From god to guide: can patient-centred care become a reality in the NHS?

Most parts of the NHS are only paying lip service to patient engagement, recently hailed as the 'next blockbuster drug'

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• • Mark Britnell
  • Guardian Professional, Tuesday 14 May 2013 03.30 EDT
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Educating patients so that they can make informed choices is vital. Photograph: Suzanne Plunkett/Reuters

As healthcare systems the world over continue to groan under the weight of rising expectations, ageing populations and squeezed finances, the search for viable long-term solutions shows no sign of slowing.

For many, the focus remains on system reform – finding new ways to make the money go further by redesigning services to be more efficient. But, increasingly, attention is turning to the people who use healthcare services as the potential saviour of them.

As Maureen Bisognano, president of the influential US-based Institute for Health Improvement, told the International Forum on Quality and Safety in Health in London in April: "Patient engagement is the next blockbuster drug."

Patient engagement is certainly not a new concept but, in truth, most parts of the NHS are still only paying lip service to it. The default position for many health professionals is still to think in terms of, "What's the matter with you?" rather than, "What matters to you?"

It's easy to see why. Most systems, our own included, are heavily geared towards the five hours a year that, on average, we each consume healthcare. However, ccording to a new report by KPMG, called Something to Teach, Something to Learn: Global perspectives on healthcare, the real gains are being made by health systems that understand the importance of the 8,760 hours a year when we are not officially classed as patients.

Technological advances, such as smartphone apps which can speed a patient's hospital discharge by allowing them to measure ECGs at home, or telemedicine systems, which deliver multidisciplinary virtual clinics, offer a partial solution to empowering patients.

But the reason these breakthroughs have not revolutionised care in the way we thought they might 10 years ago is that a more fundamental issue is being missed – that of understanding a patient's needs beyond treating the condition with which they have been diagnosed. Too often, our systems encourage the health professional to treat the illness, not the person. We chase narrow biomedical indicators, which, while important, don't capture all that matters to the patient.

There's now a great deal of evidence which shows that when patients are asked what they really want, they often choose a different (and in many cases less expensive) course of action to the one their doctor or nurse might have recommended. For example, most patients do not want to spend their last hours in hospital, yet the majority do.

Educating patients so that they can make informed choices, not just about their care but about their overall lifestyles, is vital. But it is also only half the battle. The key is listening to, and acting on, those choices – only then do patients become truly empowered.

And that's where system change comes in. The emerging evidence from around the world, as highlighted in Something to Teach, Something to Learn, is that to thrive in the challenging years ahead, healthcare systems will need to reorient themselves around the needs of patients.

Hospitals will have to look beyond their four walls, bridging the gap with primary care and transforming to become part of health systems, taking responsibility for entire pathways of care.

Primary care will need to become more accessible and more time will need to be given to understanding the needs and expectations of the 3% of patients that drive 50% of NHS costs every year.

These patients, often with multiple conditions, need continuity and access to integrated services which combine primary care, supported by specialists and the effective use of telephone and web-based tools and support. For this to work, health system funding also needs to be reshaped. There are already signs, from around the world, that payers – be they private insurers or governments – are becoming more active.

They are gaining a better understanding of what constitutes quality in the eyes of patients and designing new types of contracts that reward "value" rather than "volume".

ParkinsonNet, a ground-breaking patient-led education programme in the Netherlands, is a great example. It has shifted perceptions about what constitutes value for Parkinson's patients and, as a result, has radically changed practitioner behaviour. The programme has already halved the number of hip fractures suffered by this patient group and delivered savings of £13m.

In a system designed around the patient, clinicians need to move from god to guide, focusing their skills on the provision of information and support to help patients make effective choices and manage their own health and wellbeing.

True patient empowerment is not a bolt-on; it should be the centrepiece of the healthcare jigsaw.

This partnership is pivotal and central to an NHS which delivers both high quality healthcare and value too. Is it possible? With our greatest asset – the hundreds of thousands of front-line NHS staff who work with patients every day – yes, absolutely.

Mark Britnell is chairman of KPMG's global healthcare practice.

This article is published by Guardian Professional.

Responsible Solutions That Protect and Preserve Medicare

Posted on 05/13/2013 by Ian Cunningham  

This is a guest post by Sean Voskuhl – State Director, AARP Oklahoma

Growing up in rural Oklahoma, I saw first-hand the importance of Medicare.  Finding accessible and affordable health care was always very difficult.  Many folks had no choice but to purchase a catastrophic/high deductible plan, or they relied on a spouse to get coverage by taking a job in town, or they went without health insurance at all. Simply put, most people gambled and prayed, trying to hold on till they could get on Medicare.

