Tuesday, July 29, 2008

Mobilizing Personal Health Information - Consumer Perspective

How will consumers "mobilize" their personal health information?

On July 29, the American Health Information Community (AHIC, "The Community") examined how consumers may access, use and share their personal health information (PHI). This article highlights the consumer perspective.

Utility Service Model

John Moore from Chilmark Research compared several business models for PHI delivery. These include: 1) Consumer approach to manage health, 2) Employer and healthplan approach to reduce costs and manage risks, 3) Provider approach for consumer (patient) retention, and 4) Utility service model approach to "create an ecosystem".

The utility service model consolidates multiple data sources into a secure repository available to multiple applications and services. This model scores very well, with the notable exception of portability which is "under development". Moore scored the utility service model as the only approach with the potential for high rates of adoption.

Consumer Interest

Carol Diamond of Markle Foundation's Connecting for Health organization surveyed public attitudes towards Personal Health Records (PHR). Markle's survey found only 13.5% of respondents very interested in using a free web-based PHR and another third somewhat interested.

Markle contends that the establishment of privacy and information practices are critical to consumer PHR adoption.

Markle's Connecting for Health Common Framework and Framework for Networked Personal Health Information define clear "price of admission" requirements for PHR adoption, but are they sufficient to achieve adoption?

Standards and Interoperability
Connectivity with healthcare organizations will be required to make PHR's easy to access and manage. Jeff Blair, Lovelace Clinic, made the case for the Nationwide Health Information Network and standards based interoperability as foundational elements to achieve adoption.

Editorial comment: Where are the incentives?
The one missing ingredient in all of this: financial incentives for patients and providers. Why are payers and employers more interested in PHR adoption? They are dealing with the pocketbook issues of how population health affects their P&L.

Thursday, July 10, 2008

Senate Bill - Much more than 2008 fee schedules

Ted Kennedy returned to the Senate floor and 18 Republicans switched their votes to deliver a veto-proof majority for the bill which stops a 10.6% decrease in 2008 physician fee schedules, programmed to begin July 1, 2008.

The bill also lays the groundwork to correct major problems with the recently proposed 2009 rule from CMS.

Best summary of the legislation comes from the Heart Rhythm Society:

"Medicare Physician Payment Update
  • Stops 10.6 percent Medicare physician payment cut scheduled for July 1, 2008, continues existing 0.5 percent increase through December 31, 2008, and provides an additional 1.1 percent update for 2009
  • Effective 2009, requires physician fee schedule budget neutrality adjustments for 2007 and 2008 relative value unit changes to apply to the conversion factor, instead of work values
  • Extends the physician quality reporting initiative (PQRI) through December 31, 2010 while increasing the PQRI bonus to 2 percent for 2009 and 2010
  • Makes improvements to the PQRI, including a requirement for the endorsement of measures by a consensus-based, standard setting entity and permits group practices to report, using a sampling methodology, on measures targeting high-cost, chronic conditions
  • Requires the Secretary to provide confidential feedback to providers regarding their resource use and to submit a plan to Congress regarding transition to a value-based purchasing program for physicians
Electronic Prescribing (E-prescribing)
  • If at least 10 percent of a physician’s Medicare charges fall under the services identified by the PQRI e-prescribing measure and physicians use a qualifying e-prescribing system, they are eligible to receive a:
  • 2 percent bonus payment in 2009 and 2010
  • 1 percent bonus in 2011 and 2012, and
  • 0.5 percent bonus in 2013
  • If these physicians do not use e-prescribing, they will face penalties of -1 percent in 2012, -1.5 percent in 2013, and -2 percent in 2014 and beyond. Beginning in 2009 physicians will be ineligible to receive a PQRI bonus for e-prescribing
  • Exceptions will be made for significant hardships (e.g., rural areas without sufficient Internet access)
  • Payment bonuses are made after adoption of e-prescribing system, not as an up-front payment to facilitate initial investments
Primary Care Services
  • Adds new funding and expands the authority for the Medicare Home Demonstration Project. Medical homes are large or small medical practices where a physician provides comprehensive and coordinated patient centered medical care and acts as the “personal physician” to the patient
  • Authorizes the Secretary to expand the duration and scope of the demonstration if certain quality and/or savings targets are achieved
Diagnostic Imaging
  • In order for physicians, practitioners, facilities or other entities that perform advanced diagnostic imaging services (MRI, CT, and nuclear medicine/PET) to receive reimbursement for the technical component of Medicare imaging studies payment, they will need to be accredited by January 1, 2012. The bill gives Secretary the authority to determine other diagnostic imaging services (excluding X-ray, ultrasound, and fluoroscopy), in consultation with physician specialties, that would be subject to accreditation requirement
  • Establishes a 2-year voluntary demonstration program to determine whether physician compliance with appropriateness criteria for advanced diagnostic imaging services
Beneficiary Improvements
  • Provides Medicare coverage for “additional preventive services” determined by Secretary that identify medical conditions or risk factors recommended by the U.S. Preventive Services Task Force, subject to national coverage decision process
  • Waives deductible for “Welcome to Medicare” physical, expands timeframe for physical from six months to one year following enrollment in Medicare; and adds new services to this benefit, including “additional preventive services” and end-of-life planning
Other Provisions
  • Charges Institute of Medicine with making recommendation to Congress on methodological standards for reviewing clinical effectiveness research and best methods for developing clinical practice guidelines
  • Directs the Office of the Inspector General to report on the extent to which Medicare providers follow rules regarding discrimination against beneficiaries with limited English proficiency and Culturally and Linguistically Appropriate Services (CLAS) Standards and will require the Secretary to correct deficiencies
  • Requires MedPAC to conduct a study on the merits of establishing a Medicare Chronic Care Practice Research Network to test new models of care coordination
  • Directs Government Accountability Office (GAO) to study the interest rate and equipment utilization assumptions used in determining practice expense relative value units"

