O HIPAA, Where Art Thou?

"The Power of Photoshop Compels Me..."

Well, December 1st, and no Omnibus Final Rule yet. Now perhaps the delay is to keep it away from the "fiscal cliff" rhetorical inversion layer now descended upon DC -- one more huge regulatory thing for Republicans to hate.

Whatever.

HHS can certainly hop off the dime quickly when it suits them. to wit:

I wonder whether they'll be dropping a "November Update" pronto. Gotta demonstrate to The Hill just how loved is the Meaningful Use program. I know we're under ramped-up pressure to get every EP with a pulse registered.

It's dicey, though. Cuts both ways, given the HIT press brushfire ignited by the OIG report (see my prior post). There's long been a loud and persistent anti- Meaningful Use contingent, both in Congress and in the health care industry. Pardon my skepticism that the timing of the OIG report release was coincidental.

Gonna be an interesting month.

DEC 6th ONC UPDATE

Well, that was quick, just like I speculated it would be (props to iHealthBeat.org).

 

From the 12/5 HITPC meeting deck:

...During a meeting of the Health IT Policy Committee on Wednesday, Robert Anthony -- a specialist in CMS' Office of eHealth Standards and Services -- said that a total of $868 million in Medicare and Medicaid meaningful use payments were distributed in November. That total included:

• $645 million in Medicaid and Medicare incentive payments for hospitals;
• $150 million in Medicare incentive payments for eligible providers; and
• $73 million in Medicaid incentive payments for eligible providers.

Anthony said he expects the total amount of meaningful use payments distributed to reach $10 billion by the end of this year.

$645 million to EHs in November? That's close to the entire 62-REC four year grant allotment.

Not one word in the ONC Powerpoint deck (pptx) in support of the REC initiative. Neither any recognition of what we've done nor any recommendation that we be further supported.

I wrote my senators and congressman. 

Good day,
 
Is there any legislative movement toward eliminating the Meaningful use incentive money under ARRA/HITECH? I am with the Nevada-Utah REC (HealthInsight). RECs are busily moving along -- including planning for Stage 2 and 3 support --, but if Congress successfully eliminates funding for the incentive reimbursements (perhaps as part of resolving this "Fiscal Cliff" circus), the entire thing becomes moot. Perhaps effective January 1st.
 
The sanguinity at ONC is rather striking. Is it warranted?
 
Is the political reality simply that there would not be sufficient votes to override a presidential veto on this issue even were a recission bill to pass both Houses, so that trying to pull these (relatively small potato) funds is a waste of time, and consequently a low priority for anyone on the Hill other than the usual Barkers? Or, might MU be an actual administration sacrificial bargaining chip?
 
I will be posting this query on my independent REC blog at
 
http://regionalextensioncenter.blogspot.com
 
I look forward to hearing from you.
 
Sincerely,

Bobby Gladd 

Well, what good is Meaningful Use "Schtimulus," anyway? What will it buy?

“Part of me is ecstatic because, why not have more ‘schtimulus,’ and, part of me is, like, well, now we’re gonna ‘schtimulate’ all these losers, and, so, why couldn’t we just let them die, and we’ll just do it ourselves?”

- AthenaHealth CEO Jonathan  Bush, HIMSS 2009

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OIG REPORT PUSHBACK

This made the rounds yesterday.

Trust But Verify: Why CMS Got It Right On EHR Oversight
November 30, 2012, by Ashish Jha

Yesterday’s New York Times headline read that “Medicare Is Faulted on Shift to Electronic Records.”  The story describes an Office of Inspector General (OIG) report, released November 29, 2012, that faults the Centers for Medicare and Medicaid Services (CMS) for not providing adequate oversight of the Meaningful Use incentive program. Going after “waste, fraud, and abuse” always makes good headlines, but in this case, the story is not so simple...

What The Office Of Inspector General Recommended …
The Office of Inspector General examined how carefully CMS is overseeing this program, with particular interest given the reliance on self-reporting of meaningful use, and found areas for improvement.  Several of the OIG recommendations for improving oversight are sensible, measured, and very likely to improve the integrity of the program.  For instance, OIG recommends that CMS provide detailed guidance to providers about what constitutes adequate documentation to support their attestation.  This is the equivalent of the IRS providing guidance on what documentation you need to prove that your tax deductions are legitimate.  Another reasonable OIG recommendation is that certified EHRs be able to produce automated reports about all the functions required to meet meaningful use.  I suspect this will not be particularly onerous for EHR vendors to meet.

