Readers Write 9/19/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note: the views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

The Impact of the Affordable Care Act, Incentives, and EHRs
By Frasier Crane, MD

I wanted to offer several comments on the impact of initiatives such as the Affordable Care Act. I think it will have little or no positive effect and perhaps negative effects.

We already have the equivalent of multiple payment schemes to juggle and keep track of. Private insurance is not a single entity, and each plan has different requirements in terms of approvals, documentation, codes they will/won’t reimburse, etc. Medicare and Medicaid are also getting into chaos with various managed plans.

I’m a psychiatrist. My patients have to navigate their primary plans, but also the vagaries and different procedures and constraints for mental health care. Virtually all insurers “carve out” mental health to separate companies that have different contracts with health facilities and professionals than the patients’ main insurer. The extent to which being an accountable care organization  could act as an incentive would depend on the proportion of one’s patients that would be part of the program. It would also depend on how severely ill most of ones patients are.

I work with patients who are have severe mental illnesses, but who often have substantial medical problems such as heart disease, diabetes, hyperlipidemia, respiratory diseases, and hypertension. Dealing with all of the added requirements and risks of being an accountable care organization wouldn’t be worth the trouble in terms of reimbursements.

Also, many of the impediments to improving my patients’ health have nothing to do with the health system. They relate to basic needs, such as food and stable housing. Housing needs dramatically lengthen my patients’ stays in the hospital and it takes loads of time for our social workers to find safe housing, yet longer lengths of stay are penalized by virtually every payment system there is, and as a clinician, I have no way of controlling that. The more that quality improvement metrics and other “incentives” are outside of physician control, the less likely it will be that people will want to deal with the hassle.

It also depends on whether the amount of the incentive is worth it. When I was in grade school, my mother developed a detailed reward system for household tasks — making the bed got a one cent reward, taking out the trash got another cent. This was 40 years ago, but a penny still didn’t go too far. After a few days, the beds reverted to their chronically unmade state. Personally, I see all of these incentives (including Meaningful Use) along the same lines. The reward-to-hassle ratio for an individual just doesn’t seem very appealing, especially when we’re already at our wits end trying to deal with existing (and constantly changing) demands from a wide variety of payers and regulators.

How does this relate to EHRs? EHRs could make our lives a whole lot easier by consolidating the various requirements for documentation, quality metrics, pre-authorizations, regulatory requirements, Joint Commission demands, etc. But they remain poorly designed, clunky to use, and don’t cover all of these regulatory / payer requirements in any systematic fashion. Politically, it is clear that we won’t be getting a single-payer system with its associated administrative simplicity any time soon.

But why can’t EHRs give clinicians a front end that feels like a single-payer system to us? The computer should be able to deal with the rest of the fragmented demands and requirements on the back end. This would give me a whole lot more time to spend talking to my patients and thinking carefully about what is needed for them, not worrying about whether I have to call the insurer in one day or two and spend 40 (uncompensated) minutes on the phone answering a laundry list of questions about the reasons that my patient is still extremely ill and needs care.

When I go to an ATM in Manhattan or Mexico or Mallorca, I see a very similar and highly usable front-end display, even though it’s connecting to a different bank (and perhaps country.) It recognizes me quickly (not a two to four minute log-in time like my hospital’s EHR), asks what language i want to use, displays the extra transaction fee for my approval (which may differ from bank to bank, but the process looks the same), and spits out my money. Quick, easy, mission accomplished, minimal stress to the user, and lets the user focus on what’s important (buying shoes?) Not true with EHR/ACO approaches.

Five Tips to Prepare for ICD-10
By Blake LeGate

Are you dreading the transition to ICD-10? If so, then you’re not alone.

According to a recent survey of 480 physicians, administrators, office managers,and billers, 96% of the respondents reported that they are concerned about the potential impact of the transition to ICD-10.

Now that the compliance deadline for ICD-10 has been set for October 2014, physicians and medical personnel have an extra year to make the transition. For all you procrastinators, an extra year may seem like a lifetime, but readying your practice for ICD-10 is not something you want to wait until the last minute to tackle.

Where do I start? What will it cost? Who in my office will be affected? These are all important questions to ask yourself as you prepare for ICD-10.  Taking the right steps to prepare for a successful transition can make or break your practice.

