Study: Practice Support Facilitates PCMH Transition

Written by Heather Punke | April 25, 2013

When small or solo physician practices are given practice redesign and embedded care management support, they are more likely to improve care quality and efficiency when transitioning to a patient-centered medical home, according to study results published in the Journal of General Internal Medicine. 

Researchers performed a randomized controlled trial in which intervention practices received 18 months of practice redesign support, two years of revised payment and 18 months of embedded care management support. The control practices received participation payments.

The intervention physicians improved on two quality indicators — hypertensive blood pressure control and breast cancer screenings — and one efficiency indicator — reduced emergency department visits. In the control practices, quality and efficiency of care was either unchanged or worse, according to the study.

15 Recent Issues Between Hospitals and Payors

Written by Jim McLaughlin | April 26, 2013

Here are 15 recent issues that occurred between hospitals, health systems and payors within the past month, starting with the most recent. 

1. Aetna, Baptist Memorial Health Care Make Collaborative Care Agreement 
Baptist Memorial Health Care in Memphis, Tenn., and Aetna partnered in a collaborative care agreement to offer Aetna Whole Health, a commercial healthcare product.

2. Aetna, Carolinas HealthCare Announce Accountable Care Collaboration
Aetna and Charlotte, N.C.-based Carolinas HealthCare System are using a clinically integrated organization model to support patient-centered medical homes and other accountable care efforts.

3. Minnesota Hospitals Denounce Blue Cross Payment Changes  
The Minnesota Hospital Association called out Blue Cross and Blue Shield of Minnesota, saying the health insurer is slashing payments to rural hospitals that will "put them into deep, deep red ink."

4. Bill Requiring North Carolina Hospitals to Post Prices Passes Senate Committee 
A bipartisan North Carolina Senate committee threw its support behind a bill that would require hospitals to make their bills more transparent and comprehensible to patients.

5. CMS Rejects Pioneer ACOs' Plea for Pay-for-Performance Delay 
CMS did not accept a request from its Pioneer accountable care organizations to delay tying pay to outcomes.

6. BCBS of Tennessee, Erlanger Form Strategic Partnership 
BlueCross BlueShield of Tennessee and Erlanger Health System in Chattanooga, Tenn., signed a five-year strategic network partnership agreement, effective July 1.

7. Cornerstone Health Care, BCBS of North Carolina Form ACO 
Cornerstone Health Care, a Highpoint, N.C.-based physician group with more than 365 physicians, partnered with Blue Cross and Blue Shield of North Carolina to form an accountable care organization.

8. Pennsylvania Lawmakers: Highmark-West Penn Deal May Hurt Small Hospitals 
Four Pennsylvania state senators sent a letter to Gov. Tom Corbett, arguing the pending merger between Pittsburgh-based health insurer Highmark and West Penn Allegheny Health System could hurt small local hospitals if safeguards are not put in place.

9. Report: U.S. Healthcare System Can Save $560B in Public, Private Reforms 
If the United States tinkered with Medicare more, reformed tax policies, prioritized healthcare quality and incented states to improve care, the healthcare system could save roughly $560 billion over the next decade, according to a report from the Bipartisan Policy Center Health Care Cost Containment Initiative. 

10. UC Health, Anthem Reach New Contract 
UC Health and Anthem Blue Cross and Blue Shield of Ohio reached a new contract, meaning all UC Health hospitals and providers are now in-network again for Anthem patients.

11. Study: Bundled Payment Structures Show Promise 
When structured well, bundled payment models can be effective and profitable for hospitals that can reduce the cost of each episode of care, according to a study conducted by Singletrak Analytics and DataGen.

12. Cooper University Health Care Acquires 20% Interest in New Jersey Health Insurer 
Camden, N.J.-based Cooper University Health Care announced it will acquire a 20 percent interest in health insurer AmeriHealth New Jersey, marking the state's first hospital-payor acquisition of its kind. During a conference call announcing the deal, leaders also announced there was room at the table for more providers to join in the partnership.

13. $24M Ruling Against UnitedHealth May Enhance Payors' Scrutiny of In-Network Providers 
A Nevada jury ruled that two affiliates of UnitedHealth Group must pay $24 million in damages for negligent oversight of a physician who gave two patients hepatitis C through unsterile care.

14. Superior Health Partners, BCBS of Michigan Partner for Accountable Care 
Superior Health Partners, an alliance of eight independent health systems in Michigan's Upper Peninsula, announced an accountable care organization-like partnership with Blue Cross Blue Shield of Michigan.

15. Mountain States Health Alliance Nears Expiration of BlueCross BlueShield Contract 
The contract between BlueCross BlueShield of Tennessee and the 13 hospitals of Johnson City, Tenn.-based Mountain States Health Alliance is due to expire at the end of May, with no renewal agreement yet finalized.

Survey: Hospitals are not ready for ICD-10

More than 50% of hospitals have not started training for coding staff

Topics: Information Technology, Clinical Documentation

April 26, 2013

Almost half of small- and mid-sized hospitals are lagging behind official CMS timelines for the transition to ICD-10 code sets, according to a survey.
Is your hospital ready for ICD-10? Evaluate your preparedness across six areas using our Readiness Diagnostic. U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch from ICD-9 to ICD-10 code sets is slated for Oct. 1, 2014 and will require health care providers and insurers to change out about 14,000 codes for about 69,000 codes.
For the survey, Health Revenue Assurance Holdings polled more than 120 hospitals with fewer than 400 beds. The survey aimed to determine whether the facilities were following official CMS timelines for ICD-10 preparation.
About 20% of the surveyed hospitals said they have not begun education or training for the ICD-10 transition, according to the survey. HRAA also found that 55% of surveyed hospitals have not started training their coding staff on the ICD-10 procedure coding system, known as ICD-10-PCS.

