Archive for HIPAA

MACRA proposed rule: Good intentions from CMS but a burden for small practices, says doc

Many physicians have waited with bated breath for the end of meaningful use, looking forward to a new era of less burdensome compliance requirements and more realistic reporting guidelines.

But after closely reading the Centers for Medicare and Medicaid Services’ thousand-page proposed rule for the Medicare Access & CHIP Reauthorization Act of 2015, or MACRA – which would sunset meaningful use for Medicare physicians – it seems many providers are realizing it’s not quite the fix they had in mind.

While it’s apparent CMS had “good intentions” when it crafted the proposed ruling, there are a lot of things the agency failed to consider, John Goodson, MD, staff internist at Massachusetts General Hospital and associate professor at Harvard Medical School told Healthcare IT News.

“What’s happening with MACRA is transformational: It’s the biggest thing since the Resource-based relative value scale,” Goodson said.

But just as “CMS didn’t consider how RBRVS – could tank providers,” the results of which are playing out right now, he said, the agency may have missed its mark here too. RBRVS stands for resource-based relative value scale.

According to John Squire, president and chief operating officer of Amazing Charts, a developer of ambulatory EHRs and practice management tools, there are two potential victims if the ruling is passed as is: small practices and Medicare beneficiaries.

“By basing penalties on outcomes, you may be ranking some of these physicians on circumstances out of their control,” Squire said. “There are behavioral things a physician can’t control. And it doesn’t allow for any exemptions, outside of low-volume.”

MACRA also removes the option for providers to opt-out of reporting by paying a penalty, which means all providers who accept Medicare patients must comply.

Many small practices won’t be able to keep up, he said. And according to Goodson, “Providers are being put in a position where it’s unattainable.”

“One unintended consequence, which happened with meaningful use, is some will look at the list of requirements and feel inundated,” said Squire. “They’ll just say, ‘The heck with it; I’ll just stop accepting Medicare patients or require cash-only.’”

Furthermore, the rule sets a very high barrier for practices hoping their existing participation in accountable care organizations counts for the Alternative Payment Model path, rather than  requiring them to attest for the Merit-Based Incentive Payment System, or MIPS.

Squire said, “Providers who have already bought into ACOs are crying foul: ‘I’ve designated resources to it and you’re saying that it doesn’t matter.’”

While Goodson recognizes CMS has a difficult task in responding to the pushback from the industry, he also recognizes that healthcare is “embarking on a whole new set of complications and implications.

“Quality is really focused around recording, but another piece is built around data interchange,” Squire said. “Physicians need to weigh how their systems support MACRA – and let the technology do the work to relieve the burden for the provider. It’s your practice methodology that would need to adjust.”

“A lot of people think this is going to be a whole new system,” said Goodson. “But it’s just a modification of the current system. This is a new complicated set of recording needs.”

Hospital company sued after FCC tightens medical debt collection rules

The bar was raised for medical debt collectors last summer when the Federal Communications Commission issued a ruling that made it harder to dial patients on their cellphones without their express consent.

Now a California-based hospital chain has become one of the first providers to be sued since the FCC’s July interpretive ruling.

The class-action suit targets Prospect Medical Group’s Southern California Hospital at Culver City. It alleges that the hospital used an automated dialer to call patient Donna Ratliff on her cellphone in order to collect a debt and did not have her express consent to do so.

The FCC issued its interpretive ruling after the medical debt collection industry—hoping for more flexibility—asked for greater clarification on the decades-old Telephone Consumer Protection Act to address issues such as auto-dialing cellphones, consent to call and reaching wrong numbers.

Instead, the FCC made it clear that debt collectors need express consent before dialing a cellphone and gave little leeway for when they reach a number that’s been reassigned.

Prospect Medical declined to comment on the Ratliff case, stating that the company hasn’t yet been served with the complaint.