Monday, July 7, 2008

Summer reading: Care of CMS

The Associate CIO for one of the top medical schools in the country was telling me about the challenge he faces as a physician and CIO: "Either I can remember these large volumes of information about my specialty, or I can remember the payer rules that come in equally large tomes. But I can't remember both."

Today, CMS publishes in the Federal Register its 834 page proposed rule on Medicare Part B 2009 physician fee schedules and other changes. Comments are due before you're back from vacation... on August 29. The final rule is scheduled for November 1. For those of you with on
ly enough time for the "Cliff Notes version", check out the CMS fact sheet.

First the good news:
Medicare is proposing new HCPCS codes supporting follow-up inpatient telehealth consultations. The codes would be used by practicioners who are "consulted by the patient’s attending physician regarding the patient’s care but who are not available for a face-to-face encounter."

This rule proposes a fairly narrow application of "virtual visits", but it certainly represents a step in the right direction. In 2006, CMS had stopped coverage for these telehealth consultations.

CMS has been resistant to approving codes for any "virtual visits". CMS could serve as a market mover for private insurance, should this regulation be approved.

And now the bad news:
980,000 physicians, other practioners and medical suppliers will be paid an average 5.4% less - - $54 billion in 2009 compared to $57 billion in 2008.

Physician Reporting Quality Initiative (PQRI):
The 1.5% incentive payment for reporting PQRI measures is eliminated. Quality reporting would be extended in 2009 with addtion of 64 new measures and the carry-forward of 111 existing measures.

Electronic Health Record (EHR) Reporting of PQRI

CMS wants to begin accepting data from EHRs for PQRI individual measures (not Measures Groups) starting January 1, 2009.

Exception for Incentive Payment and Shared Savings Programs
Medicare and private insurers have been piloting pay-for-performance and other programs that use economic incentives to encourage quality cost-effective care delivery. In many of these cases, hospitals may be paying physicians and this "may implicate the physician self-referral law". CMS proposes an exception to the physician self-referral law that would permit these payments provided "specified conditions are met."

For providers submitting Part D presecriptions electronically, computer-generated faxes will continue to be permitted if there are temporary communication problems that preclude the use of the NCPDP SCRIPT standard. This is now extended to include dispensers who may also use computer-generated faxes to request refills from providers not capable of using NCPDP SCRIPT.

Other changes

There are a variety of other actions in the proposed rule with less direct impact on healthcare technology. These include anti-markup provisions, RVU review, Physician Payment Locality Options review, quality standards for diagnostic testing services, ESRD facility payment, competitive acquisition program (CAP) revisions, changes to enrollment and billing rules, beneficiary signatures for non-emergency ambulance service, commentary on organ retreival services .