How the Advisory Board can help your organization build an ICD-10 transition plan

Moreover, despite CMS recommendations that hospitals begin ICD-10 testing in 2013, 25% of surveyed hospitals said they plan to start testing in January 2014, and 24% said they plan to begin testing in April 2014 (Walsh, Clinical Innovation & Technology, 4/24; McCann, Healthcare IT News, 4/24).

HIPAA Compliance: What Providers Should Know About HITECH Act Mandatory Audits

HIPAA Compliance: What Providers Should Know About HITECH Act Mandatory Audits

Written by Holly Carnell, JD, and Meggan Bushee, JD, McGuireWoods  | April 17, 2013

 

1. HHS mandated audits
Investigations by the Office for Civil Rights related to compliance with the Health Insurance Portability and Accountability Act will no longer be initiated by only complaints and self-reported breaches. Section 13411 of the HITECH Act requires HHS to provide for periodic audits of covered entities' and business associates' compliance with the HIPAA Privacy Rule, Security Rule and Breach Notification standards. While the audits are not intended to be investigations, an audit could reveal a serious compliance issue that could lead to a separate enforcement investigation by OCR. These mandatory audits are further evidence of the increased enforcement efforts of HHS. 

2. What we learned from the pilot audit program
KPMG, on behalf of HHS, conducted a yearlong pilot audit program from November 2011 through December 2012 that included 115 audits of covered entities. The audits focused on key compliance requirements under HIPAA, including (a) various requirements of the Privacy Rule, such as notice of privacy practices and uses and disclosures of protected health information, (b) Security Rule requirements for administrative, physical and technical safeguards, and (c) requirements for the Breach Notification Rule.

The large majority of entities that were audited were providers, rather than health plans or clearinghouses (all of which are covered entities under HIPAA). The preliminary results from the pilot audit program revealed that 65 percent of the compliance issues were related to the Security Rule, while only 26 percent and 9 percent of the compliance issues were related to the Privacy Rule and Breach Notification Rule, respectively. Generally, smaller covered entities, such as physician practices and smaller providers, had more compliance issues than larger covered entities. In the future, both covered entities and business associates will be subject to audits. 

OCR is currently evaluating the pilot program to assess whether changes should be made before routine audits commence. The evaluation will focus on the pilot audit program's effectiveness, analyze the program's strengths and weaknesses and give recommendations for future audits. The evaluation process is scheduled to conclude in September 2013. We anticipate that routine audits will commence after this time. 

3. Audit process
An OCR audit begins the audit process by sending document request to the audit target, which includes an introduction to the audit contractor and a request for required HIPAA documents, including copies of privacy policies and procedures, workforce training documentation, incident response plans, risk analyses and risk mitigation plans. This documentation will generally be due to OCR within 10 business days of the request for information. Following review of the documentation, the auditor will conduct a site visit.
During the site visit, OCR will interview key personnel. Covered entities and business associates should ensure that all members of management and higher-level staff members are familiar with the entity's privacy and security policies, procedures and compliance efforts — the entity's privacy officer will not be the only workforce member interviewed by OCR.

After the site visit is completed, the auditor will provide the covered entity with a draft final report. The entity will then have 10 business days to review and provide written comments back to the auditor. The auditor will complete a final audit report within 30 business days after the entity’s response and submit it to OCR. The reports will be used by OCR to determine what types of technical assistance should be developed and whether a compliance review is necessary to address any serious issues detected during the audit.

4. How to prepare for an audit
The audit protocol can be found on the OCR website and is a great resource for entities looking to perform self-evaluations of their HIPAA compliance. As part of these self-evaluations, the audit protocol can be used by covered entities and business associates to conduct a self-audit. This process will help identify compliance gaps and prepare for an OCR audit. 

Covered entities and business associates should ensure, at a minimum, that the following HIPAA compliance measures are being taken:

a. In the case of a covered entity, provide the entity's form of Notice of Privacy Practices to every patient and update such NPP to reflect the changes under the Omnibus Final Rule (required by September 23, 2013).
b. Have written and signed business associate agreements with all entities considered a business associate.
c. Conduct an accurate and thorough assessment of the risk to electronic protected health information.
d. Implement required physical, technical and administrative safeguards to protect ePHI.
e. Have formal policies and procedures for the privacy and security of protected health information and ensure these are updated to reflect the changes under the Omnibus Final Rule (required by September 23, 2013).
f. Train all employees on privacy and security policies and procedures. Those employees who job duties are affected by the changes resulting from the Omnibus Final Rule will need to receive additional training on such changes.
g. Maintain all documentation required under HIPAA, including documentation of all employee training, disclosure logs, documentation of all breach analyses and documentation of sanctions taken against employees for violations of privacy and security policies.

Covered entities and business associates should start to prepare now rather than after receiving notice from OCR of its intent to audit. Preparing for a potential audit may also help protect covered entities and business associates from complaints to OCR related to HIPAA violations.