However, the company insisted in a statement that it follows the necessary practices to obtain consent to call patients on their cellphones. “All of our patients are asked to sign an irrevocable authorization permitting our hospitals to contact them via telephone—including, specifically, via cellphone—in their efforts to collect outstanding debt.”

The plaintiff’s exact argument is still unclear, said Justin Kay, a Chicago-based attorney at law firm Drinker Biddle, who described the suit as “threadbare,” perhaps to make it harder for Prospect to win a motion to dismiss. “Presumably, what (the plaintiff’s attorney) is going to argue is the scope of consent did not include this call based on the circumstances under which the number was provided,” he said.

Previous cases have generally given hospitals some latitude on calling patients for purposes of collecting a payment as part of an episode of care. But healthcare providers need to make sure that the debt is linked to the medical encounter during which the patient provided a cell number.

“The best practice for any hospital is to have written consent during the admissions process that is broadly worded to include all types of automated calls and texts,” said Bradley Andreozzi, a Chicago-based attorney at Drinker Biddle.

TCPA violations are already an active area for plaintiffs, with TCPA-related lawsuits increasing 560% between 2010 and 2014, according to ACA International, the Association of Credit and Collection Professionals.

“As the FCC gradually narrowed the scope of express consent, it became cause to litigate,” Andreozzi said. “We don’t see any sign that that’s going to change anytime soon.”

Penalties for TCPA infractions start at $500 per call and can reach as much as $1,500 for willful violations.

While the Prospect case deals with the issue of express consent, it doesn’t touch one of the thorniest and most controversial parts of the FCC’s recent ruling: what happens when a debt collector reaches someone in error. The FCC allows medical debt collectors to call a number just once without penalty, regardless of whether someone picks up.

“The problem is they left no room for the situation—and this is increasingly common—where the person doesn’t answer the phone,” said Lewis Wiener, a Washington-based attorney at law firm Sutherland, Asbill & Brennan. “You’ve put them in an impossible situation.”

As many as 100,000 cellphone numbers are reassigned everyday, Wiener added.

ACA International has sued the FCC challenging the July order.

“It’s impossible for companies to keep up with that level of risk factor,” Wiener said. “There’s really no way to confirm whether the person you’re calling is the right number. It’s a gotcha.”

The best ways for providers to protect themselves, Wiener said, is to have a rigorous process for getting consent, respect the wishes of people who opt out and, whenever possible, use e-mail. “You’re swimming in shark-infested waters,” he said. “Take as few laps as you can.”

The Power of Big Data

Harnessing and capitalizing upon the monstrous amounts of available healthcare information

By Peter Edelstein, MD, Elsevier

Big Data. Population Health Management. Patient Engagement.

Healthcare reform churns out buzzwords at an alarming rate.  But at least big data has a more defined meaning, having come to linguistic life long before the Affordable Care Act was a gleam in President Obama’s eye presumably.

Today’s world runs on big data.”  It’s big data that allows millions of us to almost instantaneously receive insurance quotes online; creates your credit score; select a mortgage; and pushes pop-up advertising that just happens to be exactly what you were looking for yesterday.

As is our healthcare industry’s history, big data is yet another capability that has entered the medical arena long after becoming an integral part of non-medical sectors.  That said, big data is (finally) here to stay, in our hospitals, our pharmacies, in our insurance systems (where it has been the longest), and in our ambulatory care centers.

Big Data Goals

And like population health management, patient education, and other buzzwords, understanding our specific big data goals and how to achieve them is critical if we are to maximize the success of healthcare reform.  So the first question is, What Are Our Healthcare Goals for Big Data?

If an underlying goal of healthcare reform itself is to improve the quality and cost efficiency of care for populations and for individual patients, then we must turn away from reactive care provided in the acute, inpatient facility and strive for proactive, preventative, and maintenance care provided in the ambulatory world (both the outpatient physician office and in the place where patients spend virtually 100% of their time:  their homes and workplaces).

