academy of Family Physicians among other key physicians groups.

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A Congressional Budget Office analysis released in February 2013 slashed $107 billion from the cost of eliminating the SGR and is credited with resuscitating efforts to repeal the unpopular formula. Whether the seemingly significant financial incentive is enough to overturn the SGR remains to be seen.

Last week the House Ways and Means subcommittee on Health spent several hours exchanging ideas about reforming the SGR with a group of influential healthcare stakeholders. At this point it's difficult to imagine what new information remains to be discovered.

The House Ways and Means Committee sent a similar letter in April 2012 to the American Medical Association and the Medical Group Management Association. In their responses, the AMA and MGMA identified possible alternative payment models, including performance-based and bundled payments.

Baucus and Hatch hosted a number of roundtables about Medicare payments in 2012 that featured physicians, former administrators of the Centers for Medicare & Medicaid Services, and private payers. While those meetings covered a wide range of topics, including models of care, specialty reimbursements, and quality and efficiency, no magic bullets were identified.

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Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media. 

Expanded Coverage for Diabetes Outpatient Self- Management Training Services and Supporting Regulations (CMS-R-247)

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Centers for Medicare & Medicaid

Services

[Document Identifiers: CMS–R–70, CMS–R–

72, CMS–R–247, CMS–10287, CMS–R–43,

CMS–855(POH), CMS–2552–10, and CMS–

10062]

Agency Information Collection

Activities: Proposed Collection;

Comment Request

AGENCY: Centers for Medicare &

Medicaid Services, HHS.

In compliance with the requirement

of section 3506(c)(2)(A) of the

Paperwork Reduction Act of 1995, the

Centers for Medicare & Medicaid

Services (CMS) is publishing the

following summary of proposed

collections for public comment.

Interested persons are invited to send

comments regarding this burden

estimate or any other aspect of this

collection of information, including any

of the following subjects: (1) The

necessity and utility of the proposed

information collection for the proper

performance of the agency’s functions;

(2) the accuracy of the estimated

burden; (3) ways to enhance the quality,

utility, and clarity of the information to

be collected; and (4) the use of

automated collection techniques or

other forms of information technology to

minimize the information collection

burden.

1. Type of Information Collection

Request: Reinstatement with a change of

a previously approved collection; Title

of Information Collection: Information

Collection Requirements in HSQ–110,

Acquisition, Protection and Disclosure

of Peer review Organization Information

and Supporting Regulations in 42 CFR,

Sections 480.104, 480.105, 480.116, and

480.134; Use: The Peer Review

Improvement Act of 1982 authorizes

quality improvement organizations

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Federal Register /Vol. 78, No. 91 / Friday, May 10, 2013 /Notices 27401

(QIOs), formally known as peer review

organizations (PROs), to acquire

information necessary to fulfill their

duties and functions and places limits

on disclosure of the information. The

QIOs are required to provide notices to

the affected parties when disclosing

information about them. These

requirements serve to protect the rights

of the affected parties. The information

provided in these notices is used by the

patients, practitioners and providers to:

obtain access to the data maintained and

collected on them by the QIOs; add

additional data or make changes to

existing QIO data; and reflect in the

QIO’s record the reasons for the QIO’s

disagreeing with an individual’s or

provider’s request for amendment.:

Form Number: CMS–R–70 (OCN: 0938–

0426); Frequency: Reporting—On

occasion; Affected Public: Business or

other for-profits; Number of

Respondents: 400; Total Annual

Responses: 21,200; Total Annual Hours:

42,400. (For policy questions regarding

this collection contact Coles Mercier at

410–786–2112. For all other issues call

410–786–1326.)