M&A trends suggest shift from 'blockbuster' to 'strategic' deals | The Advisory Board Daily Briefing

M&A trends suggest shift from 'blockbuster' to 'strategic' deals | The Advisory Board Daily Briefing

2013 HEALTHCARE DESIGN Conference

The HEALTHCARE DESIGN Conference is devoted to examining how design directly impacts the safety, operations, clinical outcomes, and financial success of healthcare facilities now and into the future. Produced by the industry-leading magazine and with support from the Center for Health Design, American Institute of Architects, Health Care Council of IFMA, and International Interior Design Association, the HEALTHCARE DESIGN Conference has quickly become the industry’s best-attended and most respected conference on evidence-based design for healthcare.  2013 HEALTHCARE DESIGN Conference attendees will include top architects, interior designers, administrators, operations executives, contractors, engineers, facility managers, researchers, and educators. Exhibitors and sponsors will have numerous opportunities to engage with their peers and prospects through networking receptions, educational sessions and workshops. All exhibiting and sponsoring companies are encouraged to participate in all aspects of the conference including sessions and several networking events held throughout the four days. By joining us you will not only reach your target market, but forge new relationships, gain new perspectives, and expand your knowledge of the market and your target audience through  exhibit, sponsorship, networking and custom opportunities.
http://10ff844694f55e1ab433-0fa89f3e0a775bb9ab632939ec217a23.r63.cf2.rackcdn.com/HCD13_Prospectus.pdf

Discovering Your Innovative Spirit in Evidence-Based Healthcare Design

By Rosalyn Cama, FASID, EDAC

If you are about to embark on a new building project or maybe even just a small renovation project, during the development of the project guidelines, ask yourself how innovative you would like the project to be. If you are inclined to seek the excitement of discovering new solutions, then there is a systematic way to approach innovation in a relatively safe manner.
Here are a few thoughts to help discover the scope of your innovative spirit.

Map your innovative prowess
According to the Rogers Adoption Innovation Curve (noted below), 2.5% of newly released design interventions and/or operational or clinical practices qualify as innovations and 13.5% as early-adopted practices. What is your project’s tolerance for innovation?

Innovator is a status to aspire to, and not a place to begin your journey into the world of healthcare design. Being an early adopter is sometimes adventurous enough given the complexity of most facility-related decisions.
There are two scales to consider for achieving the appropriate balance before you forge new roads—or even follow the trailblazers in the field. One scale is related to what drives decision-making on your project, and the other is relative to the level of innovation you will tolerate.
Where you decide to be on each of these scales will drive a unique set of decision-making practices. Remember, these scales provide an interesting exercise to create the litmus for decision-making throughout the course of your project's lifecycle.
The first scale is about how to base your decisions in order to achieve a certain set of outcomes. Will the approval of design interventions known to improve outcomes merit a primary decision based upon financial value or institutional values? Too many projects start with values-based desires and then engineer out good design interventions, because of a later misdirected value-driven or price-based decision.
These two opposing factors can be easily reconciled with solid evidence-based design knowledge.
The greater the alignment between the design decision and your values, the more meaningful the financial value discussion will be. If aligned with your values, then the decision where to spend money sets your coordinates on this scale early in the planning process and will likely show a return so great that the costs are recouped in the first few years of operation.
The second scale deals directly to the degree of innovation your project will drive. You have a choice as to whether to just engage in baseline knowledge or to innovate. Innovation can be one small detail or a major shift in the industry's mindset on how to deliver medical care.
Often, a project team is surprised at how much industry advancement has been made since their last project, and it all seems innovative.
It is important to understand the current state of baseline data so you can provide clear direction to the project team. Providing baseline knowledge so that healthcare facilities change rather than stay static—or worse, regress—is central to The Center for Health Design’s work. Often, a project just needs to hover at the baseline knowledge level, while others need a higher level of innovation.
If you can be honest on each of these scales, then you will begin to profile a design program that your design team can follow with certainty and accurate delivery.

Converse about industry drivers
Most design conversations start with a driver that determines which outcomes need addressing. In 1999, when the Institute of Medicine came out with a report on safety, it drove all healthcare design conversations around outcomes related to safety. It was because of those conversations that the single-bedded room was born.
A new set of questions also arose that created innovative concepts, like the variable-acuity room to reduce the risks associated with transfers and the bathroom's placement on the headwall to avoid the risk of patient falls.
With health reform as the driver, we are all currently seeking outcomes related to efficient and effective models that deliver more care while using fewer resources. Design interventions are currently supporting Lean work processes, like decentralized personnel and supply distribution, resulting in community-based healthcare delivery.
As we move into a more accountable-care model, we will need to find a way to keep our most vulnerable population in a state of good health. Innovative health-related design interventions will move from the acute care facility into the community, and maybe even into the home.
These shifts are occurring faster and faster, and the need for innovation to be inspired, vetted, proven or disproven, and then adopted into baseline data is greater now than ever. We no longer have the typical 10-to-15-year cycle where one team innovates and then waits for the rest of the industry to follow before we consider what comes after what comes next.
The Center has opened that conversation up across all platforms with the most likely innovators—our Pebble Project partners, as well as others testing new concepts in the field, like our Affiliates and those in the Built Environment Network. Consider finding your community of interest and avoid falling into the laggard’s position.

Use the EBD process
Most meaningful innovation has its seed planted long before the design project begins. A crucial step in the evidence-based design process is to have the foresight to align corporate strategy with facility planning. Mapping your strategy across your physical assets is fortuitous if you have the luxury of time and a team in place that understands the current baseline knowledge—a target that is continually on the move.
Is your facility and design team really using an evidence-based design process or is it just a marketing buzzword? The implication for falling behind in this fast-moving industry is too great to not know the answer to this question.
Add an evidence-based design expert to your team long before there is a project, so when the time comes to develop a meaningful program, you will have a resource who can guide the process more effectively.

Call to arms
I have a prediction in mind for where we are headed after what comes next, so catch up and, please, do not hang back in the laggard's position. If you are reading this publication or my blog post, then you are looking for the “what's next” on the healthcare industry's blurry horizon.
Use the group brain at The Center and those who are participating in the conversations to move this industry, and all who use it, into a state of wellbeing.