Today, Medicare is the primary health insurance program for the 49 million Americans who are 65 and older.  Roughly, one in four of those beneficiaries are rural residents, and that number will only rise in coming years.  With changing demographics and rising health care costs, Medicare is facing a number of challenges.  Unfortunately, some in Washington believe the only way to address those challenges is to cut Medicare benefits or force seniors to pay more.  No doubt any such changes to Medicare will greatly impact rural America.

Is there a better way?  What about cracking down on waste, fraud and abuse?  The U.S. health system wastes as much as a third of all spending because of inefficient payment systems, uncoordinated care, duplication, over-testing and unnecessary paperwork.  It’s estimated that Medicare could save hundreds of billions of dollars just by reducing waste.  More could be saved by stepping up fraud detection.  In 2011 alone, anti-fraud efforts recovered $4.1 billion.  In October 2012, Medicare Strike Force operations in seven cities led to charges against 91 individuals-including doctors, nurses and other licensed medical professionals-for their alleged participation in Medicare fraud schemes involving some $432 million in false billing.  And yet we know much more can and should be done.

Here are some other examples of Medicare fraud that may hit closer to home: a healthcare provider bills Medicare for services you never received; a supplier bills Medicare for equipment you never got; someone uses your Medicare card to get medical care, supplies, or equipment; a company offers a Medicare drug plan that has not been approved by Medicare; or, a company uses false information to mislead you into joining a Medicare plan.

If we want to preserve and protect Medicare for future generations, it’s essential to crack down on fraud and abuse.  The resulting savings will cut costs for families, businesses and the federal government, and increase the quality of services for those who need care. But stopping fraud requires the cooperation of everyone-the federal government, state governments, health care providers, insurers, law enforcement, and even people like you and me.

To learn more about the challenges facing Medicare, and hear what you can do to help stop Medicare fraud, tune in to AARP Live on RFD-TV this Thursday, May 16^th at 9p.m. CT on RFD-TV. I’ll be joined by AARP state director Greg Marchildon (VT), AARP senior advisor Pete Jeffries, and AARP Iowa volunteer Maryalice Larson, all of whom have a first-hand view of the challenges facing Medicare. Let’s find responsible solutions that will keep Medicare strong without shifting the burden of higher health care costs onto seniors and future retirees.

Tune in to AARP Live on RFD on Thursday, May 16^th at 9 pm CST to learn more.

Please join me this Thursday night for AARP Live! on RFD-TV, or watch it streaming live at www.aarp.org/rfdand on Facebook

(click here  for “by zipcode” channel locator) Viewers are encouraged to phone in during the show, 888- 687-2277 toll-free, to share your questions/concerns.

Managed Medicare Advantage Plans Demonstrate Better Outcomes for Patients

By Analyzing Insurance Claims From 3 Million U.S. Medicare Patients, The Boston Consulting Group Finds That Managed Private Plans Outperform Traditional Fee-for-Service Medicine on Health Care Quality and Value

BOSTON, MA--(Marketwired - May 14, 2013) - As health systems around the world experiment with alternative models for care delivery and reimbursement to improve health care quality and lower cost, they can learn a lot from the care-delivery models used by private payers in U.S. Medicare Advantage plans, according to a new study by The Boston Consulting Group (BCG).

After analyzing claims data for 3 million Medicare patients, BCG found that on three internationally accepted dimensions of health care quality -- single-year mortality, recovery from acute episodes of care requiring hospitalization, and the sustainability of health over time -- patients enrolled in Medicare Advantage plans offered by private insurers had considerably better outcomes than those participating in Medicare on a traditional fee-for-service basis. The improved quality is delivered on top of the well-understood point that these models already deliver lower costs.

"Our findings demonstrate that the more managed plans do not compromise quality. Just the opposite: they deliver higher-quality care at a lower cost than fee-for-service medicine and thus do a better job of improving health care value," said Jon Kaplan, a BCG partner and lead author of the study. "Payers, providers, and policymakers have a lot to gain by more broadly aligning incentives and delivering strong care management, similar to that utilized by the Medicare Advantage plans."

The findings are detailed in a new report titled Alternative Payer Models Show Improved Health-Care Value, released today on www.bcgperspectives.com.

