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Sunday, November 25, 2012

HIT and the "Fiscal Cliff"

Well, this week the 2012 lame duck Congress convenes to start not addressing the "fiscal cliff." RECs could be toast by year's end.

But, our Lobby Trade Association is all over it.

Five months since the launch press release back in June?


Seriously, though, Dire predictions of Doom abound at every turn.

The American science programs that landed the first man on the moon, found cures for deadly diseases and bred crops that feed the world now face the possibility of becoming relics in the story of human progress.

American scientific research and development stands to lose thousands of jobs and face a starvation diet of reduced funding if politicians fail to compromise and halt the United States' march towards the fiscal cliff's sequestration of federal funds.

The Bureau of Labor Statistics reported 1,082,370 U.S. citizens employed in the life sciences, such as biology and genetics, as well as physical and social sciences. Of these, approximately 31,000 stand to lose their jobs if sequestration takes place, according to a study conducted for the Aerospace Industries Association by Steve Fuller, director of the Center for Regional Analysis and professor of public policy at George Mason University.
These potential job losses represent approximately 3 percent of the total life, physical and social science jobs in the United States.

The possible $56.7 billion cut to the the Department of Defense (DOD) budget may result in 14,982 lost science jobs out of a total 325,693 lost, or 4.6 percent of the total DOD jobs cut, according to Fuller's report. Reducing the budgets of other agencies, such as the U.S. Geological Survey, by $59 billion could result in 15,980 science jobs lost, or 3.8 percent of the 420,529 total non-DOD jobs destroyed.

Unfortunately, the loss of research and development jobs is only the tip of the unemployment iceberg the fiscal cliff could create if scientific progress loses funding...
More broadly:
The American _________ programs that ______________, found ___________________ and did ________________, now face the possibility of becoming relics in the story of human progress.
Should be an interesting ONC annual meeting in DC in December. They're circling the bow ties as we speak.

A little ASQ Health Care Division birdie told me that "REC Sustainability" will be on the menu.

We're "broke," right? We must cut government spending, right? Drastically, right? 

  • the latest nominal U.S. unemployment is still around 8%;
  • the current Fed discount rate is 0.75% (that's not a typo);
  • current 30 year Treasuries only pay 2.8% (think about that);
  • The U.S. is a sovereign currency issuer;
  • U.S. industrial capacity is not quite 78%.
What's wrong with this picture? Painted over by the fevered spectres of Greece, Invisible Bond Vigilantes and Inflation-Hedge Bogeymen Gold Bugs?

Some of us are broke. Others of us have been doing palatially well of late, and intend to keep it that way. Both the Spread and the tax advantages of unearned income have rarely been better.


This AHIMA Journal piece is more than a year old.
Working to Make RECs Sustainable
Nov 07, 2011 04:26 pm | posted by Chris Dimick

The REC grants cover a four-year period ending in 2013. Originally ONC planned to reimburse the extension centers for 90 percent of the costs per provider in the first two years of the contract. The RECs would be responsible for the remaining 10 percent. In the second two years that ratio would flip, with ONC covering 10 percent, and the RECs responsible for 90 percent.

However, ONC soon realized it had underestimated the time it would take the RECs to become self-sufficient. In January 2011 the office announced it would pay 90 percent of the costs per provider throughout the full four years of the program.

ONC did not issue additional grant money. It only adjusted the rules for how it will pay out the money. The change means that RECs will receive steady funding throughout four years, but without additional money, they need to reconfigure their budgets. They must spend less money on the front end or work with fewer providers.

The extension was meant to ensure RECs had sufficient funding during the last two years of their contracts, when the majority of their actual implementation work with providers would occur...

Some RECs are tying their model into federal national quality strategy programs that will soon launch. RECs would charge for services to help providers become accountable care organizations and patient-centered medical homes, help facilities meet upcoming pay-for-performance quality measures by offering quality analytics, and act as a consultant on the later stages of meaningful use...
I had to chuckle when I read that last paragraph: "...charge for services to help providers become accountable care organizations and patient-centered medical homes, help facilities meet upcoming pay-for-performance quality measures by offering quality analytics..."

Precisely what I recommended during our recent Salt Lake City REC "retreat" (I'd not previously seen the AHIMA piece). Though, my recommendation was more specific and tangible: become a regional ACO/PCMH'ish umbrella management organization (I don't give a flip what you call it; it's all gotta be a P4P model) that leverages our decades-long broad QIO experience, along with our HIT/HIE chops (DOQ-IT, REC, and HealtHIE Nevada).

47 million people (42 million were you to exclude Colorado), 30 million in California alone.

I seriously doubt this proposal will go anywhere. I would seriously like to be wrong.


During his keynote speech to the Accountable Care & Health IT Strategies Summit in Chicago.

"Muntz said the current estimate is that the electronic health-record system incentive payment program created under the American Recovery and Reinvestment Act of 2009 has a "potential" maximum payout of $22.5 billion, down from earlier estimates of $27 billion, with the "most recent number" of total EHR incentive payments made at over $8 billion..."
Well, OK.
Do I detect a waft of Fiscal Cliff "don't-cut-MU" heebie-jeebies?