PPACA Implementation Pending, Health Insurance Coverage Gaps Persist

PPACA Implementation Pending, Health Insurance Coverage Gaps Persist

OIG Issues Alert Warning Physicians that They Can Be Liable for False Claims Submitted by Entities to Which They Have Reassigned Their Medicare Billing Rights

On February 8, 2012, the Office of Inspector General (OIG) issued an OIG Alert warning physicians to exercise caution when reassigning their right to bill the Medicare program. According to the Alert, “[p]hysicians who reassign their right to bill the Medicare program and receive Medicare payments by executing the CMS-855-R application may be liable for false claims submitted by entities to which they reassigned their Medicare benefits.” The OIG indicated that it had recently reached settlements with eight physicians who had allegedly violated the civil monetary penalty law by causing the submission of false claims for claims submitted to Medicare by physical medicine companies to which the physicians had reassigned their Medicare billing rights in exchange for medical directorship positions. According to the OIG, the physical medicine companies billed Medicare for services that were not actually performed or performed as billed. The physical medicine companies, using the physicians' reassigned billing numbers, falsely certified to Medicare that services performed by unlicensed physical therapy technicians had been performed or directly supervised by the physicians, when such was not the case. The Alert states that physicians have an obligation to monitor billing and other records to ensure that claims using their reassigned provider numbers are billed correctly. The OIG noted that physicians who reassign their billing rights to an entity have a right to access the entity’s billing and claim information for the services that the physicians are alleged to have performed.


Health Headlines – Editor:
Dennis M. Barry dbarry@kslaw.com +1 202 626 2959

Medicare Whistleblower Program Increases Maximum Reward to $9.9M

The Obama administration is proposing to increase the maximum reward for reporting Medicare fraud to $9.9 million, saying that it could provide an incentive to whistleblowers.

Since 2010, the Centers for Medicare & Medicaid Services (CMS) has recouped more than $14.9 million in fraudulent Medicare funds. The new proposal, the agency says, will root out a net $24.5 million in additional recovered revenue each year.

“President Obama has made the elimination of fraud, waste and abuse, particularly in healthcare, a top priority for the administration,” said Health and Human Services Secretary Kathleen Sebelius in a statement on Wednesday.

The proposal “is a signal to Medicare beneficiaries and caregivers, who are on the frontlines of this fight, that they are critical partners in helping protect taxpayer dollars,” Sebelius continued.

“The IRS program has proved to be highly successful in generating leads that returned far greater sums than the existing Medicare [Incentive Reward Program] IRP, which limited rewards to 10 percent of the first $10,000 of the final amount collected,” the department said in its proposal.

Regulations in the new program would increase the rewards from 10 percent to 15 percent of the total amount of recovered funds. The new proposal would also increase the cap on the recovery fund awards to $66 million, meaning a person can earn as much as $9.9 million if CMS collects more than $66 million as a result of a fraud tip.

HHS said the cost to bolster the program would be $70,000.

Read more: http://thehill.com/blogs/regwatch/pending-regs/295907-medicare-whistleblower-program-increases-maximum-reward-to-99m#ixzz2RZdcqD00 
Follow us: @thehill on Twitter | TheHill on Facebook

CMS and OIG Propose Changes to the Electronic Health Records Exception and Safe Harbor

On April 10, 2013, the Centers for Medicare & Medicaid Services (“CMS”) and the Department of Health and Human Services Office of Inspector General (“OIG”) published parallel proposed rules revising, respectively, the Stark exception and Anti-Kickback safe harbor concerning electronic health record (“EHR”) items and services. Highlights of the proposed rules include:
Sunset Provision. The EHR exception and safe harbor are scheduled to sunset on December 31, 2013. The proposed rules seek to extend the sunset provision to December 31, 2016.
Deeming Provision. The EHR exception and safe harbor specify that the donated software must be interoperable at the time it is provided to the physician. Currently, for purposes of meeting this condition, software is deemed interoperable if a certifying body recognized by the Secretary of Health and Human Services has certified the software no more than 12 months prior to the date it is provided to the physician. The proposed rules eliminate the 12-month certification window. Any software will be deemed certified if, on the date it is provided to the recipient, it has been certified to any edition of the EHR certification criteria that is identified in the then applicable definition of Certified EHR Technology in 45 C.F.R. part 170. In addition, the proposed rules place the Office of the National Coordinator for Health Information Technology, instead of the Secretary of Health and Human Services, in charge of recognizing bodies able to certify the interoperability of EHR systems.
Electronic Prescribing Provision. The current EHR rules require the donated software to contain e-prescribing capability. The proposed rules seek to eliminate this condition because sufficient alternative policy drivers exist to support the adoption of e-prescribing capabilities.
Additional Proposals and Considerations.
 Protected Donors. The EHR exception and safe harbor are currently available to a broad class of donors. The proposed rules seek to limit the availability of the EHR exception and safe harbor to cover only the original MMA-mandated donors: hospitals, group practices, Part D plan sponsors and Medicare Advantage organizations. In the alternative, the rules propose to exclude certain suppliers associated with a high risk of fraud and abuse in this context including laboratories, DME suppliers and independent home health agencies.  Data Lock-In and Exchange. Due to the concern of using the EHR exception and safe harbor to lock-in referrals, the proposed rules request comments on new or modified conditions that could be added to the rules to achieve the goals of: (a) preventing data and referral lock-ins, and (b) encouraging the free exchange of data.  Covered Technology. The proposed rules seek comments on whether the regulatory text should be modified to explicitly reflect the items and services that fall within the scope of covered technology. The agencies consider the current regulatory text, when read in light of the preamble discussion, sufficiently clear but seek input from the public regarding this issue.
CMS and OIG are accepting comments on the proposed rules through June 10, 2013.