The majority of the U.S. Medicare-eligible population receive care from doctors and other providers on a traditional fee-for-service basis, with the costs of the services reimbursed directly by Medicare. About one-quarter are enrolled in Medicare Advantage health plans provided by private insurers.

What distinguishes Medicare Advantage plans from traditional fee-for-service plans is the degree to which they use mechanisms designed to encourage the delivery of cost-effective quality care. Three critical mechanisms are financial incentives that are aligned with clinical best practices, a selective network of providers, and more active care management that emphasizes prevention to minimize expensive acute care.

Of the 3 million patients for which BCG analyzed data, approximately 1.3 million used providers on a traditional fee-for-service basis. The remainder were enrolled in one of three types of private Medicare Advantage plans: a preferred provider organization (PPO), a health maintenance organization (HMO), or an HMO with global capitation.

Among the study's specific findings:

   -- Single-year mortality rates fell from 6.8 percent in the traditional fee-for-service sample to 1.8 percent in the three progressively managed delivery models. The lowest rates and the greatest performance were seen in the HMO plans with global capitation. Patients in the three managed models achieved these lower levels of single-year mortality quickly, within the first year of enrollment. 
 
   -- Patients in the Medicare Advantage plans had shorter average stays in the hospital. Compared to the fee-for-service sample, the capitated HMO sample had stays that were, on average about 19 percent shorter. 
 
   -- Patients in the managed plans were more likely to receive preventive care and less likely to suffer from disease-specific complications. For example, diabetic patients in the fee-for-service sample had an average of 11.5 amputations per 1,000 patients; those in HMO plans with global capitation had only 0.3. 

"We've found that U.S. private insurers have created an operating model that can deliver better care at a lower cost and have a major role to play in the ongoing national efforts to improve health care quality," said Stefan Larsson, a BCG senior partner and coauthor of the report. "Quite simply, we've found that the more aligned the care, the better the quality delivered."

Best Opportunities & Biggest Threats in Healthcare

Written by Jim McLaughlin | May 13, 2013

At the Becker's Hospital Review Annual Meeting in Chicago on May 10, a panel of health system executives discussed the greatest opportunities and biggest threats ahead for the healthcare industry. 

Barry Arbuckle, PhD, president and CEO of MemorialCare Health System based in Fountain Valley, Calif.; Daniel Slipkovich, CEO of Franklin, Tenn.-based Capella Healthcare; Sandra Bruce, president and CFO of Chicago-based Presence Health; and Stephen Bonner, president and CEO of Cancer Treatment Centers of America based in Schaumburg, Ill., sat on the panel, moderated by Fox News anchor and former White House correspondent Bret Baier.

Here is an edited transcript of the panelists' discussion:

Bret Baier: What opportunities do you see in the healthcare industry as we move into the first year of health reform?

Stephen Bonner: We need to bring more intelligence into healthcare. We're now moving into a phase of consumers, regardless of what might be set by federal policy, becoming more engaged in their healthcare with more health savings and savvier in how they buy their care. The health reform law and the exchanges are rapidly accelerating that whole structure. It's an unintended consequence, but we're going to end up with more engaged consumers. If we listen, they'll help us deliver cheaper and better care without needing to funnel money through the feds. There's a lot left to be determined, but we think [the U.S. healthcare system] is really missing a major opportunity. We have this incredible capability and capacity, but there's a disconnect between desire and what's available,  and that's not a U.S. phenomenon. Why shouldn't we flip it around and use our excess capacity and invite people to come to the U.S. and improve on that?

Sandy Bruce: Only God knows. We're the largest Medicaid provider in the state, and the exchanges are a big worry for us.  Lots of people will get coverage, but then what happens when they come into our doors without realizing they'll still owe 30 percent of the bill? That'll create a financial burden on providers, if we're not careful. Most of us have grown up building hospitals and filling beds, but that's clearly changed. I think the real opportunities for healthcare lie in the changing revenue streams in different care settings and for different metrics of care. I think we also have a huge opportunity to reduce variation in healthcare. Within my own system of 12 hospitals, we think we could save between 20 and 40 percent by reducing clinical variations among our physicians. [Electronic health records], although they're expensive, can help us achieve that. Another piece I'm particularly concerned about is that a quarter of Americans could be covered by Medicaid in a year. We are oblgated to figure out a way to deliver care to them at a very different cost structure. It can't look like what we've been doing.

Barry Arbuckle, PhD: The upcoming changes are mindboggling in significance. I'm a big fan of complete connectivity and seamless connection to population health. You're fooling yourself if you think you can do population health or keep physicians integrated without it. There are also lots of interesting and creative partnerships being formed between providers that provide benefits of scale but fall short of a full transaction.