Here are five things practices can do to make sure they are prepared for a smooth ICD-10 transition:

1. Establish a Baseline
   The only way to know how far you have to go is to first figure out your starting point. Practices should conduct an impact assessment to help determine specific needs, whether it’s adding additional staff, attending ICD-10 training and/or installing software upgrades. It is also important to try to estimate and prepare for any additional expenses associated with ICD-10 implementation. Don’t be caught off guard by added costs.
2. Educate Your Staff
   Your coding staff will need to spend quite a bit of time familiarizing themselves with an exponentially larger number of diagnosis codes (69,368 codes to be exact) with far more specificity. While individual specialties will likely only use a fraction of these codes, there will still be a learning curve. Practices that start training their staff early and on a continual basis will be ahead of the game. ICD-10 training is available through numerous organizations such as AAPC, the nation’s largest training and credentialing organization for medical coding, auditing, compliance and practice management. Depending on the size of the practice, it may be more beneficial and cost effective to provide in-depth training to a small number of staff members who can then train the rest of the staff.
3. Evaluate Software Vendors
   Are your software vendors ready for ICD-10? Check with your practice management software vendor(s) to make sure they are taking the necessary steps to update their software with the new ICD-10 code set. Also, make sure your software will have some way of maintaining ICD-9 codes along with ICD-10 codes during the transition phase. Some vendors are including ICD-9 codes as custom code sets so that practices will have the ability to resubmit unpaid claims with service dates prior to October 1, 2014.
4. Explore Your Options
   For many small and medium-sized practices, coding for ICD-9 is difficult enough as it is. Training in-house staff on new ICD-10 codes may not necessarily be the best option for some practices. The cost of additional training, increased workload, and potential reimbursement issues may end up being more expensive than if you were to outsource your billing needs. When looking into clearinghouses or third-party billing services, make sure that they are prepared to comply with the ICD-10 transition.
5. Exhibit a Positive Attitude
   While it may seem overwhelming, there is light at the end of the tunnel. ICD-10 provides many long-term benefits that largely outweigh the initial headache and investment that may come with the transition.  ICD-10 should reduce coding errors and increase accuracy, which results in higher quality information used to measure health care service quality. It also puts the United States back on par with the rest of the world in terms of coding systems. Europe has been using ICD-10 successfully for the past decade. Regardless of how you choose to approach ICD-10 implementation, remember that you are contributing to the betterment of healthcare nationwide.

Blake LeGate is assistant manager of social media of Nuesoft Technologies, Inc. of Marietta, GA.

News 9/13/12

From Green Shades: “Re: EMR garbage. An ophthalmologist forwarded me this EHR-generated note from another physician, saying this is ‘typical of what I see.’ Note that this patient has been BLIND in the right eye since childhood. Garbage in, garbage out. EMRs that have pre-populated fields or standardized data that create bad data are much worse than medical records with missing data.” Is the garbage the result of a low-end EMR that doesn’t offer more customization for the specialty? Or is the problem that the EMR has an inefficient workflow and selecting anything beyond the standard defaults is too time consuming? Or is the physician and his/her staff not taking the time (or lack the time) to customize the templates and documentation? Even if a “bad” EMR is to blame, isn’t it ultimately the physician’s responsibility to make sure the documentation is accurate?

From L. Sternin: “Re: specialists and Meaningful Use. I can only comment for psychiatry and why more are not attesting for MU. The MU provisions aren’t particularly meaningful for us and require a lot of extra documentation that we wouldn’t otherwise do, such as check vital signs every visit. It’s straightforward to do when indicated, but not simply to meet arbitrary MU criteria since the time would be taken from other important tasks. Many EHRs do not have psychiatry-specific documentation templates and the choice of menu items for quality measures under MU are not straightforward for all psychiatric patients. Even a requirement such as giving a visit summary seems rather inane if seeing someone every few weeks for psychotherapy when medications or other information is unchanged. Furthermore, many EHR systems are not well designed in terms of protecting the privacy of sensitive information which makes clinicians (and patients) reluctant. The amount of incentive that would be received can be fairly paltry depending on how many Medicare patients one sees. There are some good reasons to implement an EHR, if it’s well designed to begin with, but for most of my psych colleagues, MU doesn’t seem to be one of them.”