Integrated Coding Compliance Program

The Department of Justice recently stated that it is not their policy to assess fines and penalties for honest billing mistakes. However, DOJ also stated that hospitals, physicians and health plans must establish adequate internal procedures to ensure the accuracy of submissions.

Components of an Integrated Coding Compliance Program:

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4. Engagement – Patient and Provider outreach to minimize gaps and add value.

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UnitedHealth Issues Warning Over Medicare Advantage Cuts - Kaiser Health News

UnitedHealth Issues Warning Over Medicare Advantage Cuts - Kaiser Health News

UnitedHealth Issues Warning Over Medicare Advantage Cuts

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TOPICS: INSURANCE, MARKETPLACE, MEDICARE, HEALTH COSTS

APR 19, 2013

UnitedHealth attributed a 14 percent drop in profits in the first quarter to higher medical costs. The nation's largest insurer also warned that cuts to Medicare Advantage plans could hamper its earnings growth next year.

The Wall Street Journal: UnitedHealth's Outlook Cautious Amid Medicare Debate
UnitedHealth Group Inc. on Thursday sounded a cautious tone as it deals with the near-term impact of the government's crackdown on spending and looks ahead to lower funding for its Medicare plans. The comments, from the nation's largest managed-care company by both revenue and members, indicate the uncertainty that the industry is experiencing as insurers gear up for fuller implementation of the Affordable Care Act in 2014. That process has been made more complicated by the recent automatic U.S. spending cuts known as the sequestration and expectations for lower incoming payments for Medicare Advantage plans next year (Kamp, 4/18).

Kaiser Health News: Capsules: Despite Win, UnitedHealth Criticizes Medicare Rates, Eyes Pruning Business
If the Obama administration expected the biggest health insurance company to give thanks for this month’s decision to reverse cuts to private Medicare plans, it was wrong. UnitedHealth Group CEO Stephen Hemsley said Thursday that Medicare Advantage rates are still far too low and that the company may shrink its business of managing care for seniors. ... But in Thursday’s call to discuss the company’s quarterly profits of $2.1 billion on revenue of $30.3 billion, Hemsley said other changes — including the Affordable Care Act’s long-term reduction in Medicare Advantage payments – would still lead to a net reduction next year of more than 4 percent. That's inadequate when medical costs are rising in the 3 percent neighborhood, he said" (Hancock, 4/19).

Los Angeles Times: UnitedHealth Reports Lower First-Quarter Profit, Higher Costs
UnitedHealth Group Inc., the nation's largest health insurer, said its first-quarter profit dropped 14 percent as medical costs climbed higher. The Minnetonka, Minn., company said its health plan membership increased 18 percent in the quarter to 42 million people, boosted by international growth (Terhune, 4/18).

The Associated Press: UnitedHealth Warns Of Medicare Profit Squeeze
UnitedHealth Group, the largest provider of Medicare Advantage plans, warned Thursday that funding cuts for the privately-run versions of the federal Medicare program will force it to reconsider its expectations for earnings growth next year. CEO Stephen Hemsley told analysts that the government-subsidized coverage for elderly and disabled people faces a reimbursement cut of about 4 percent next year (Murphy, 4/18).

In the meantime, Humana has launched an internal investigation after leak of a significant government policy change led to some suspicious stock trading --

The Wall Street Journal: Humana Fires Lobbying Firm, Launches Internal Review
Health insurer Humana Inc. said it has started an internal probe into the circumstances surrounding the leak of a significant change in government health-care policy. "We have launched an internal review primarily to determine whether our interests were harmed" by the tie between an outside lobbyist employed by Humana and an investment firm that sent out early word of the policy shift, a Humana spokesman said. That alert set off a sudden jump in shares of Humana and other insurers late April 1 (Mullins and Mathews, 4/18).

Planned CMS Changes on MA HRAs Draw Criticism, Questions on Need

CMS’s surprising proposal in the Feb. 15 “45-day notice” for Medicare Advantage plans’ 2014 payment rates to place strict limits on the use of health risk assessments (HRAs) for risk-adjustment purposes is getting mixed reviews from MA industry participants.