Linking to this goal, Big Data can drive the identification of individuals and populations at risk of suboptimal quality and/or cost of care and then to guide intervention to reduce or prevent the realization of the identified risks.

Already, Big Data is playing a foundational role in the first part of this goal.   Monstrous amounts of claims data serve to feed clinical analytics models, including predictive models.  Such powerful tools allow us to predict which patient populations and individuals are at risk of specific forms of clinical deterioration, high cost care, and/or unanticipated hospitalization and Emergency Department visits.

And recently, the incorporation of public records Big Data (including moving, home ownership, eviction, lien, and property value history; estimated annual income, wealth index and financial stress; and accident, fraud, burglary, and criminal history) along with health claims data has allowed for the development of even more powerful predictive analytics models.  (For example, inclusion of such non-medical data may more accurately predict risk of early post-discharge hospital readmission and/or risk of failure to pay).

Big Data Expansion

Today, non-clinical Big Data is expanding from the clinical analytics world into site of health care delivery.  The Institute of Medicine is recommending the inclusion of social and behavioral data within the EHR, where (as with analytics) this expansion of Big Data is projected to more clearly and accurately guide patient care.

Whether empowering clinical analytics models or more clearly defining individual patients and populations from within the EHR, the ultimate impact of our evolving Big Data is in guiding evidence-based content and clinical decision support tools which are targeted to meet the specific needs of an identified patient population, subpopulation, or individual, content which can be pushed to every point of care (hospital, ambulatory setting, patient home, etc.) and delivered in a format appropriate for the specific provider (doctor, nurse, patient, etc.).

As we widen the net of data sources and types included within our analytics models and electronic information systems, we are increasing our ability to hone down, to fine-tune our understanding of specific and populations’ and patients’ risks, needs, and opportunities to improve both the quality and cost efficiency of their care.  To provide the most appropriate evidence-based content wherever it needed, whenever it is needed, for whoever needs it.

Peter Edelstein is chief medical officer, Elsevier Clinical Solutions

Will States Sell Ads Like Nevada to Break Even on Health Exchanges?

By law, the online health insurance marketplaces created under the Affordable Care Act (ACA) must be financially self-sustaining by 2015. Most states are planning to pay for their operation by charging a user fee to insurers that sell their plans on the marketplaces, also known as exchanges. But those costs will likely be passed onto the customer, making health coverage under the ACA a little less affordable.


That gave one state, Nevada, an idea: sell advertising space on the exchange’s website to generate some extra revenue.


The state doesn’t yet know exactly how much money banner or pop-up ads could yield for the exchange, but every advertising dollar means a lower price for the people purchasing coverage. Officials are in the process of drafting a request for proposals and hope to have ads on the exchange site by the middle of 2014. Nevada’s marketplace — like others across the country — launches Oct. 1, 2013.


“If we broaden our revenue base, we will have a viably funded exchange. We want to be sure that we don’t just burden the insurance buyer,” says C.J. Bawden, a spokesperson for Nevada’s marketplace, the Silver State Health Insurance Exchange. “The more we can broaden our base, the more we can hopefully lower those charges and lower the price of insurance.”


For now, Nevada is the only state with definite plans to sell ads on its website. Governing surveyed 16 of the 17 state-based exchanges (Idaho was excluded because of its late start) and only three—Colorado, Hawaii and Vermont—said they were considering selling ads in the future.


As for the federal exchange that will sell insurance plans for the 30-plus states that decided not to set up their own marketplace, officials at the U.S. Department of Health and Human Services (HHS) say it won’t sell ads as a revenue source — but there’s nothing stopping the state-based exchanges from doing so.


So why aren’t more of them following Nevada’s footsteps?


Most likely because of the administrative and publicity headaches that might come with selling ads on a political lightning rod like the ACA’s exchange, says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation.