Vitera Healthcare kicks off its VIBE 2012 user conference this week in Orlando.

CMS hosts a National Provider Call on September 13 to clarify details of the Stage 2 final rule.

Key-Whitman Eye Center (TX) selects Versus Advantages RTLS from Versus Technology to track patient progression and staff workflows.

St. Vincent Health (IN) offers iSALUS Healthcare’s OfficeEMR to its independent physicians.

UC Davis researchers find that health expenditures are 10% less for patients that have access to office-based care on evenings or weekends, versus patients with no after-hour care options. The study, which was published in the Annals of Family Medicine, found an association with lower prescription drug and office visit-related expenditures for tests when patients had access to care after-hours.

E-mail Inga.

HIStalk Practice Advisory Panel: Impact of ACA on Patient Volumes

In our most recent HIStalk Practice Advisory Panel post, we asked physicians what they thought the potential impact of the Affordable Care Act would be on patient volumes. The general the consensus was that even though providers may have an opportunity to increase their income by seeing more patients, providers don’t care and would rather just go home on time. That’s an ominous message for those expecting PCPs to pick up the slack just because they’ll make more money since it appears that many are not motivated to increase their workload. We asked the panel to comment further.

• As one of six family physicians in a practice in New England, I can report we had essentially no decline in patient volume through our transition to an EHR, and we are now able to realize more appropriate payment for our services. However, we too are not necessarily interested in seeing more patients to increase our income.  Rather we’re interested in learning to do a better, more organized job of seeing the patients who do present, and – ultimately – to rebalance services we provide to our community such that those who need more care (more complex, less confident in self-management) receive the care they need. Income is important, but doing a quality job for the individual patient as well as our broader community is also critical.
• I do not believe that a central solution to our nation’s primary healthcare problem is to simply see more patients. Our profession cannot continue to provide care in the manner to which we (and our society) have become accustomed. Ultimately, we will benefit if we train ourselves as patients to become confident in self-management, and if – as providers – we learn to identify and care well for those in most need of our services.
• I find it rather incredulous that anyone might think PCPs aren’t already, for the most part, working to capacity. Sure, there may be some who have a little room for growth, but most every PCP I know is pretty much stretched as thin as they’re capable of being stretched. Speaking for myself, while I love what I do and am honored to be able to serve my community and my patients/families, there’s only so much you can ask of yourself before something gives (i.e., burnout). I believe we – myself and most of my colleagues – are usually walking right along the edge between giving all that we can and giving too much.
• I want to see all patients receive care, but as Clint in his Dirty Harry role so famously said, “A man’s got to know his limitations.”
• Medicine is a calling. Many of us are not motivated by money. It’s professional satisfaction that makes a difference. That’s the root of burnout – lack of professional satisfaction. The hours and pay are just the straws that broke the camel’s back.

News 9/11/12

Have pledged to let patients view/download/transmit by @himss: @eclinicalworks @athenahealth @soapware @greenwaymedical #ONCPledge #VDTnow

— Farzad Mostashari (@Farzad_ONC) September 8, 2012

National coordinator Farzad Mostashari asks EHR vendors to pledge to allow patients to view/download/transmit their data by HIMSS13 in March. Committed vendors include eClinicalWorks, athenahealth, Greenway, SOAPware, Allscripts, and Cerner.

Loyola University Health System (IL) selects Phytel’s population health management tools for its 75 primary care physicians.

digiChart, a provider of EHR/PM systems for OB-Gyn practices, will integrate the Dialog Health mobile engagement module with its digiChart PracticeSmart software, allowing physicians to communicate with patients via texts about appointments and procedures.

Yul Ejnes, MD, an internal medicine physician and former chair of the American College of Physicians Board of Regents, grades his EHR, which his practice implemented six years ago. In terms of  time (both his own and that of his staff), reliability, and safety, the EHR has met expectations. He rates the EHR “above expectations” for  practice finances and notes his staff is more efficient, claims are cleaner, and the practice has qualified for several EHR incentives. Ejnes gives a “below expectations” rating for quality of care, primarily because of the EHR’s lack of decision support tools. Finally, he says  information exchange has been below expectations, as the practice still must rely heavily on faxes and paper mail. Great exercise.