2. Type of Information Collection

Request: Reinstatement without change

of a previously approved collection;

Title of Information Collection:

Information Collection Requirements in

42 CFR 478.18, 478.34, 478.36, 478.42,

QIO Reconsiderations and Appeals; Use:

In the event that a beneficiary, provider,

physician, or other practitioner does not

agree with the initial determination of a

Quality Improvement Organization

(QIO) or a QIO subcontractor, it is

within that party’s rights to request

reconsideration. The information

collection requirements at 42 CFR

478.18, 478.34, 478.36, and 478.42,

contain procedures for QIOs to use in

reconsideration of initial

determinations. The information

requirements contained in these

regulations are imposed on QIOs to

provide information to parties

requesting the reconsideration. These

parties will use the information as

guidelines for appeal rights in instances

where issues are actively being

disputed. Form Number: CMS–R–72

(OCN: 0938–0443); Frequency:

Reporting—On occasion; Affected

Public: Individuals or Households and

Business or other for-profit institutions;

Number of Respondents: 2,590; Total

Annual Responses: 5,228; Total Annual

Hours: 2,822. (For policy questions

regarding this collection contact Coles

Mercier at 410–786–2112. For all other

issues call 410–786–1326.)

3. Type of Information Collection

Request: Reinstatement with a change of

a previously approved collection; Title

of Information Collection: Expanded

Coverage for Diabetes Outpatient Self-

Management Training Services and

Supporting Regulations Contained in 42

CFR 410.141, 410.142, 410.143, 410.144,

410.145, 410.146, 414.63; Use:

According to the National Health and

Nutrition Examination Survey

(NHANES), as many as 18.7 percent of

Americans over age 65 are at risk for

developing diabetes. The goals in the

management of diabetes are to achieve

normal metabolic control and reduce

the risk of micro- and macro-vascular

complications. Numerous epidemiologic

and interventional studies point to the

necessity of maintaining good glycemic

control to reduce the risk of the

complications of diabetes. Despite this

knowledge, diabetes remains the leading

cause of blindness, lower extremity

amputations and kidney disease

requiring dialysis. Diabetes and its

complications are primary or secondary

factors in an estimated 9 percent of

hospitalizations (Aubert, RE, et al.,

Diabetes-related hospitalizations and

hospital utilization. In: Diabetes in

America. 2nd ed. National Institutes of

Health, National Institute of Diabetes

and Digestive and Kidney Disease, NIH,

Pub. No 95–1468–1995: 553–570).

Overall, beneficiaries with diabetes are

hospitalized 1.5 times more often than

beneficiaries without diabetes. HCFA–

3002–F ‘‘Expanded Coverage for

Outpatient Diabetes Self-Management

Training and Diabetes Outcome

Measurements’’, provided for uniform

coverage of diabetes outpatient selfmanagement

training services. These

services include educational and

training services furnished to a

beneficiary with diabetes by an entity

approved to furnish the services. The

physician or qualified non-physician

practitioner treating the beneficiary’s

diabetes would certify that these

services are needed as part of a

comprehensive plan of care. This rule

established the quality standards that an

entity would be required to meet in

order to participate in furnishing

diabetes outpatient self-management

training services. It set forth payment

amounts that have been established in

consultation with appropriate diabetes

organizations. It implements section

4105 of the Balanced Budget Act of

1997. Form Number: CMS–R–247 (OCN:

0938–0818); Frequency: Recordkeeping

and Reporting—Occasionally; Affected

Public: Business or other for-profit

institutions; Number of Respondents:

5327; Total Annual Responses: 63,924;

Total Annual Hours: 197,542. (For

policy questions regarding this

collection contact Kristin Shifflett at

410–786–4133. For all other issues call

410–786–1326.)

