Archive for September 13, 2012

In Arkansas, building an HIE from scratch

Ray Scott was pretty much ready to retire when Arkansas Governor Mike Beebe asked to him to work as a consultant in the state’s health IT office. With Arkansas lagging in electronic health record use and also ranking as one of the poorest, sickest and most obesity-plagued states, Beebe, a Democrat, was trying to improve and modernize the state’s health system, and wanted Scott to help craft an application for the ONC’s HITECH Act grant to build a statewide health information exchange.

“He said, ‘We only need you for 90 days,’” recalled Scott, a veteran Arkansas politico and bureaucrat who’s worked for seven governors, including Bill Clinton and Mike Huckabee, and most recently was head of the state’s health agency. “I tried to convince him that I wasn’t the guy.”

[Related: Delaware HIE wants to be ‘another pillar’ of health information.]

Scott then became Arkansas health IT coordinator in 2010, and has led the construction of Arkansas’ statewide HIE, the State Health Alliance for Records Exchange or SHARE. SHARE, its infrastructure and policy, has basically been built from scratch. A few community health systems, hospitals and Blue Cross Blue Shield Arkansas had internal HIEs, but there wasn’t much regional exchange, and at one large hospital, Scott said, more than half of the patients have been coming from outside its network. In a state where a lot of areas still lack broadband Internet, small practices are just starting to use, or consider using, digital health records.

“I knew we were way behind in terms of how health information is used, compared to how IT is used in finance,” Scott said.
SHARE has been built as a public utility, a model that in other states, like Kansas, has been controversial and not panned out as intended. Although the details about data ownership and financing haven’t been worked out, leaving some stakeholders, like the Arkansas Hospital Association, with lingering concerns, SHARE seems to have mostly broad support.

“He’s gone out of his way to be inclusive of all parties,” Paul Cunningham, vice president of Arkansas Hospital Association, said of Scott.

Experience with public policy — where politics, business and science intersect — is probably why Scott was chosen for the job. He recalls Governor Beebe saying to him: ‘’I need you to do this because you know the players and this ain’t your first rodeo.”

“We weren’t trying to build a new large bureaucracy that would control and run everything,” Scott said. “I tried to disarm any notion that folks had of ‘Here goes Ray building an empire.’”

The public utility model evolved out of stakeholder talks, Scott said. He focused on what functions the HIE would have and how to build it, rather than the more controversial question of who owns the data, who’d be running the HIE and how it would be financed.

“If we started there,” Scott said, “we would never get anywhere.”

Those are central questions, of course, and they haven’t been answered yet. Now doing direct messaging with 2,000 providers (and about as many signing up currently) and with query functionality set to go live in a year, SHARE, its IT built by the vendor OptumInsight, is operating on the original $8 million ONC grant and set to start financing itself with provider fees in the future, their nature still to be decided.

Those issues aside, the progress with SHARE is palpable, said Joe Thompson, the state’s surgeon general and director of Arkansas Center for Healthcare Improvement.
“I think we’re in a transition period, we’ve got to find the balance between how do we keep the IT nimble enough and secure,” Thompson said. “We’re really trying to transform the whole system,” referring to Arkansas plan to shift private and public healthcare away from a fee-for-service system to a pay-for-quality model, as recently noted in The New York Times Opinionator blog.

Both Thompson and Cunningham, from the Arkansas Hospital Association, note that there is always the option to turn SHARE into a private nonprofit or create private HIEs.

“Whichever route you take, there’s going to be a cost for it,” Cunningham said.

[Q&A: Taking a radiology practice from no IT to HIE — with ROI.]

And whichever route SHARE ultimately takes, the ONC is pretty impressed.

“One state that seems to truly have embodied the goals of the State Health Information Exchange (SHIE) Cooperative Agreement program is Arkansas,” ONC spokesperson Peter Ashkenaz said. “They look towards the overall bigger picture of the quality and efficiency of health care, and are always seeking ways to increase meaningful exchange, including collaboration with other programs such as payment reform initiatives.”

And Scott, who is also a noted nature photographer and is retiring at the end of the year, has much praise for the ONC and federal government: “I think the wisdom by those visionaries who wrote the HITECH Act is that you’re not going to transform the healthcare system in this country if you don’t build a comprehensive communications network.”