Dan Slipkovich: We're repeating a lot of what we did in the 1990s. We're expanding outside our walls and buying other entities, etc., but I'd tell you it's going to stick this time. In the '90s, we simply didn't have the technology to follow through on the initiatives of the time. The trouble for us now is going to be meeting the influx of new patients, many of whom will be covered by Medicaid. Many say hospitals will benefit from more insured patients, but it's going to be a shift to re-spending the same dollar amount on a much broader population. Access is also a big issue. Our emergency department services grew 10 percent last year, but that's because so many patients didn't have anywhere else to go.

Mr. Baier: What looming threats have been keeping you up at night?

Dr. Arbuckle: There are solvency concerns about the Medicaid program, as well as Medicare so long as politicians keep using it as their piggy bank to solve other budget problems. The solution, I believe, is in managed care. It's the only thing that can cause those programs to survive, but it takes infrastructure and experience. Everything is harkening back to the '90s, but I truly believe we're doing it different this time. We have better systems, better technology, even better intentions. Before it was all about money, but now it's survival. We have better regulation now, too. We might actually be successful this time.

Mr. Bonner: The biggest threat is misleading for what we're trying to create and what it'll take to create it. Healthcare has become so politicized, but can we really engage people in the discussions about how to do healthcare better? I think we're failing to engage in the right conversations. We need to connect the will to drive quality to where it belongs and cost what it ought to cost. There's a lack of will to tackle really tough systemic issues, such as primary care. Can we tackle malpractice in this country? Can we tackle transparency? We equip people with the kind of information that JD Power & Associates give to keep them from buying crummy products, but not in healthcare. How do we pretend to be a consumer-driven industry if we can't do that? The greatest clinical opportunities are through innovations in oncology, finding the best balance between safety, efficacy and speed.The cost we can take out of the system and the human cost we can take out in avoiding side effects is astounding.

Ms. Bruce: We believe there's probably overcapacity in hospitals today, and acute care will shrink. Everything's moving into medical home office ambulatory settings. What will become of the capital investments we've all made in patient towers and all the rest over the years. We're struggling on where to place the bets on where the industry is going. We're also starting to worry that our biggest competitor is no longer other large hospital systems but Walgreens and the retail clinics. We're still protecting our big-box assets, while others are coming in who'll get into the new industry better.

Mr. Baier: What do you predict other systems will begin doing to adapt to the changing landscape of healthcare?

Dr. Arbuckle: I have a hard time predicting what's going to happen. There will be changes in resource utilization without a doubt. At the same time, there's a burgeoning population of seniors who will utilize healthcare resources at six times that of the commercial population. We've also got  an obesity epidemic in this country and all the problems that causes. I believe we'll see fewer beds in larger markets as we shift to more population health management in the ambulatory setting. Freestanding, non-profit hospitals historically have had an amazing ability to lose money and hang on for years, and this time, I worry they may not. Now is the time to be exploring partnerships and transaction opportunities of all kinds, not when you're desperate. There's a major problem with staffing resources as well. I have hundreds of open positions that I can't fill, even in this unemployment market. Right now we've got excess capacity in the marketplace, consolidation will drive that excess out. I firmly believe over the next five to eight years, you'll see 500 fewer hospitals in this country. 

Ms. Bruce: The framework of our competition is changing. Consumers are changing rapidly too. If we connect with them, learn what they value and how to deliver that to them, we'll still fill our patient towers, but we don't need to make people come to the big boxes to get their height and weight. There's no need for them to come in if their iPhone can send a high-resolution image of their lesion to a physician who can diagnose and prescribe care remotely. Customers know that, so how can we engage them, and will we get paid to deliver that way? One of my doctors has been doing just that, but hasn't told people about it because he knew it wouldn't produce any RVUs. Johns Hopkins is piloting a stay-home admission model, which is cheaper and minimizes infection risk, but it still has to be approved by payors.

Dr. Arbuckle: I think we'll see a resurrection of worksite clinics, but the only way it can work economically is if there are aligned incentives. We know there is a lot of waste in the healthcare system. I recently learned I have an allergy to beestings. I now get allergy shots twice each week. For those who'd have to leave work to travel to a physician's clinic, wait to be seen, handle the billing and return, that's two hours of work time lost, and twice  per week. The productivity loss is crazy for employers! That's a perfect candidate for a worksite clinic. Obviously we've got a lot of changes and challenges, and for us it starts with people. Everyone should engage their boards and physicians to get the people side  of this right. Beyond that, it's easy to get caught up in the problem of the day. Despite what happens with Medicaid, we know what we have to do — stay very focused.