“States will want to be really careful about the ads that they allow on the exchanges. I suspect that’s why many states have chosen not to allow ads to be sold,” she says. “But as long as the state is really careful, it could be a good vehicle for revenue.”


That’s an issue already weighing on the minds of Nevada officials. Bawden gives the admittedly outlandish example of one of the state’s legal brothels trying to purchase ad space on the exchange.


“Obviously, that’s something we don’t think taxpayers would appreciate,” he says. “It’s easy to imagine the accompanying headlines.”


To avoid such a scandal, Nevada’s exchange is hoping to attract advertising partners who would further its mission of extending health coverage to uninsured Americans. Dental and vision insurance plans, which could supplement the more traditional medical coverage that will be sold on the marketplace, could be obvious targets. The details will be ironed out after the request for proposals is finalized and responses are received.


The relative smoothness (or bumpiness) of Nevada’s experience could inform other states’ decisions, Tolbert says, but there’s another to-be-determined factor: how much it actually costs to operate an exchange. Right now, with the federal government footing the bill, it’s mostly guesswork, but estimates of exchange operating costs range from $25 million to $60 million or more, according to the Kaiser Family Foundation.


If the exchanges end up being more expensive than states expected or if fewer people enroll in the exchanges than anticipated, that could cause officials to return to the idea of advertisements as a revenue stream.


“If it comes down to a choice between significantly increasing the assessments and looking toward other ways to generate revenue, states could be open to trying something new,” Tolbert says.


The Year Ahead in Health Reform: Dylan Scott’s educated guesses about what to expect from the Affordable Care Act in its first year of full implementation.

Exchange enrollment will be (a little) lower than expected. The almost exclusive focus on outreach in the six months or so leading to the exchange openings on Oct. 1 should tell you that even supporters of the law are worried about whether they can get enough people to sign up for coverage. When four in 10 Americans say they don’t know the ACA is still law — and those proportions rise among the low-income people the law is intended to benefit — I think the White House might struggle to reach its goal of 7 million enrollees in the first year. At least five more states will expand Medicaid by 2015. I’m looking to historical precedents on this one. ACA supporters will often point out that nearly half the states didn’t join Medicaid when the program was created in 1965, but almost all of them had within the next few years. I think the prospect of losing another year of 100 percent federal funding for expansion will be too much for at least a handful of states to pass up. The 2014 midterm election complicates this a bit, but there are enough states that were close to expanding this year — Florida, Ohio and Tennessee, to name a few — that it’s easy to see them finishing the job next year. Obamacare will become a little more popular once it’s fully implemented. I’m not expecting conservatives to have a sudden change of heart and embrace the law, but the ACA’s approval and disapproval ratings have hovered in the low 40’s since it was passed, which means that close to 20 percent of people are undecided. That’s a lot of people who could be won over, and 2014 finally brings the most visible parts of the law: the exchanges and the Medicaid expansion. People will actually know other people who are getting health coverage because of Obamacare. I think that starts to turn the tide in the law’s favor.

Whatever Happened To … White Space Network Products, L.A.’s Gmail Contract, Fingerprint ID Program?

The Original Story: In 2010, Wilmington became the first city in the nation to begin testing TV “white spaces” and applications. White space networks take advantage of unused bands of wireless spectrum that were left over when television broadcasters switched from analog to digital. Wilmington was a natural choice to be a guinea pig for applications based on white space networks. The city was the first major market in the U.S. to switch to digital TV in 2008.


In spring 2010, Government Technology reported that Wilmington planned to use wireless traffic cameras at intersections to monitor traffic, travel time and fuel consumption, and to support local law enforcement. In addition, water-level sensors would be used to monitor and manage wetland areas in the coastal city without a boat trip.


Project Update: As planned, Wilmington became a valuable test bed for white space devices and it has put the technology to work on several “smart city” initiatives.