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Romney and Ryan camps clarify health law positions

On Sunday, GOP presidential nominee Mitt Romney, appearing on NBC’s Meet the Press, said he would keep the popular provision in President Barack Obama’s health law that “makes sure those with pre-existing conditions can get coverage.”

And on ABC’s This Week with George Stephanopoulus, Paul Ryan appeared to back a lesser-known part of the law called “maintenance of effort” that prohibits states from making it harder for people to get covered by Medicaid, the state-federal health program for the poor, until 2014.

Both statements seemed to signal dramatic shifts in position for the Republican presidential ticket. But campaign officials later insisted the men hadn’t said anything they hadn’t said before.

[See also: What the platforms tell us about parties’ stance on health IT.]

On pre-existing conditions,  campaign officials said later Sunday that Romney supports coverage for people with pre-existing conditions, but only for those who have had continuous coverage — a position Romney has had for months. That helps people who change jobs, but leaves out those with a gap in coverage. The Commonwealth Fund found that about 89 million Americans between 2004 and 2007  had at least a one-month gap of coverage.

A Romney official said that such people would be taken care of by state high-risk insurance pools.

In contrast, the federal health law starting in 2014 blocks insurers from denying coverage for pre-existing conditions for everyone. The provision is already in effect for children.

Since 1996, a federal law has protected people from being denied coverage for pre-existing conditions if they continually have coverage. The downside of that law is there is no limit on what insurers can charge. Under the federal health law, in 2014, insurers won’t be able to charge higher rates based on a person’s health status.

On the “maintenance of effort” provision, which was first included in the federal stimulus package in 2009, then continued by the 2010 health law,  campaign officials clarified that despite Ryan’s comment, he is still in favor of killing the requirement because it inhibits state flexibility with Medicaid.

Ryan favors giving states block grants so they have broader power over the program. Stephanopoulus noted that the Urban Institute has estimated that between 14 million and 27 million fewer people will be covered under Medicaid block grants.

[Survey analysis: Romneycare vs. Obamacare, do Americans care?]

“I won’t get into the details, but with maintenance of effort requirements, which is what we’ve done in the past, they still have to serve this population,” Ryan said in the television interview.

Joe Antos, an economist with the conservative American Enterprise Institute, said he thinks Ryan meant to say that even if Medicaid became a block grant, states would have to continue serving those eligible for the program.

To receive guaranteed federal funding, states today must cover certain “mandatory” populations. These include children under age 6 with family income below 133 percent of the federal poverty line; children ages 6 to 18 with income below the poverty line; pregnant women with income below 133 percent of the poverty line; and most seniors and persons with disabilities who receive cash assistance through the Supplemental Security Income  program.

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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As Obama goes so go many groundbreaking ACA benefits

The presidential election holds potential to alter the Patient Protection and Affordable Care Act’s (ACA) fate.

For most of the ACA’s impactful benefits to be realized, President Barack Obama must be re-elected, because GOP nominee Mitt Romney has spent many months campaigning on the promise that he will repeal the ACA on his first day in office.

Acknowledging that the health reform law “is not the end of efforts to improve healthcare,” the Democratic Party National Platform lays out the vision to “continue to fight for a strong health care workforce” by “emphasizing primary care,” and “eliminating disparities in health” as well as strengthening Medicaid.
That last phrase also shows up in the Republican’s National Party Platform, which lists ‘Strengthening Medicaid in the states’ as one of its top two tenets; the other is ‘Saving Medicare for future generations.’

[One-liner: Health IT in the Democratic platform. And Don’t blink: What health IT means to the GOP.]

Both platforms are indicative of parties looking toward the future. Indeed, the health reform law will become more popular over time as it is put in place and people use its benefits, according to an advisor for the Obama campaign. “People get used to the law, and they become dependent upon it. And it becomes very hard to repeal it,” said Chris Jennings, who is also president of Jennings Policy Strategies Inc. and former senior healthcare advisor to former President Bill Clinton, at a recent conference sponsored by the Bipartisan Policy Center. Historically, the initial response to Social Security and Medicare were similar.

Individuals and families are already taking advantage of ACA benefits, namely young adults staying on their parents’ plans until they are 26; insurers unable to refuse to cover children with pre-existing conditions; and seniors able to close the funding gap known as the “donut hole” for prescription drugs.

The 2012 Democratic National Platform, released Sept. 4, also highlighted provisions, such as preventive screenings for women and contraception with no out-of-pocket costs; small businesses receiving tax credits to help them cover their workers, and insurers paying rebates to businesses and families when they are overcharged based on the ratio of medical-to-administrative costs.