4. Type of Information Collection

Request: Extension of a currently

approved collection; Title of

Information Collection: Medicare

Quality of Care Complaint Form; Use: In

accordance with Section 1154(a)(14) of

the Social Security Act, Quality

Improvement Organizations (QIOs) are

required to conduct appropriate reviews

of all written complaints submitted by

beneficiaries concerning the quality of

care received. The Medicare Quality of

Care Complaint Form will be used by

Medicare beneficiaries to submit quality

of care complaints. This form will

establish a standard form for all

beneficiaries to utilize and ensure

pertinent information is obtained by

QIOs to effectively process these

complaints. Form Number: CMS–10287

(OCN: 0938–1102); Frequency:

Reporting—Occasionally; Affected

Public: Individuals or Households;

Number of Respondents: 3,500; Total

Annual Responses: 3,500; Total Annual

Hours: 583. (For policy questions

regarding this collection contact Coles

Mercier at 410–786–2112. For all other

issues call 410–786–1326.)

5. Type of Information Collection

Request: Reinstatement with change of a

currently approved collection; Title of

Information Collection: Conditions of

Participation for Portable X-ray

Suppliers and Supporting Regulations

in 42 CFR Sections 486.104, 486.106,

486.110; Use: The requirements

contained in this information collection

request are classified as conditions of

participation or conditions for coverage.

These conditions are based on a

provision specified in law relating to

diagnostic X-ray tests ‘‘furnished in a

place of residence used as the patient’s

home,’’ and are designed to ensure that

each supplier has a properly trained

staff to provide the appropriate type and

level of care, as well as, a safe physical

environment for patients. CMS uses

these conditions to certify suppliers of

portable X-ray services wishing to

participate in the Medicare program.

This is standard medical practice and is

necessary in order to help to ensure the

well-being, safety and quality

professional medical treatment

accountability for each patient. Form

Number: CMS–R–43 (OCN: 0938–0338);

Frequency: Yearly; Affected Public:

Business or other for-profit and Not-forprofit

institutions; Number of

Respondents: 578; Total Annual

Responses: 578; Total Annual Hours:

948. (For policy questions regarding this

collections contact Alesia Hovatter at

410–786–6861. For all other issues call

410–786–1326.)

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27402 Federal Register / Vol. 78, No. 91 / Friday, May 10, 2013 / Notices

6. Type of Information Collection

Request: New collection (Request for a

new OMB control number); Title of

Information Collection: Annual Report

of Physician-Owned Hospital

Ownership and/or Investment Interest;

Use: Section 6001 of the Affordable Care

Act (ACA) requires Medicare hospitals

to report whether they have any

physician owners including

immediately family members of the

physician.

Currently the CMS 855A captures

basic ownership/managerial information

on providers. The CMS 855A was

revised in July 2011 and a specific

attachment designed to capture

physician-owned hospital ownership

and investment interest data was added

to the form. The attachment is being

removed from the CMS 855A

application because the annual

reporting requirement for physicianowned

hospitals is not required for

Medicare enrollment processing. This

physician-owned hospital data

collection is mandated to be reported on

an annual basis. Additionally, the ACA

prohibits the expansion of current

physician-owned hospitals and banned

the establishment of new ones making

the CMS 855A the improper method to

collect this required annual report.

CMS is requesting the physicianowned

hospital ownership information,

investment information or both,

previously collected in Attachment 1 of

the CMS 855A enrollment application to

become a stand-alone form with a

unique OMB number for the following

reasons:

• The physician-owned data

collection has a small targeted audience

of approximately 140 physician-owned

hospitals nationwide.

• The physician-owned data

collection is required annually, as noted

above.

• The data required under section

6001 is more specific than the data

currently collected on the CMS–855A

provider enrollment application.

• The data is not required for

Medicare provider enrollment purposes.

Form Number: CMS–855 (POH)(OCN:

0938-New); Frequency: Reporting—

Yearly; Affected Public: Private Sector—

Business or other for-profits and not-forprofit

institutions; Number of

Respondents: 140; Total Annual

Responses: 140; Total Annual Hours:

140. (For policy questions regarding this

collection contact Kim McPhillips at

410–786–5374. For all other issues call

410–786–1326.)