Navicure names Jeff Wood (MedAssets) VP of product management.

Medical technology and services company Millennium Healthcare announces that its acquisition of physician practice management firm Premier Healthcare Resources should be completed by October 3.

athenahealth identifies its top HIT priorities for the remainder of 2012, including its “More Disruption Please” initiative to connect HIT stakeholders to promote disruptive innovation in healthcare; Meaningful Use transparency on how its athenaClinicals providers are performing against MU standards; and its Leadership Forum initiative to create and nurture healthcare leaders.

I was looking at the latest Meaningful Use figures from CMS and am intrigued by the breakdown by specialty. Medicare reports that almost 60,000 EPs have been paid $1 million in incentives since the program’s inception. About 42% of those are family practice and internal medicine physicians. Family practice and internal medicine each represent three times as many EPs as cardiology, the third-highest specialty identified. Why are specialists not being paid MU payments at the same rate as primary care? Is it because the the specialists are not embracing EHRs for MU because they find workflow unfriendly and a hindrance to productivity? Do specialists find the incentives too small to justify making necessary changes to software and workflow? Or, are there really that many more practicing FPs and IMs providers, compared to cardiologists, OB/GYNs, and other specialties?  I suspect it is a combination of all these factors, but wonder what theories readers might have.

E-mail Inga.

From the Consultant’s Corner 9/7/12

Collaboration: The Key to Future Success for Independent Practices

For the last few years, there’s been a lot of talk about healthcare’s transition to collaborative care. But all that stuff about a “paradigm shift” goes in one ear and out the other if there’s no financial incentive to get on board.

If you’re part of an independent physician practice, that day has arrived. There are plenty of sound financial reasons for jumping on the collaborative care bandwagon—and a distinct financial downside for not doing so.

In short, small independent practices can’t do it alone any more. While Marcus Welby could afford to be a maverick, I believe all practices now need to work closely with other physicians and hospitals to be able to document the quality care that leads to higher reimbursements.

For independent physicians, this requires a completely new mindset: moving from individual episodes of care to a focus on improved outcomes for entire populations. It also requires electronic medical record data to document quality improvements as well as greater teamwork with other area physicians and hospitals.

You have to demonstrate that you’re helping improve care for, say, all of your diabetic patients and helping to lower the number of avoidable hospital readmissions. Your practice’s financial health will be directly tied to how well you meet these metrics.

Now’s the time for small independent practices to begin leveraging data to prove that they can hit the quality and financial benchmarks that will land them a share of the reimbursement pie. Here are four strategies that can help independent practices access the systems that can help them enjoy the financial benefits of quality-based care:

• Take the EMR plunge. Access to an EMR is critical to future viability as a practice. There are affordable EMRs many practices can implement right now.
• Get help from a Health Information Exchange (HIE). This strategy works well in some localities like Rochester, New York, where the HIE is already selling information technology services to independent practice associations (IPAs) in the region.
• Start or join an IPA in your area. This is arguably the best choice because you get more negotiating leverage when you join forces with other independent practices. You can band together to get the best pricing on EMRs, risk contracting, and incentives from commercial payers. Better yet, focus on clinical integration – providing the right care for your patients at the right time.
• Work closely with your hospital’s medical staff.  Many forward-looking medical staffs are actively reaching out to independent practices, offering to share strategies and the hospital’s formidable IT resources.

In recent years, we’ve seen countless articles about how cooperation and care coordination are the pathways to a brighter healthcare future. But now those aren’t clichés—they’re the key to your practice’s financial performance.

In the state of Massachusetts, for example, there’s already been a sea change due to Blue Cross/Blue Shield’s Alternative Quality Contract (AQC) program, which provides incentives for large physician groups to meet quality care metrics. Physicians who meet those metrics get a sizeable bonus—up to 20 percent of total reimbursement.

Working closely with other physicians and your hospital isn’t optional any more. It’s the only way to gather the quality data that leads to higher reimbursements.

Jeff Wasserman is vice president of strategic and executive leadership services for Culbert Healthcare Solutions.