Mr. Bonner: The fundamental here is to stay clear on our fundamental purpose and who we need to serve. Healthcare is rightfully under the spotlight. The wisdom of the customer coupled with the wisdom of medicine and employers brings us all to a more efficient, more effective delivery of care. We know waiting in hospitals builds stress, wastes time for us and for employers, so last year we took 150,000 hours of patient wait time out of our process. Listen to customers. There's a great future in healthcare in America. A lot of [healthcare executives] have one foot on the dock and one foot in the boat. Call your shots, be courageous and increase your appetite for risk.

The Real Cost of Education, Auditing and Patient Engagement: $5 PMPM

Kameron Gifford, CPC   www.ermconsltinginc.com

Republican, Democrat or Independent; Provider, Patient or Payor, It doesn’t matter what side of the line you fall on – we can all agree on one thing – Healthcare Reform is as necessary as it is Inevitable. We must align ourselves for the paradigm shift that lies ahead. We can’t continue to repeat the same actions over and over again with the expectation of different results? That, by definition, is insanity.

I recently wrote an article, “Mission Critical, Target Missed: $34.1 Billion in Overpayments to MA Plans in 2012” in which I referenced a recent study that found MA plans were (on average) overpaid $2,600 per beneficiary last year. If we break that down month over month we are looking at approximately $200 per month per enrollee. What did MA plans spend that money on in 2012?

How did their enrollee’s experience of care compare to their neighbors who elected to stick with traditional Medicare? And what about the providers who took care of these patients? How did their experience of providing care to MA members compare to those patients with traditional Medicare?

It might surprise you that the answer to that question would fluctuate greatly depending on who you asked, where they lived, what type of care they needed (or provided) and what plan they were enrolled with (or contracted with) last year.

According to the Kaiser Foundation, Medicare Advantage enrollment grew by 10% in 2012, exceeding 13 million enrollees or 27% of the total Medicare population. Of those 13.1 million, only 26% of all Medicare Advantage enrollees were covered by plans that were rated as above average or excellent, and 575,000 enrollees, about 9% were in plans that were “underperforming” and received less than 3 stars.

This is our solution? A solution that is plagued with complex reimbursement systems and unsustainable costs? One in which the access to care has been severely restricted all in the name of cost reduction? A system in which patients with insurance are unable to access the care they need and as a result do not get cost saving, preventive services. A solution that is only providing average care to the majority of our seniors?

We know that the cost of care is directly proportionate to the value it provides, and to be effective, that value must be meaningful to the patient.

So how much money was invested in 2012 by Medicare Advantage plans to close traditional gaps, improve access to care and educate patients? What incentives were paid to primary care doctors who went over and above the traditional “standard of care” to coordinate, monitor, and deliver care even during those critical periods of transitions? What about on patient outreach? Who is calling the member who hasn’t reached out to their PCP after enrolling? Or, are we only reaching out to those that are over-utilizing services?

Education is the only answer to a sustainable system.

What training is mandated for HCC Coders? Why aren’t physicians being taught the underlying principles of risk adjustment instead of being asked to assign specific ICD-9 codes to their MA members? Where is the transparency that Obamacare was intended to provide?

What if the answer to our healthcare crisis isn’t in the millions of medical records we are auditing and re-auditing? What if the answer isn’t in the “missing diagnosis” codes or the “monetary penalties such as recoupments”?

But, instead in the investment of education for patients, providers and office staff? What if the answer was creating more flexibility in the delivery of care or strengthening communities to bring that sense of responsibility into our neighborhoods? What if we took the money invested in prosecuting and defending waste, fraud and abuse and redirecting it into improving access and developing mobile platforms to meet the needs of patients?

Empirical Risk Management was able to create this personalized, comprehensive, integrated care in our recent pilot program. The cost of the program was less than $5 per member per month, and the value it created extended beyond quality measures and HEDIS - it instilled a desire to make better choices.

If we can innovate for as little as $5,per member per month, I can't help but wonder where the other $195 was spent?

Lincor Solutions Launches World’s First Mobile Solution for Patient Engagement and Clinical Services

MEDIVista MOBILE delivers services to Apple iPad and Android devices

DUBLIN -- 

Lincor announces the latest addition to the MEDIVista product suite – MEDIVista MOBILE, during eHealth Week in Dublin.