… And Where OIG Went Wrong
Where the OIG goes astray is their recommendation that CMS “obtain and review supporting documentation” from selected doctors and hospitals prior to payment.  This is the equivalent of the IRS asking a large chunk of Americans to send in their receipts and detailed explanations along with their 1090s before they get their refund.  Based on the screening tool discussed in the OIG report, about 100,000 physicians and 800 hospitals would be subject to creating these detailed reports with a large amount of supporting evidence each year — and CMS would need to add a substantial number of staff to review all these reports before making any payments.

CMS chose not to concur with this recommendation, and I think CMS is right. There is little evidence to date of any fraud, waste, or abuse in the EHR incentive program.  Were they to follow this OIG recommendation, CMS would effectively make waste in the program more likely...

CMS’s Approach On EHR Payments Strikes The Right Balance
Given that there is no evidence that doctors and hospitals are systematically committing federal fraud by reporting that they are meaningfully using EHRs when they are not, CMS has instead planned a post-payment audit.  And if physicians or hospital executives are found to have deliberately and consciously lied in order to get incentives, they should be prosecuted.  If they made an honest mistake — and given the complexity of meaningful use criteria, this is a real possibility — they should give the money back and potentially pay a fine.  But creating a huge new burden will dissuade many providers from even adopting EHRs, and continuing to rely on paper records is no way to deliver health care.  The cost of the latter to the American public, in terms of duplicate tests, medical errors, and general poor quality care, is far more substantial.

In each regulatory decision, there is a balancing act:  have too few checks and there will be widespread fraud; be overly heavy-handed and you may end up penny-wise and pound-foolish.  The approach that CMS seems to be taking is, in the famous words of President Reagan, “trust, but verify.”  Trust that providers are being honest – but verify through selected audits.  It appears to get the balance right. This approach was good enough for President Reagan’s dealings with the Soviet Union and I suspect that it’s good enough for CMS’s dealings with doctors and hospitals.

I have to agree.
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UPDATE

Thank you for your interest in ARCH-IT!
Our website is currently under development.
We hope to have it up sometime in the near future. 

FROM THE NEW YORK TIMES

A Hospital War Reflects a Bind for Doctors in the U.S.
By JULIE CRESWELL and REED ABELSON
Published: November 30, 2012. 452 Comments

For decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.

But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground...

A Drive to Consolidate
An array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation in health care and transforming the practice of medicine in Boise and other communities large and small. In one manifestation of the trend, hospitals, private equity firms and even health insurancecompanies are acquiring physician practices at a rapid rate.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000, according to estimates by Accenture, a consulting firm.

Many policy experts praise the shift away from independent practices as a way of making health care less fragmented and expensive. Systems that employ doctors, modeled after well-known organizations like Kaiser Permanente, are better able to coordinate patient care and to find ways to deliver improved services at lower costs, these advocates say. Indeed, consolidation is encouraged by some aspects of the Obama administration’s health care law.

“If you’re going to be paid for value, for performance, you’ve got to perform together,” said Dr. Ricardo Martinez, chief medical officer for North Highland, an Atlanta-based consultant that works with hospitals.

The recent trend is reminiscent of the consolidation that swept the industry in the 1990s in response to the creation of health maintenance organizations, or H.M.O.’s — but there is one major difference. Then, hospitals had difficulty managing the practices, contending that doctors did not work as hard when they were employees as they had as private operators. Now, hospitals are writing contracts more in their own favor.

“Hospitals are constructing compensation in ways that are based on productivity and performance,” said Steve Messinger, president of ECG Management Consultants, which advises on physician acquisitions.

But the consolidation of health care may be coming at a hefty price. By one estimate, under its current reimbursement system, Medicare is paying in excess of a billion dollars a year more for the same services because hospitals, citing higher overall costs, can charge more when the doctors work for them. Laser eye surgery, for example, can cost $738 when performed by a hospital-employed doctor, compared with $389 when done by an unaffiliated doctor, according to national estimates by the independent Congressional panel that oversees Medicare. An echocardiogram can cost about twice as much in a hospital: $319, versus $143 in a doctor’s office...