Dr. Mostashari said only recently that there was no cap on MU incentive payments, that the more EPs and EHs that signed up and attested, the more checks would be cut.

RazorInsights Remains Perfect with Hospitals Attaining Meaningful Use
Rural hospitals are leveraging single-database, ‘ONE EHR’ from RazorInsights to meet Meaningful Use and receive ARRA incentive payments
Kennesaw, Georgia (PRWEB) November 29, 2012

RazorInsights, a leading provider of health IT solutions for rural, critical-access and community hospitals, today reported that 100 percent of its “live” clients have attested to Meaningful Use and are receiving incentive payments as provided by the HITECH provisions of the American Recovery and Reinvestment Act (ARRA).

Michael McKenzie, COO for RazorInsights, is quite pleased with the success of both RazorInsights and its hospital clients alike. “We are all extremely excited to see each and every one of our eligible clients meet Meaningful Use,” he said...
Nice. These settings are not easy ones.

Pretty spiffy looking GUI:

That's an iPad, btw.

Meanwhile, my hardcore friends at SBM continue to throw down:

 Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.

The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either...


Full report (pdf)
As reported by California Healthline:
Thursday, November 29, 2012
Medicare EHR Incentive Program Vulnerable to Abuse, Report Finds
CMS and HHS need to strengthen their oversight of Medicare's electronic health record incentive payment program because of potential issues with the data that they use to determine payment eligibility and amount, according to a report by the HHS Office of Inspector General, Modern Healthcare reports (Conn, Modern Healthcare, 11/29)...
Report's Conclusion and Recommendations
The report stated, "Although CMS is not required to verify the accuracy of this information prior to payment, doing so would strengthen its oversight" of the anticipated payments through 2016, adding, "Verifying self-reported information prior to payment could also reduce the need to identify and recover erroneous payments after they are made" (CQ HealthBeat, 11/29).
The report recommended that the agency strengthen its prepayment assessment program by randomly selecting "high-risk" providers and asking them to "submit supporting documentation for prepayment review" (Modern Healthcare, 11/28). The report also called for clearer guidance on specific examples of documentation that providers and hospitals should maintain to prove their compliance with the meaningful use requirements...
Better late than never, I guess. This is red meat for Republicans. Forbes happily piles on:

Maybe Sean Hannity is moonlighting as a Forbes headline writer.

The author took exception to my objection to the "slamming" hyperbole. I stand by it. From the OIG summary:
This study is an early assessment of CMS's oversight of the Medicare electronic health record (EHR) incentive program, for which CMS estimates it will pay $6.6 billion in incentive payments between 2011 and 2016. Because professionals and hospitals self-report data to demonstrate that they meet program requirements, CMS's efforts to verify these data will help ensure the integrity of Medicare EHR incentive payments.

This study reviewed CMS's oversight of professionals' and hospitals' self-reported meaningful use of certified EHR technology in 2011, the first year of the program. To address our objective, we analyzed self-reported information to ensure it met program requirements. We also reviewed CMS's audit planning documents, regulations, and guidance for the program and conducted structured interviews with CMS staff regarding CMS's oversight.
CMS faces obstacles to overseeing the Medicare EHR incentive program that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements. Currently, CMS has not implemented strong prepayment safeguards, and its ability to safeguard incentive payments postpayment is also limited. The ONC requirements for EHR reports may contribute to CMS's oversight obstacles.
We recommend that CMS: (1) obtain and review supporting documentation from selected professionals and hospitals prior to payment to verify the accuracy of their self reported information and (2) issue guidance with specific examples of documentation that professionals and hospitals should maintain to support their compliance. CMS did not concur with our first recommendation, stating that prepayment reviews would increase the burden on practitioners and hospitals and could delay incentive payments. We continue to recommend that CMS conduct prepayment reviews to improve program oversight. CMS concurred with our second recommendation.

We recommend that ONC: (1) require that certified EHR technology be capable of producing reports for yes/no meaningful use measures where possible and (2) improve the certification process for EHR technology to ensure accurate EHR reports. ONC concurred with both recommendations. 
Critical findings, with recommendations. Not "slamming."


So, today, one of my colleagues took an REC client question while out in the field -- basically, "we're ready to Attest --  all of our measures are in compliance, but, we don't do our e-Rx through our Certified EHR. Can we add those numerator / denominator data along with the rest?"

I was dubious. According to my understanding, any system or module that generates MU data for Attestation must be ONC-CHPL certified.

"They go through SureScripts, right? Shall we check to see whether SureScripts itself is MU certified, to maybe justifiably use it as a proxy?" We're under a lot of pressure to get EPs attested prior to Jan. 1st, 2013, but, still, we can't simply look the other way.

They are apparently not. They don't show up in CHPL, and that is an Attestation choke point if you can't cough up the appropriate Certification number(s).

I tweeted SureScripts on the question, and also posed it through their email portal.

Their canned response later in the day:



More to come. No HIPAA Omnibus Final Rule again today...

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