Trade group America’s Health Insurance Plans (AHIP), in a March 1 letter to CMS, for instance, urged the agency to “reconsider” the proposal (MAN 2/28/13, p. 1) so that it “does not inappropriately limit inclusion of diagnoses from the 2014 data year that are valid predictors of health status in the subsequent payment year.” But the CEO of one firm that specializes in assessing MA beneficiaries in their homes suggests that what CMS is asking — primarily for HRA findings to be followed up in a subsequent clinical encounter — is what the MA plans with which it works already are doing.
CMS in the 45-day notice said it “is concerned that these risk assessments could be used as a vehicle for collecting risk adjustment diagnoses without follow-up care or treatment being provided to the beneficiary by the plan.” The HRAs, according to the agency, contribute to “increased risk scores and differences in coding patterns between MA and” fee-for-service (FFS), and thus to higher payments for MA plans.
To analyze what is occurring, CMS proposed that beginning with 2013 dates of service, MA plans will have to flag those diagnoses collected in an MA enrollee HRA. And for 2015, the agency added, “CMS is considering excluding, for risk adjustment payment purposes, the diagnosis data collected from MA enrollee risk assessments that are not confirmed by a subsequent clinical encounter by a provider type” approved for such purposes.
AHIP, in detailed comments to CMS, notes first that HRAs “must be offered” to new MA enrollees and as part of the annual wellness visit available for both MA and Medicare FFS beneficiaries. Regardless of whether they occur in a physician’s office or, as some MA plans arrange, in the beneficiary’s home or another location “convenient for the enrollee,” AHIP asserts, “it is our understanding that the results can currently be included in the patient’s medical record, and diagnoses may be reported for risk adjustment” when the assessments are conducted “face-to-face by medical professionals.”
Adds the trade group: “CMS’ proposal appears to signal a re-evaluation of its policies in the fundamental areas of medical record documentation and the role of chronic conditions in the risk adjustment model. We strongly disagree with the conclusions reflected in the draft Call Letter.” If CMS “has concerns that some health risk assessments are not sufficiently thorough,” AHIP says, it should consider developing criteria for HRAs to address this issue “rather than potentially disallowing all diagnoses collected through these efforts.”
And the group calls the HRAs the foundation of care management programs and counseling for beneficiaries that, while they may “not be documented in a subsequent medical record,” are valued by beneficiaries and “clinically significant.”
Jack McCallum, M.D., CEO of CenseoHealth, a Dallas-based firm that conducts in-home health evaluations for MA and other health plans, tells MAN that “what MA is doing is not upcoding; it’s more accurate coding.” And he says the issue CMS is raising is just a short-term one, since in about 2016 it will have enough provider encounter data from MA plans that it can rely on an “MA-specific model” as a basis for diagnosis-related decisions.
There are several problems with what CMS is proposing in the 45-day notice regarding HRAs, according to McCallum. One is that there now is no specified method for collecting data from HRAs, and there is not even a definition of what constitutes an HRA. It can’t be limited to what is done by primary care physicians, since many Medicare beneficiaries don’t get care from PCPs, he says.
And the “underlying beauty” of the risk-adjustment system, in McCallum’s view, is that it gives MA plans an incentive to figure out where there are gaps in care and to be “productively involved” in finding non-inpatient ways to furnish this treatment since a good HRA will lower costs of care “down the road.”
CenseoHealth, he asserts, never captures a diagnosis on a beneficiary in a home HRA without recommending follow-up care for that beneficiary. Moreover, it has ways, including via its call center and claims tracking, to check whether these recommendations are acted on, McCallum notes. He says that CMS verification of such follow-up would not be a problem for CenseoHealth, and to the extent that there are plans doing HRAs just “for the money,” he would “share the agency’s concern.”
If the CMS proposal were adopted, McCallum tells MAN, it would be “my suspicion” that some entities just collecting diagnoses and not doing anything about what they find “might go away.” The extra scrutiny in this aspect of what CMS is considering is “fine” and “appropriate,” he says, but he adds that “I’m not sure how much of what CMS is worried about is really going on.”

Reprinted from MEDICARE ADVANTAGE NEWS,

By James Gutman, Managing Editor

March 14, 2013Volume 19Issue 5

Physician turnover rate hits all-time high

By Frank Irving, PhysBizTech.com

Medical groups reported an average turnover rate of 6.8 percent in 2012, according to the annual Physician Retention Survey from Cejka Search and the American Medical Group Association (AMGA), who released their findings March 18.
The 2012 physician turnover rate rose from 6.5 percent in 2011. It was significantly higher than the lowest rate of 5.9 percent reported in 2009 at the depth of the recession, according to researchers, and exceeded 6.4 percent reported in 2005, the first year data was collected.
Survey respondents also reported turnover of 11.5 percent among advanced practice clinicians (APCs), which includes physician assistants and nurse practitioners. This was essentially unchanged from 2011, the first year APC data was collected.
The Cejka Search and AMGA 2012 Physician Retention Survey was distributed electronically via e-mail to 2,174 medical organizations, representing both AMGA medical group members and non-members. Researchers collected survey data from October 2012 through January 2013, and attained a 3.6 percent survey response rate. Eighty respondents, who collectively employed 19,596 physicians, reported the 2012 physician turnover data. A subset of 72 groups, who collectively employed 4,213 advanced practice clinicians, reported the APC data.
This increased turnover tracks with improvements in the housing market and recovery in stock prices and marks a shift from physicians delaying relocation and retirement due to depressed home and investment portfolio values, researchers reported.
Medical groups do not expect relief in turnover in the coming year, the researchers commented. The report indicates that competition to hire and retain top performing physicians will intensify as retirement accelerates among an aging physician workforce and health reform increases the demand for primary care.
“The survey findings provide evidence that recruitment and retention continue to be major challenges for health systems,” stated Donald W. Fisher, PhD, president and CEO of AMGA, in a prepared statement. “To rise to these challenges, medical groups are demonstrating remarkable leadership by investing in new staffing and delivery models, building and nurturing their teams in a strategic way, and making accountable care work for their patients and their communities.”
“The implementation of healthcare reform and changing demographics make efficient recruitment and effective retention paramount for medical groups,” stated Lori Schutte, president of Cejka Search, in a prepared statement. “Delivering data and insight points the way toward best practices and drives our industry toward innovative solutions.”
Other key findings from the report:

•   More than one-third (36 percent) of reporting groups expect the pace of retirements to increase in the coming year, compared with 27 percent with that expectation two years ago.

•   Nearly three-quarters (74 percent) of groups with fewer than 50 physicians said they expect turnover to “stay the same.” However this small group segment is already experiencing the highest rate of turnover among physicians over 64, at 19.4 percent, compared with an average 12.7 percent for physicians of this age in all groups.

•   The average turnover rate for physicians in their second to third year of practice is 12.4 percent and small groups suffer from 20.8 percent turnover among physicians in those early years.

•   More than three-quarters (76 percent) of respondents plan to hire more primary care physicians in the next 12 months.

•   Within that group, 22 percent said they will hire “significantly more” – more than twice the 9 percent reported in 2011.