Dr. Mark Johnson, a family practice physician who has worked in Boise for about 25 years, was part of a five-person practice that sold itself to St. Luke’s. Among the factors behind the decision were the high cost of adopting an electronic health records system, and a concern that the group members would not be able to find younger doctors willing to buy them out of the practice.

“But probably the driving reason was the changing landscape of health care delivery and the uncertainty around that,” Dr. Johnson said. “The thought was that we were going to be in a safer position if we were aligned and affiliated with a network.”...

This is a fairly searing, detailed, and important article. Read the entire piece.

Couple of other things to note on this topic:

Why Health Care Is Reshaping Itself
by JOE FLOWER on NOVEMBER 29, 2012

Costs and revenue: This is the oxygen of any business, any organization. What are your revenue streams? How much does it cost you to produce them? Life is not just about breathing, but, if you don’t get that in-out equation right, there is nothing else life can be about...

Good article. Though, with respect to apt analogies, I would say that revenue is the oxygen and cost is the CO2. 

From The Peoples' Republic comes this bit of angst:

Health insurance rates could shoot up
Critics call proposed rate increases an attempt to pad profits before new law takes effect
Victoria Colliver, Updated 10:57 p.m., Thursday, November 29, 2012
 
California health insurers are proposing double-digit rate increases for hundreds of thousands of policyholders, drawing criticism that health insurers are padding their profits as the nation prepares to carry out the federal health care law.

Anthem Blue Cross, the state's largest for-profit health insurer, wants to raise rates an average of 17.5 percent for 744,000 members in February, with some Anthem policyholders seeing increases as high as 25 percent.

"Here we go again," said Bruce Trummel, 62, who just got notice from the insurer about a 24.6 percent increase. Trummel, a self-employed piano tuner from the small town of Aromas, which borders Monterey and San Benito counties, said this will be the second rate hike of the year from Anthem, totaling 45.6 percent. His premiums will jump from $423 to $616 per month if the new rates go through.

Other insurers are also proposing hikes.

Aetna is planning a nearly 19 percent raise in rates for about 69,000 members with individual policies in April, and Kaiser Permanente wants to raise rates by 8 percent for more than 220,000 members in January, according to filings with the state's two regulatory agencies, the Department of Insurance and the California Department of Managed Health Care.

Also in January, UnitedHealth Group has proposed 10 percent hikes for 11,000 policyholders...

One's head fairly swims at all of this. I have United HealthCare at work (mine is PPO). They're sticking it to us as well. They want 12.5% more next year. Hemsley too has bills to pay.

Bachelor's degree. I don't know what ONC's Farzard (MD) makes, but it's a safe bet that it's perhaps 1/300th of that per year.

Who delivers more value to society?

Asked and Answered.  
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VEGAS AS A "MEDICAL TOURISM" DESTINATION?

The joke I've heard repeatedly across the 20 years I've lived in Las Vegas goes like this:

• Q: Where do you go when you get really sick in Las Vegas?
• A: McCarran airport.

So, I had a good chuckle when I saw this press release:

Sunday, 02 December 2012
The American Academy of Anti-Aging and Regenerative Medicine (A4M) has inked a five-year contract to bring its educational world conference to Las Vegas through 2016. A4M, who's hosted their conference in Las Vegas since 2002, chose to continue to host its annual conference for the next several years in Las Vegas, due to its commitment to advancing medical and wellness tourism as a key growth market.

Therefore, A4M plans to bring its education curriculum to local, national, and international healthcare practitioners to understand the key advances in medicine and raise awareness of medical tourism...

Yeah, the Mayor and the LVCVA are apparently all over this.

LAS VEGAS PLACES ITS BETS ON MEDICAL TOURISM
by Nick Verrastro November 17, 2011
Guide Details Vegas Health & Wellness Travel Options
The Las Vegas Convention and Visitors Authority has produced a 176-page Las Vegas Health and Wellness Destination Guide, in cooperation with the Medical Tourism Association. The guide contains information on medical and dental treatments, cosmetic procedures, corporate wellness programs and retirement living in Las Vegas and southern Nevada. Also included are a directory of medical facilities and travel information.