MEDIVista MOBILE delivers patient services to iPads and Android wireless tablets and is a modular extension to the proven MEDIVista service delivery platform already deployed in over 20 countries and 125 hospitals. MEDIVista provides patient centric content and applications to fixed bedside terminals, improving patient outcomes and workflow for both nurses and physicians.

“Many hospitals are facing demands to develop a BYOD (Bring your own Device) strategy so patients can use their own mobile devices,” explains Lincor Solutions co-founder and CTO Enda Murphy. “Without proper management and control, this can lead to strain on the hospital wireless infrastructure. The proven MEDIVista server technology gives hospitals this control plus the ability to fully manage a potentially lucrative revenue stream.”

Business Wire - MEDIVista MOBILE in use by a patient to access a range of services including live TV and Movies on Demand

Richard Cooke, Lincor Solutions CEO,continues, “The rise of tablet devices has led to an increased expectation from patients and their visitors that they can use their own devices while in hospital. MEDIVista MOBILE enables just that and is a world first solution for hospitals to deliver live TV, Movies on Demand, internet access and Skype to both fixed bedside terminals and mobile tablet devices through a centrally managed service. Customers new to MEDIVista also get the peace of mind that comes from having the solution underpinned by tried and tested technology designed for the hospital environment.”

About Lincor Solutions

Lincor Solutions, founded in 2003, operates internationally from corporate offices in Nashville, Tennessee, as well as Dublin and Cork, Ireland. With sales offices in Toronto, Canada, Bordeaux, France, and Vienna, Austria, the company supports the largest installed base of its type worldwide. Lincor’s MEDIVista product set is delivered through a network of channel and technology partners in Europe, Middle East, Asia and the Americas.

Lincor will be showcasing MEDIVista MOBILE at eHealth Week Booth #617

For more information, visit www.lincor.com

10 Guiding Principles of HCC Coding

Compliant Coding and Documentation begins with Education.... 

The following 10 principles guided the creation of the CMS-HCC diagnostic classification system:

 •Principle 1—Diagnostic categories should be clinically meaningful. 

•Principle 2—Diagnostic categories should predict medical expenditures.

•Principle 3—Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures. 

•Principle 4—In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate.  Because each new medical problem adds to an individual’s total disease burden, unrelated disease processes should increase predicted costs of care.  However, the most severe manifestation of a given disease process principally defines its impact on costs.  Therefore, related conditions should be treated hierarchically, with more severe manifestations of a condition dominating (and zeroing out the effect of) less serious ones.

•Principle 5—The diagnostic classification should encourage specific coding. 

•Principle 6—The diagnostic classification should not reward coding proliferation.  The classification should not measure greater disease burden simply because more ICD-9-CM codes are present. 

•Principle 7—Providers should not be penalized for recording additional diagnoses (monotonicity).  This principle has two consequences for modeling: (1) no condition category (CC) should carry a negative payment weight, and (2) a condition that is higher ranked in a disease hierarchy (causing lower-rank diagnoses to be ignored) should have at least as large a payment weight as lower-ranked conditions in the same hierarchy.

•Principle 8—The classification system should be internally consistent (transitive).

•Principle 9—The diagnostic classification should assign all ICD-9-CM codes (exhaustive classification). 

•Principle 10—Discretionary diagnostic categories should be excluded from payment models.

Characteristics of CMS-HCC Model

 

•What is a Hierarchical Condition Category?

▫Category of medical conditions that map to a corresponding group of ICD-9 diagnosis codes

•2,913 ICD-9 Codes Map to 1 of 70 HCC’s

*Per the ICD-9-CM Official Guidelines for Coding and Reporting:

“Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”

If you would like to learn more information about HCC Coding please visit our website: www.ermconsultinginc.com or www.cms.gov

https://www.cms.gov/Medicare/HealthPlans/MedicareAdvtgSpecRateStats/downloads/Evaluation_Risk_Adj_Model_2011.pdf

Mission Critical: Target Missed: $34.1 Billion in Overpayments to MA Plans in 2012

$34.1 Billion: Overpayments to MA Plans in 2012

By: Kameron Gifford, CPC 5/11/2013
www.ermconsultinginc.com

Medicare Advantage plans received $34.1 billion in overpayments in 2012, according to a study published today in the International Journal of Health Services by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled "Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.”