As more elements of the health reform law take effect, insurers will no longer be able to deny coverage based on pre-existing conditions; Medicaid will cover more working households; and those who don’t get insurance through an employer will shop for coverage on exchanges and may be eligible for tax credits to help afford it.
The re-election of Obama will offer more certainty that those elements will be realized.

Whereas the Democratic platform views health care as a linchpin for economic prosperity and security “so people, business and government are not constrained by rising costs,” the Republicans offer stark contrast.
Romney pledged in his speech in accepting the GOP nomination to repeal and replace the Affordable Care Act, which the Supreme Court recently upheld for the most part. In addition to repealing the law, Romney has indirectly supported strong cuts for Medicaid through calling for its conversion to a block grant program, Jennings said.

[Survey analysis: Romneycare vs. Obamacare, do Americans care?]

Not only would the millions of citizen who stand to gain coverage under the ACA lose it, but many who are currently covered could see reduction or elimination of such coverage.

“It means a shifting of cost and burden to people and to states and fundamentally undermining the insurance market and making it even worse than what we already have,” Jennings said (pictured at right).

For Republicans, however, the effect of the Supreme Court decision on health reform feeds into the GOP view that the elections will be about choosing “big government or not so big government,” said Tom Scully, general partner, Welsh Carson Anderson & Stowe, senior counsel, Alston & Bird; and a Romney campaign designee. He was also an administrator of the Centers for Medicare and Medicaid Services under former President George W. Bush.

Scully doesn’t anticipate hearing a lot of details revealed about health care between now and the election. The perception of the health reform law is more about “taking on a massive entitlement expansion and massive growth of the federal government.”

“Doing massive entitlement expansion, even though it may be something you morally believe in, is not responsible,” Scully said, with debt and entitlement spending at unsustainable levels.
“Someone has to take leadership in fixing our national problems,” he added. “You can’t punt everything forever.”

For the Republican view, reining in healthcare costs is about state-based and market incentives.

“Money is getting tighter across the board. Even with Democratic governors, the world is moving to capitation and Medicaid managed care,” Scully said. It makes sense shifting to a third party contractor and reducing risk, referring to them as “private managed care bundlers.”

Scully knows about entitlement expansion. As CMS administrator, he was instrumental in shepherding the Medicare modernization law and the prescription drug plan, which favored using the market to provide services.

[Related: Political strategists on how candidates should shape healthcare messages in the election.]

“In Part D, once you came up with the money, and if the structure can work and provide the services they predict that they can manage and market, they will show up,” Scully said.

For the Obama administration, it was important to have broad healthcare industry and consumer support for the health reform legislation to make the market work, Jennings said.

“Coverage is a moral imperative, but that really wasn’t their driver. Theirs was to make sure people were in the system so you can have plans compete on cost and quality and not on their ability to avoid certain people, which creates all sorts of strange and warped incentives,” Jennings said. “We can have a discussion of allocation of resources and making it work, but the fundamentals of coverage, exchanges, insurance reform, tax credits are all pillars to make the system work.”

And a number of those pillars will likely die or survive depending on the outcome of Tuesday, November 6, 2012.

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ONC drops pursuit of NwHIN governance

The Office of the National Coordinator for Health IT has dropped pursuit of a regulation for establishing “rules of the road” for the nationwide health information network (NwHIN) based on feedback it has received.

Commenters from industry and the public made it clear that federal regulation could slow development of health information exchange just as those activities are starting to emerge and pick up steam, “perhaps more than is widely appreciated,” according to Dr. Farzad Mostashari, national coordinator for health IT.

ONC issued a request for information (RFI) in May to collect public comment on a possible approach for rulemaking to spell out “conditions of trusted exchange,” including safeguards and technical and business practices. ONC wanted to receive broad input before issuing a proposed rule, he said.

ONC also considered establishing a voluntary accreditation and certification process through which to approve organizations as being legitimate participants in NwHIN, somewhat similar to the procedures for certifying electronic health records for meaningful use functions.

“Based on what we heard and our analysis of alternatives, we’ve decided not to continue with the formal rulemaking process at this time, and instead implement an approach that provides a means for defining and implementing nationwide trusted exchange with higher agility, and lower likelihood of regret,” he wrote in a Sept. 7 blog.