Las Vegas Mayor Carolyn Goodman, in her introduction to the guide, stated that the recent opening of the Cleveland Clinic’s Lou Ruvo Center for Brain Health “has put [Las Vegas] on the map as a premier medical travel destination.”...

I know; the jokes just write themselves.

OK, ENOUGH SNARK. WHAT'S THIS "A4M"?

They're having an event here this month. Interesting.

From their website:

What is Anti-Aging Medicine?

Anti-aging medicine is the pinnacle of biotechnology joined with advanced clinical preventive medicine. The specialty is founded on the application of advanced scientific and medical technologies for the early detection, prevention, treatment, and reversal of age-related dysfunction, disorders, and diseases. It is a healthcare model promoting innovative science and research to prolong the healthy lifespan in humans. As such, anti-aging medicine is based on principles of sound and responsible medical care that are consistent with those applied in other preventive health specialties. The anti-aging medical model aims to both extend lifespan as well as prolong healthspan - the length of time that we are able to live productively and independently.

Anti-aging medicine is the following:

• It is scientific. Anti-aging diagnostic and treatment practices are supported by scientific evidence and therefore cannot be branded as anecdotal.
• It is evidence-based. Anti-aging medicine is based on an orderly process for acquiring data in order to formulate a scientific and objective assessment upon which effective treatment is assigned.
• Is well-documented by peer-reviewed journals. As of this writing, the National Library of Medicine hosts more than 3,000 peer-reviewed articles on the subject of anti-aging medicine.

Hundreds of scientific research studies clearly prove that modest interventions in diet, exercise, nutrition and single-gene modulation in the laboratory setting beneficially and significantly impact healthy function in old-age...

A first-ever study reveals the secrets of exceptional health in old age. Mark Kaplan, from Portland State University (Oregon, USA), and colleagues utilized the Health Utilities Index Mark 3 (HUI3), a multidimensional measure of health status, to examine the maintenance of exceptionally good health among 2,432 elder Canadians enrolled in the Canadian National Population Health Survey, which tracked participants' health for a ten-year period, 1994 to 2004. The researchers found that the most important predictors of excellent health over the entire decade were:

• absence of chronic illness
• income over US $30,000
• having never smoked
• drinking alcohol in moderation
• maintaining a positive outlook
• managing stress levels

The team comments that: "Many of these factors can be modified when you are young or middle-aged. While these findings may seem like common sense, now we have evidence of which factors contribute to exceptional health [as we age]."

Can't argue with that last bullet list.

Check out their "Master's Degree in Metabolic and Nutritional Medicine."

After seven years in the making, The American Academy of Anti-Aging Medicine is proud to announce that The Fellowship in Anti-Aging, Regenerative, and Functional Medicine is now qualified to extend a master's degree program from one of the leading US medical schools. The School of Biomedical Sciences College of Medicine, University of South Florida School of Medicine (USF) is offering a Master of Science in Medical sciences with a Concentration in Metabolic and Nutritional Medicine...

It is imperative for those committed to the prevention of the diseases of aging arm themselves with the proper credentials in this area of medicine. The master's degree offered through the University of South Florida, following completion of the Fellowship program will allow physicians and practitioners to practice independently and confidently in this specialty area...

I'd like to get a look at the coursework. And get a precise definition as to who counts as eligible "practitioners."
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DIVERSION

My other world.

Doing some DVD cover art for my friends' band. Using my subscription Adobe Suite Illustrator CS6. Fun. Gonna do one for the Ole Borud guest artist night show as well.

Back on topic shortly. Will we get a HIPAA Omnibus Rule in the morning?
___

MONDAY MORNING DEC 3rd

No HIPAA Final Rule today :(

apropos of HIPAA, see

What plan sponsors are required to do under the HIPAA Privacy Rule

The Health Insurance Portability and Privacy Act (HIPAA) governs the use of Protected Health Information (PHI), and failure to comply with the requirements of the policy can be a costly mistake.

As an employer who sponsors a health plan, it is important to fully understand your responsibilities under the act, as failing to do so can result in severe penalties, says Jessica Galardini, president and COO of JRG Advisors, the management arm of ChamberChoice.