This number is even more alarming if we consider that there were only 3,518 private health plans providing benefits to 13 million Medicare beneficiaries in 2012. That is, on average, $100,000,000 in overpayments per plan.

Who is regulating this spending and where is it going?

It is a typical Monday morning at my office, I won’t transfer the phones for another 15 minutes, but I already know that we are in for a long day. My computer screen informs me that we have received 73 refill requests over the weekend and I have 2 “emergencies” that “really need to see the doctor”. After politely reminding, that we do not accept walk-ins, I agree to work them in and they are happy to wait.

Mrs. Jones saw her cardiologist on Friday and he changed her BP medication, but she couldn’t remember what else she was asked to stop. Our patients are taught early on to bring all of their medicine bottles with them to their appointments. After 15 years, this has become habit and before I even ask I have two plastic bags filled with various prescription bottles, creams, inhalers and vitamins piled in front of me. It takes about 3 minutes for us to retrieve the notes from her cardiologists and another 3 minutes to mark a large red “X” across three bottles. Mrs. Jones thanks me over and over again for my help and I can see the relief in her face as she proudly shows me the notes she has taken in her journal. Under her Medicare Advantage HMO, Mrs. Jones doesn’t have to pay a copay when she sees her PCP and there is no charge for our services today.

Mr. Garcia is next. He states that he doesn’t remember why he is here, but then his eyes light up, as he pulls out a crumpled up piece of paper from his back pocket. In blue pen, his daughter has written down his temperature, BP and pulse readings from 5 various times and even made notes of some symptoms her father had been complaining of over the weekend as well as a list of a current medications. I made a mental note to call Maria after lunch and thank her (HIPPA release on file gives us permission to coordinate care with his daughters and wife). No one was able to get off work to bring her dad this morning, so he had to ride the bus. By the time he got there he was so tired and anxious from the journey (not to mention early dementia) that he couldn’t remember anything except that little note in his pocket.

After seeing the doctor, orders are given for a urine to be collected. A quick look under the microscope and in less than 10 minutes the origin of the fever was discovered to be an acute UTI. A prescription for antibiotics was emailed to his pharmacy and Mr. Garcia was feeling much better in 48 hours. The cost of his care was $3.14 for the urinalysis done in the office and he took his first dose of Cipro at 9:15 AM. His total out of pocket cost came to $5.

Tragedy averted by a simple act of kindness? Perhaps, but I prefer to use the modest words of my father, “It’s Just Good Medicine!”

His primary care practice is still located within 15 miles of where he completed his residency 35 years ago. Over 50% of our patients have been with the practice for more than 20 years, and our typical patient is an 83 year old male with 3 or more chronic conditions.

In 2012, with a patient mix of 65% Medicare Advantage, 25% Medicare and 10% Commercial patients we posted real profits of over $400,000.

My father was a business man first, physician second, and true to his roots, he has spent his career working to provide quality, comprehensive, preventive care at a tremendous cost savings to both his patients and their health insurers.

The structure of his practice closely resembles the early days, one physician and 3 staff members. In some respects, we still practice “old school” medicine.

When you call our office, we still answer the phone, not a confusing recording. The majority of our patients wait less than 5 minutes to be seen and can be worked in same day if necessary. A patient’s history is not completed in the waiting room by placing checkmarks next to applicable conditions. It is taken in question and answer form face to face with the physician. We schedule appointments every 15 minutes, but new patient visits average 30 minutes. When a patient is referred for a test or to a specialist we make the appointments. This ensures that WE get the report. Every patient gets an annual comprehensive exam, if they are willing (and most are.) All diabetic patients are seen every 3 months fasting, even when they complain. Changes in medications (such as BP) are followed up on in 2-3 weeks to ensure target levels. Everyone in the office works together to ensure that all patients have a current LDL and all efforts are made to keep it under 100. Prescription medications are not refilled for 12 months at a time. We allow enough refills only until the next appointment to provide a safety net for “lost patients”. This system, although labor intensive, provides the best outcomes for our patients.

All referrals and authorizations are processed by set protocols that deliver continual oversight and monitoring of our patients between home providers, specialists, inpatient facilities, outpatient facilities and rehabs. Most importantly, we strive to educate our patients at every point along the way.

The brilliance is in the simplicity of that solution my father sought back in 1979 to guarantee his patients received the “Gold Standard” of care. It is that system that he has refined and modified over and over again, year after year, to continually do what is right for the patient.

In Managed Care terms, our practice was able to provide high quality care at an average savings of $400 per member when compared with our counterparts.