In 2011, the FCC officially approved the use of white space for wireless broadband networks. The ruling was significant because wireless broadband requires the use of spectrum, which is a limited resource. Using white space to provide broadband service is now part of the FCC’s overall plan to find more wireless spectrum and expand broadband availability across the country.


Today, Wilmington uses white space spectrum to monitor real-time water quality and traffic conditions on roads that previously lacked access to a broadband connection. In addition, the city helped with the development of new white space devices that are just now reaching the market.


“Over the past couple of years, Wilmington has done a lot of work with original equipment manufacturers and radio vendors to test and evaluate their products,” said Rodney Dir, president and CEO of Spectrum Bridge Inc., a company involved in the early testing efforts.


In 2012, the FCC approved the first white space device. There are several additional devices pending approval. Estimates are that by the end of 2013 there could be six FCC-certified devices available, many of which were tested in Wilmington. — Justine Brown


The original story: Los Angeles stepped way out on a limb in 2009, becoming the biggest city in the nation to move its entire email system — used by 30,000 municipal employees — to Google’s Gmail service. The city’s massive shift to the cloud would become one of the most closely watched IT deployments in local government over the next several years. Los Angeles CTO Randi Levin told Government Technology in 2010 that using Gmail to replace the city’s in-house GroupWise email system would let her eliminate 92 servers and reassign nine employees responsible for maintaining that equipment. In addition, city workers would get more reliable email and a suite of new features.


Project Update: Four years later, the project never exactly delivered on its promises and never was completely finished. Although the city moved email for 17,000 employees into the cloud, it could never transition police and other public safety personnel to the hosted system, leaving about 13,000 employees on the GroupWise platform. The city formally abandoned plans to move cops into the cloud in 2011, citing security concerns.


Now Steve Reneker, who replaced Levin as city CTO last year, is prepared to rebid the contract. Los Angeles’ five-year contract with Google ends in a year, and Reneker said he has no preconceptions about what the city will do next.


“We are at a juncture right now,” he said.


Reneker said the next contract will be 10 years long and split into three parts: email, applications and security. That will give Los Angeles flexibility. His sense is that city employees are comfortable with Gmail and don’t want to switch away from it, but he says “conversion issues” between Google Docs and Microsoft Office have made life difficult. Most city departments still prefer Office.


The Los Angeles Police Department will continue to use an on-premises email system, Reneker added, to ensure compliance with California Department of Justice requirements.


Reneker credits his predecessors in the Los Angeles Information Technology Agency for making a bold move, even though there were unforeseen obstacles and some erroneous assumptions. He said Gmail “significantly” reduced total cost of ownership for the city’s email, even though the extent of the savings hasn’t been what was forecast in 2009. — Matt Williams


The original story: In 2010, Bergen County, N.J., began scanning the fingerprints of people coming to its food banks. The new technology was meant to solve a dilemma the county had dealt with for years: Its Department of Human Services (DHS) could not accurately estimate how many homeless individuals received services like food, medicine and shelter. Because many people served by the department did not have accurate forms of identification, DHS staff had no way to track who was receiving services or how often.


“It’s not like you can do a head count,” said Susan Nottingham, the department’s Homeless Management Information System administrator. “We could sit down and say, ‘Can we talk to you for 45 minutes?’ But we didn’t want them to turn around and say, ‘We’re not that hungry.’”


Project Update: Bergen County’s fingerprint technology appears to be working as intended, and use of biometric identification is spreading to the state level. County officials say the technology improved both the accuracy of records and the speed in which people receive food. The Bergen County DHS now has a more accurate account of the number of people in the system and the real demand for services. With this information, officials have been more effective in getting state and federal funding for homelessness programs.


The county system also inspired state officials to phase in a similar tracking system for homeless services. In April 2013, New Jersey began using a new biometrics data management system that includes a Web-based fingerprinting component to track and manage food, shelter, medicinal services and other necessities the state provides to its homeless population. The system will help state officials track who is receiving homeless services and the types of services rendered.  — Justine Brown