“As an employer, you may think that HIPAA doesn’t apply to you,” says Galardini. “But if you are an employer that also sponsors a health plan, ignorance of the law could lead to fines and even jail time.”...

Interesting piece.

Ran across this site and signed up, just out of curiosity.

WEGO Health is a different kind of social network, built from the ground up for the community leaders, bloggers and tweeters who are actively involved in health online. WEGO Health is a platform for committed health advocates to foster new relationships, gain access to helpful resources, and to grow their communities. And it’s free.

Our goal is to equip our network with opportunities designed for the active contributor, relevant content, powerful educational resources and shareable interactive media. We hope that the bloggers, tweeters, and community leaders that we call Health Activists will find inspiration, strength and support here.

Sounds good. We shall see.

The HIT naysayers are, as usual, in full throat over at THCB:

Curly Harrison, MD says:
November 30, 2012 at 7:29 pm

Dear Dr. Berwick,

I am all for the precepts set forth by you, Dr. Berwick: “…with emphasis on using scientific methods and evidence-based medicine…”

Well, where is the scientific method and evidence based medicine to support “meaningful use”, EHR devices, CPOE devices, and CDS devices? Do they improve outcomes and reduce costs, Dr. Berwick?

Where is the proof that they even have the potential to do such?

Where is the scientific method and evidenced based medicine that proves that patient privacy is not violated by the systems of computerized EHR devices that are being promulgated by the US Government?

Where is the after market surveillance of the above devices?

Where is the evidence that EHR outages never have an impact on patient care?

I hope you cover these topics and present a transcript of your remarks.

Curly
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Doctor McDonald says:
December 2, 2012 at 11:31 am

Health care is being transformed whereby the patient is the computer and the sick person is grist for the cash register of the hospitals and the corporations.

Yeah. Sigh...
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DECEMBER 3rd EVENING UPDATE

Interesting blog find here:

Single Payer Health Systems and the Affordable Care Act
by Margot Heffernan, MLS

President Obama’s re-election means that The Affordable Care Act will come to fruition.  Many questions remain, however, about just how his signature health care legislation will take shape in the coming months and years. So far, twenty states have opted out of creating their own health care exchanges, leaving this onerous task to the federal government. Even though fissures in the system are already apparent, some believe that  “Obamacare”  will eventually lead to a single payer health system...

As stark realities of modern medicine collide with an idealized vision of universal health care, necessary changes to Canada’s one payer system have taken place. Legal challenges to the Canadian system coupled with ongoing dissatisfaction with long waits for medically necessary care have eroded the once iconic status of Canadian health care. Private health care options are gradually becoming reality.

Many believe that the implementation of  The Affordable Care Act will eventually provide the gateway to a single payer system similar to the one that Canada is edging away from. This would be a calamity for the United States, which has a population ten times that of Canada. The single payer system, far from the progressive model envisaged by some, will lead us all back to the end of long lines, where we will wait...

Good post. My only lament is that she summarily exited stage right after throwing cold water on Single Payer.

Interesting author background.

apropos of "ObamaCare." -

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FISCAL CLIFF QUESTION

Recent House antics aside, what's a mere $20 billion or so in MU Incentives in the context of our multi-trillion dollar Biblical Flood of red ink? Moreover, absent the President voluntarily tossing us in the center of the card table as a cheap sacrificial poker chip, it'd take a large enough majority Senate vote to withstand a Veto.

ONC doesn't seem concerned.

One way or another, we should know shortly.

NFL, MEET HIT

NFL makes switch to EHRs

Dr. Tony Yates, president of the NFL Physicians Society and member of the EMR Committee for the National Football League, said “The NFL and its healthcare professionals pride themselves in maintaining a leadership role in sports medicine developments.  We are always looking for innovative ways to enhance healthcare within the organization. Electronic health records are the next logical step and we look forward to partnering with eClinicalWorks on this initiative.”

The NFL is implementing the eClinicalWorks EHR solution across the organization to streamline processes between locations and coordinate care.

According to one report, “the eClinicalWorks system will include a direct video feed into the EHR, allowing the league to view player injuries as they happen.”...

Interesting. Very nice marketing accomplishment. They might have expand the "Active Meds List" database and add a firearms ownership template in Social History, though.

DECEMBER 6th UPDATE

Still no HIPAA Omnibus Final Rule.