The majority of Medicare Advantage plans are operating light years behind where they need to be. Employer sponsored health plans have long been reaping the benefits of their innovative Wellness Programs designed to engage employees as partners instead of numbers.

Correct me if I wrong, but wasn’t it this expertise that the government so desperately sought to save our Medicare program. Twelve years have passed since the inception of “Part C” and what value have we added to America’s health system for seniors?

Last week, I received a call from one of my patients, who had been with our practice for about a year. During that time, her MA plan, like many others experienced many “system errors” a common side effect these days of healthcare companies trying to frantically upgrade hardware and software to comply with new regulations. Her call that morning was to tell me that she was switching doctors. It wasn’t because she had been treated badly or because she didn’t like the doctor. Her reason was simple. Her insurance company had denied our third appeal to cover a routine check-up for rheumatoid arthritis and again refused to pay the $49 cost of her visit. I couldn’t believe what I was hearing. She went on to say that when she called the number on the back of her card to ask why she was again told, it was “because her PCP didn’t obtain an authorization for services.”

The patient had a valid authorization, but it had “accidentally” gone into the wrong system. We all make mistakes, but it is what we do to correct the situation that defines our integrity.

Even after submitting all supporting documentation and following “standard procedures” the decision was final: DENIED.

Now, allow me to pose the question again, where did that add value?

Medicine is the only trade in the world in which we provide a service and then have to fight to get paid. Where is the accountability to the patient who signed up with the plan or to the tax payers who fund the system?

$31.4 Billion in Overpayments to Medicare Advantage plans and my patient can’t sleep at night because she is worried her rheumatologist (the only one in town) won’t see her next month…

As Americans, we must demand fiscal responsibility and stop allowing seniors to pay the price.

The future of our healthcare system depends on putting the patient first, and change must be initiated at the initial point of contact. Care must be integrated, and flexible enough to fit the needs of each patient. Disruptive innovation doesn’t necessarily mean a new idea or concept, but additionally represents the ability to improve the experience for our patients.

Our public health care system is in serious trouble, we must act before it is too late.

Medicare Advantage, as it is today, must be changed. We need to eliminate the opportunity for big business to profit from this system, and give the power back to the physicians and patients. I can’t help but ask, have we forgotten who pays the premiums?

We must create educational opportunities for patients, office staff and providers to empower a partnership for greater health. Solutions founded in the most basic ideas of prevention and primary care combined with patient centered technology will provide long term stability and positive outcomes. The greatest thought leaders of our time have yet to be defined, who will be the next disruptor? 

Published on FierceHealthPayer (http://www.fiercehealthpayer.com)

OIG: Cigna overbilled Medicare Advantage for $28M in 2007

May 8, 2013 | By Dina Overland

Cigna Healthcare of Arizona, a subsidiary of national insurer Cigna providing Medicare Advantage plans, overbilled Medicare by about $28 million in 2007, according to a new report released last week from the U.S. Department of Health & Human Services Office of Inspector General.
The OIG determined that Cigna submitted diagnoses to HHS for its risk score calculations that didn't always comply with federal requirements. Of the 100 beneficiaries in the sample OIG analyzed for the report, 40 had invalid risk scores because either the documentation didn't support the associated diagnosis or the diagnosis was unconfirmed.
Because Cigna's contracts require its providers submit accurate claims, the insurer assumed all providers were submitting accurate diagnoses as well. But the OIG said providers often report incorrect diagnoses or report diagnoses for conditions that didn't exist when providers treated the beneficiaries.
Based on its investigation, the OIG said Cigna must repay at least $151,000 in improper charges. The federal auditor also recommended that HHS conduct a more in-depth review of the disputed payments. Also, CIGNA needs to bring its "significant error rate" into compliance with federal rules, the report said.
"For one beneficiary, Cigna submitted the diagnosis code for 'congestive heart failure, unspecified,' " the report said. "However, the documentation that Cigna provided indicated that the beneficiary visited the physician because of knee pain. The documentation did not support the diagnosis of congestive heart failure."
Cigna, however, disagreed with the OIG's findings. In a written response to the report, Cigna said the OIG didn't properly account for frequent disparities in charges shown in claims data and in medical records. What's more, the OIG should have analyzed more medical records in its sample and taken a different statistical approach, both of which would have resulted in Cigna owing a total of just $440,000.
HHS will review the report and decide whether to implement the OIG's recommendations or take separate action. Cigna can appeal the report's findings.
To learn more:
- here's the OIG report