•   Hiring plans for APCs will also accelerate: 67 percent plan to hire more nurse practitioners and 61 percent plan to hire more physician assistants. This compares with 49 percent and 48 percent (respectively) in 2011.

•   A significant majority (85 percent) have an onboarding process for physicians, yet only one-third (33 percent) of these groups stated that their process is formalized through an onboarding committee or task force.

•   Groups who assign a mentor during onboarding reported a lower overall turnover rate of 6.0 percent compared with the 6.8 percent average turnover rate for all groups.

•   Extended onboarding correlates to higher retention of physicians in the early years with a practice. Groups that provide a year-long onboarding process reported a turnover rate of 10.5 percent compared with the average 12.5 percent for physicians between two and three years with the practice, when turnover peaks.

OIG pressures CMS on home health sanctions

By Stephanie Bouchard, Managing Editor

As the number of home health agencies and fraud cases related to home health agencies continues to skyrocket, the Office of Inspector General (OIG) is exerting more pressure on the Centers for Medicare & Medicaid Services (CMS) to fulfill an obligation that is 15 years old.
Back in 1987, the Omnibus Budget Reconciliation Act (OBRA) directed CMS to implement intermediate sanctions for noncompliant home health agencies (HHAs). OBRA specified that the intermediate sanctions CMS created should include civil money penalties, payment suspension and appointment of temporary management. While there is a corrective process for noncompliant HHAs, the only HHA sanction option CMS currently has at its disposal is termination, an option it doesn’t use often.
Even though the number of Medicare-certified HHAs has seen a 59 percent increase between 2002 and 2009, CMS still has not issued a final rule for intermediate sanctions. It did issue a Notice of Proposed Rulemaking in 1991 but later withdrew it.
In 2008, OIG issued a report about HHAs with repeat deficiency citations and the lack of intermediate sanctions. OIG recommended that CMS follow OBRA’s 1987 directive to implement intermediate sanctions. CMS agreed with OIG’s recommendations but as of the spring of 2012, had yet to issue a proposed rule on intermediate sanctions. (CMS did not respond to an interview request for this story.)
Last March, OIG again pressed CMS on implementing the intermediate sanctions. In a letter to Marilyn Tavenner, CMS’ acting administrator, OIG reminded CMS of its legal obligations and that OIG had already prodded the agency on this issue in 2008.
“Although CMS indicated activities toward promulgating regulations to implement HHA intermediate sanctions, it has not yet issued a proposed rule,” OIG’s letter to Tavenner said. “Given the length of time since the passage of the original statute, CMS should make HHA intermediate sanctions a high priority and should complete their implementation as soon as possible.”
HHAs are aware that a proposed rule on intermediate sanctions may be issued soon – by some reports, in September – so there is some concern within the industry, said Mary St. Pierre, vice president, regulatory affairs, the National Association for Home Care and Hospice, about what additional burdens the new rule may add.
“Agencies now have condition levels, they are writing their plan aggression, they are being resurveyed, they are staying in the program and so they would look on this as an additional burden,” she said. “Having to either pay a fine or have some sort of management over them or whatever else CMS comes up with.”
HHAs need to begin preparing themselves now for more CMS scrutiny, said Neil Hoffman, an Atlanta-based lawyer with Arnall Golden Gregory, who represents home health agencies and providers.
“Any home health agency that has been experiencing (problems related to Medicare conditions of participation), try and get their house in order because, obviously, the ultimate penalty is the exclusion from Medicare and nobody wants that,” Hoffman said.
While HHAs are not excited about the likelihood of more hoops to jump through, they also recognize more oversight from CMS could help the industry tamp down the dark cloud it labors under because of the many reports of home healthcare fraud.
“I would politely state that we do not believe that CMS is doing all that they could/should to enforce home health rules and penalize noncompliant, sometimes fraudulent and abusive providers,” said Vicki Purgavie, executive director, Home Care and Hospice Alliance of Maine. “Instead, we have been battling for years with the constant ‘broad brush’ and black eye given to the entire industry for the behaviors of a few providers.”
“It’s too easy for CMS to say ‘Let’s regulate them more,’” she added. “They just keep putting out more regulations but they’re not providing the oversight.”

Practice Management: Key Resource for Medicare Advantage

 

Practice Management: Key Resource for Medicare Advantage

Who has more face time with your members than anyone else? Is it their primary care physician? Probably not. Think back to your last doctor’s appointment, how much time did you spend face to face with the doctor? What about the nurse or the front office?

A physician’s closest ally is his office manager. Why aren’t health plans tapping this important resource?

Patient engagement has recently taken center stage as everyone is focused on finding new and meaningful ways to connect with their members.

As a practice manager for over 10 years, I urge health plans to open up new lines of communication with practice managers and office staff.

If a plan wants to change processes within the delivery of care, you must start with the initial point of contact.

If a plan wants to know what their members want, ask the person who answers the phone at their PCP’s office.
 

The perspective of practice management can offer incredible insight and adds value that the patient will understand.

Contact ERM today for Innovative Solutions
www.ermconsultinginc.com

Will The Leaders of Today, Be The Leaders of Tomorrow?

Will The Leaders of Today, Be The Leaders of Tomorrow?

If history repeats itself, they will not. Today’s leaders and their corporations will be replaced by new companies that no one has heard of with young innovative leaders at the helm. The uptown offices will be exchanged for Wellness Centers in neighborhoods because patients will demand greater shared decision making and value-based care with increased fiscal responsibility.

Why will the industry’s strongest and most powerful corporations loose the innovation race? Because their “Innovation Department” will never be able to convince the most senior executives that innovation is more than just a new product or a marketing angle. It is a mindset, a corporate culture that originates from the top and is woven into the foundation of a corporation.