7. Type of Information Collection

Request: Revision of a currently

approved collection; Title of

Information Collection: Hospital and

Health Care Complexes and Supporting

Regulations in 42 CFR 413.20 and

413.24; Use: Medicare Part A

institutional providers must provide

adequate cost data to receive Medicare

reimbursement (42 CFR 413.24(a)).

Providers must submit the cost data to

their Medicare Fiscal Intermediary (FI)/

Medicare Administrative Contractor

(MAC) through the Medicare cost report

(MCR). We are submitting a revision of

the Hospital and Hospital Health Care

Complex Cost Report, Form CMS–2552–

10. Form CMS 2552–10 is used by

hospitals participating in the Medicare

program to report the health care costs

to determine the amount of

reimbursable costs for services rendered

to Medicare beneficiaries. The revisions

were caused by legislative requirements

in the Patient Protection and Affordable

Care Act of 2010 and the Temporary

Payroll Tax Cut Continuation Act of

2011. Form Number: CMS–2552–10

(OCN: 0938–0050); Frequency:

Reporting—Yearly; Affected Public:

Private Sector—Business or other forprofits

and not-for-profit institutions;

Number of Respondents: 6,171; Total

Annual Responses: 6,171; Total Annual

Hours: 4,153,083. (For policy questions

regarding this collection contact Nadia

Massuda at 410–786–5834. For all other

issues call 410–786–1326.)

8. Type of Information Collection

Request: Reinstatement with change of a

previously approved collection. Title of

Information Collection: Collection of

Diagnostic Data from Medicare

Advantage Organizations for Risk

Adjusted Payments. Use: CMS will use

the data to make risk adjusted payment

under Parts C. MA and MA–PD plans

will use the data to develop their Parts

C bids. As required by law, CMS also

annually publishes the risk adjustment

factors for plans and other interested

entities in the Advance Notice of

Methodological Changes for MA

Payment Rates (every February) and the

Announcement of Medicare Advantage

Payment Rates (every April). Lastly,

CMS issues monthly reports to each

individual plan that contains the CMS–

HCC and RxHCC models’ output and the

risk scores and reimbursements for each

beneficiary that is enrolled in their plan.

Form Number: CMS–10062 (OMB 0938–

0838). Frequency: Quarterly. Affected

Public: Private Sector (business or other

for-profit and not-for-profit institutions).

Number of Respondents: 766. Total

Annual Responses: 830,000. Total

Annual Hours: 40,650. (For policy

questions regarding this collection

contact Michael Massimini at 410–786–

1566. For all other issues call 410–786–

1326.)

To obtain copies of the supporting

statement and any related forms for the

proposed paperwork collections

referenced above, access CMS’ Web site

address at http://www.cms.hhs.gov/

PaperworkReductionActof1995, or

Email your request, including your

address, phone number, OMB number,

and CMS document identifier, to

Paperwork@cms.hhs.gov, or call the

Reports Clearance Office on (410) 786–

1326.

In commenting on the proposed

information collections please reference

the document identifier or OMB control

number. To be assured consideration,

comments and recommendations must

be submitted in one of the following

ways by July 9, 2013:

1. Electronically. You may submit

your comments electronically to http://

www.regulations.gov. Follow the

instructions for ‘‘Comment or

Submission’’ or ‘‘More Search Options’’

to find the information collection

document(s) accepting comments.

2. By regular mail. You may mail

written comments to the following

address: CMS, Office of Strategic

Operations and Regulatory Affairs,

Division of Regulations Development,

Attention: Document Identifier/OMB

Control Number lll, Room C4–26–

05, 7500 Security Boulevard, Baltimore,

Maryland 21244–1850.

Dated: May 6, 2013.

Martique Jones,

Deputy Director, Regulations Development

Group, Office of Strategic Operations and

Regulatory Affairs.

[FR Doc. 2013–11035 Filed 5–9–13; 8:45 am]

BILLING CODE 4120–01–P

http://www.regulations.gov/#!documentDetail;D=CMS-2013-0099-0001