NwHIN is a set of comprehensive standards, services and policies that enable healthcare organizations to share information securely through the Internet.

ONC’s goal is that information follows the patient where and when it is needed, across organizational, vendor, and geographic boundaries.

But the current state of information exchange and care coordination is far from this ideal. In addition to technical challenges with interoperability, “the absence of common ‘rules of the road’ may be hindering the development of a trusted marketplace for information exchange services,” Mostashari said.

However, voluntary governance bodies are now forming both for directed and query-based exchange. ONC wants to encourage the exchange activities that are gaining steam, “and not to hobble them,” he said, especially with the expectations for standards-based exchange in stage 2 of meaningful use.

“And let me assure you that if systemic problems or market break-downs emerge that might require regulatory action, we will again seek input from the public and our stakeholders, including the Health IT Policy and Standards committees,” Mostashari warned.

Participation in the NwHIN Exchange previously was limited to federal health agencies and primarily large healthcare organizations that contract with them or are federal grantees. Agreement on how to assure conditions for trusted exchange will enable many more organizations to participate.

Among the actions that ONC will press for to promote trusted exchange are:

• Identify and shine a light on good practices that support secure and interoperable exchange and provide a guide for evolving governance models

• Learn from and engage with groups in governance and oversight roles for exchange partners in order to foster models within and across communities

• Continue to use existing authorities and convening powers to create consensus and provide guidance and tools around specific barriers to interoperability and exchange

• Evaluate how and what consumer protections can be appropriately applied to health information exchange through existing regulations

• Monitor and learn from the wide range of activities that are occurring.

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Medical Transcription and Coding demand will increase with ICD-10

Medical Coder and TranscriptionistThe world of medical transcription and medical coding is extensive and always changing. The change that has the medical field buzzing right now is the change from ICD-9 to ICD-10 (International Classification of Diseases – Version 10). Currently, health care facilities use ICD-9 for documentation and coding, but by October of 2014 every facility must abide by the new system. These new changes will increase the need for skilled medical transcription and medical coding. It will also bring these two jobs expertise closer and merge at some time in the future.

Why will demand for transcription and coding increase?

For healthcare employees already working as a medical transcriptionist or medical coder, they don’t need to worry about these changes affecting their chances of employment. The truth is that the need for these highly skilled workers will actually increase with the implementation of ICD-10.

One of the main reasons for the increase of work is that the new book of codes is a lot more specific than ICD-9. For instance, in ICD-9, the code for a burn on the left arm is the same code as a burn on the right arm. While this may not matter to the insurance company, it does matter to the treating physician, the patient and the transcription. There are not numerous new diseases in the new manual, but it will have over 70,000 codes listed. These are also going to be seven digits, instead of the five seen in the past. The increase in codes and length of codes will help the medical coder be more specific.

There is no substitute for an intelligent human mind, so the fear that medical transcription will be obsolete after the new implementation is unfounded. Both transcriptionist and coders will actually have to work harder and attend more training to become compliant. The new system may be confusing and overwhelming to those who have worked on ICD-9 for years. As these older employees leave the workforce, fresh new recruits will be needed.

Importance of Implementing Electronic Health Records (EHRs) from ICD-10 prospective

In order to be compliant with the new rules, healthcare facilities will find that having an efficient EHR (electronic health record) system in place first will be a huge benefit. There are still thousands of private practices that have not made the switch to electronic medical records, but this will hurt them when they must face compliance with the new coding regulations.

By implementing an easy to use and efficient EHR, the transition to ICD-10 will be a lot smoother. If a facility does not yet use computers for their records, they should consider doing this as soon as possible to be ready for the upcoming coding and documentation changes.

The reason an EHR is so important is because it helps streamline the coding process. It is much easier to use a search function on a computer than trying to pore through hundreds of pages in a patient’s chart to find information. To determine whether an injury was on the left or right side of the body, for example, the coder can simply search for this terminology within the patient’s electronic record. To find this information in a paper chart wastes hours of valuable time.

How will the New System Help Medical Transcription?

It may be true that the new system will mean less hours of transcribing work but it doesn’t appear transcription will be absolute. In fact, those that choose to stay in the field and learn ICD-10 coding will be rewarded with more hours than ever of transcribing work.

Because ICD-10 demands greater detail, physicians will have to begin giving greater detail in their records. This translates into more words for the transcription, which equals greater pay. Also, the increased need for transcription with coding expertise will mean better rewarding opportunities.

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