The most brilliantly written legislation supported by the best and brightest auditors with access to the entire collection of big data will NEVER change the current trend in healthcare spending if patients are not involved. This involvement, or patient engagement must be center stage over the entire continuum of care; not a follow up call after a hospital admission by a Case Manager. We must look outside the box to address the needs of patients and not insurers. Then, we must create flexible solutions that meet those specific needs.

The ability to adapt quickly will be necessary and this conflicts with current corporate ethos. Accountability has been diluted by board meetings and conference calls. While emails are shuffled around from person to person, no one wanting to take action. Instead of teaching physicians and clinical staff how to document to a higher level of specificity we are hiring companies to re-code medical records. Is that really a solution?

 

Be proactive. Start making changes today. The next wave of innovation is on the horizon.

Empirical Risk Management www.ermconsultinginc.com 877-938-9232

Whose Patient Engagement Goals Are We Talking About? | Center for Advancing Health

Whose Patient Engagement Goals Are We Talking About? | Center for Advancing Health

ICD-10 Transition Basics

The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. 

1. What does ICD-10 compliance mean?
ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes.

2. Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding? 
No. The switch to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10-PCS codes are for hospital inpatient procedures only.

3. Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?
Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not accept Medicare. 

4. Do state Medicaid programs need to transition to ICD-10?
Yes. Like everyone else covered by HIPAA, state Medicaid programs must comply with ICD-10. 

5. What happens if I don’t switch to ICD-10?
Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient procedure codes. (This does not apply to CPT coding for outpatient procedures.) Claims that do not use ICD-10 diagnosis and inpatient procedure codes cannot be processed. It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes.

6. If I transition early to ICD-10, will CMS be able to process my claims?
No. CMS and other payers will not be able to process claims using ICD-10 until the compliance date. However, providers should expect ICD-10 testing to take up to 19 months. 

7. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?
ICD-10 codes are different from ICD-9 codes and have a completely different structure. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 is more robust and descriptive with “one-to-many” matches in some instances.

Like ICD-9 codes, ICD-10 codes will be updated every year.

What strategies have you developed to successfully transition your company to ICD-10? 
Have you completed Documentation Improvement Initiatives? Have you mapped your 50 most commonly billed codes to ICD-10? Are you tracking and monitoring your progress through internal compliance reviews?  How will you protect your revenue while managing the costs of transition?

If not, you must start now. The deadline is fast approaching!

Call ERM today for a free consultation 877-938-9232

April 22, 2013, 9:08 a.m. ET

Quintiles Unlocks Path for Digital Patient Engagement

New report demonstrates how the digital patient can yield efficiencies throughout the biopharma product lifecycle

RESEARCH TRIANGLE PARK, N.C.--(BUSINESS WIRE)--April 22, 2013-- 

Harnessing the power of the digitally connected patient can not only help produce enormous amounts of savings in the health care system, but can also improve patient outcomes.
Companies that can successfully engage with the digital patient will distinguish themselves and increase their probability of success according to a new report from Quintiles, "Harnessing the Power of the Digital Patient." The report explores a more modern approach to patient engagement to streamline product development, prove product value and accelerate product adoption and adherence.
Declaring this, "The Age of the Digital Patient," Quintiles tracks the evolution of patient engagement models over time and argues that the patient is at the center of today's model--a change from the more company-centric models of the past.
The report dismisses the value of "old-school" patient databases to find patients, and declares the 2.4 billion people with an internet connection as "today's database."
Core to the Quintiles Digital Patient model is the building of trusted relationships via patient communities, and the creation of opportunities for patients to engage in managing their own health. These programs range from introductions to clinical trials, to enrollment in adherence programs, to virtual studies that include collection of patient reported outcomes, medical records, lab data and device diagnostics to prove a product's value or safety--all collected directly from patients without introducing site burden.
"It's not a question of 'when' these capabilities will be available," says co-author David Coman, senior vice president Quintiles communications, "it's a question of when the industry will give itself permission to make these approaches standard. We have been preparing for 'The Age of the Digital Patient' since 2007, and have the capabilities and experience to provide transformational change today."
Quintiles digital patient experience extends back to its creation of Mediguard.org in 2007 and ClinicalResearch.com in 2009, and its completion of more than 350 custom patient programs on behalf of sponsors in its Digital Patient Unit. To date, Quintiles manages relationships with more than three million clinically profiled patients across nearly every therapeutic area.
First Patient Enrolled in Six Minutes
An example of the promise the digital patient holds can be found in an observational research study in which Quintiles recruited 425 patients with chronic obstructive pulmonary disease (COPD) from its online patient community. The first digital patient was enrolled in the study in a mere six minutes with the last patient confirmed in only nine calendar days.
59% Increase in Retention Rates
A second example can be found in a 1,255-patient women's health study in which Quintiles developed a custom communication plan for each patient in order to reduce the number of patients that become lost to follow up or drop out of the study entirely. The customized communication program kept patient engagement high and resulted in a 59% increase in the retention rate for the duration of the study.
The full Quintiles report, "Harnessing the Power of the Digital Patient, " can be accessed here.
About Quintiles
Quintiles is the world's largest provider of biopharmaceutical development and commercial outsourcing services with a network of more than 27,000 employees conducting business in approximately 100 countries. We have helped develop or commercialize all of the top-50 best-selling drugs on the market. Quintiles applies the breadth and depth of our service offerings along with extensive therapeutic, scientific and analytics expertise to help our customers navigate an increasingly complex healthcare environment as they seek to improve efficiency and effectiveness in the delivery of better healthcare outcomes.