"Mr. President, this is a big … deal"

Joe Biden filled in the dots with a choice expletive and the health reform bill became law today.

Some little noted sections of the bill related to administrative simplification include:

• Mandated: CAQH operating rules to standardize HIPAA transactions
• Standards to be developed:  EFT (including auto-reconciliation of payment and remittance advice), health plan identifiers and claims attachments
• HHS to consider:  greater consistency for claims transactions' edits and published timeliness of payments by health plans

NIST Health IT Standards and Testing

The National Institute of Standards and Technology (NIST) has launched the Health IT Standards and Testing website with the first installments of a new health IT test method and related software.

Starting in 2011, the federal government will provide extra Medicare and Medicaid payments to physicians’ offices that implement health IT systems conforming to specific technical standards and put to “meaningful use”, performing specifically defined functions. Late last year, the U.S. Department of Health and Human Services (HHS) identified the required standards and provided a concrete definition of “meaningful use.” To help physicians’ offices evaluate possible health IT systems against these requirements, the HHS’s Office of the National Coordinator (ONC) has established a national health IT certification program.

As mandated by the American Recovery and Reinvestment Act (ARRA), NIST and HHS are working with health IT system vendors, standards organizations that include the American National Standards Institute (ANSI) Healthcare Information Technology Standards Panel, certification bodies and system implementers to develop a suite of software tools to support the health IT testing infrastructure. The tools are intended to help vendors test their health IT products and ensure basic functionality, such as the calculation of body mass index or proper formatting of common electronic health records in XML (eXtensible Markup Language).

The health IT testing infrastructure does not create any new standards, only the tools necessary to test for compliance with existing standards that HHS announced late last year. Testing laboratories will use these tools in the testing component of the certification programs established by ONC. ONC has stated its intention to use NIST’s National Voluntary Laboratory Accreditation Program (NVLAP) to perform the accreditation of testing laboratories.

A new Health IT Standards and Testing web site has been established to provide more information on the program and the testing infrastructure suite.

Conformance Test Method Rollout Schedule

CBO Scores Health Reform Bill

The Congresssional Budget Office released their analysis of the $940 billion health reform legislation, which may be voted on as soon as Sunday.

The CBO estimated the budgetary effects of the reconciliation proposal, in combination with the effects of the Senate passed bill.  The combination would reduce federal deficits by an estimated $138 billion over the 2010-2019 period.  CBO estimated a reduction in federal budget deficits over the decade following of roughly $1 trillion.

And the House of Representatives posted the reconciliation proposal which is documented as changes to the Senate passed bill.

Passage of the legislation requires 216 votes in the House, of which 197 are certain and 34 are still in play. 

Health Wonk Review - Call for Submissions

Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant's blog. For participants, it's a way to network and share ideas, and for those readers who don't live in this space every day, it's a way to sample some of the latest thinking and the "best of the best."

Submit your posts to healthwonkreview (at) avancehealth (dot) com.   Please include post title, post URL, post description, post author, blog name and blog URL.  Submissions are due by 12 noon on Sunday March 28th.

Improving Care Coordination Through Health IT - Part II

Dr. Ann O'Malley and a research team from the Center for Studying Health System Change were profiled asking how care coordination could be improved through health IT. In Part II of this report, HTN sits down with Dr. O'Malley to ask about the study and its implications.

The study, published in The Journal of General Internal Medicine article, titled "Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices," interviews physicians and staff with at least two years of experience with commercial ambulatory EMRs in place, along with CMO's from Health IT vendors and national thought leaders on health IT.

HTN: Why is coordination of care so difficult?

Ann O'Malley: First, it is not compensated. So coordination activities carried out by clinicians and their staff are done at the expense of other billable activities. Next, the average Medicare beneficiary sees 7 different physicians in a given year, that's a lot of people with whom that person's regular doctor may need to communicate. Third, systems are not in place to facilitate communication among clinicians caring for the same patient.

HTN: What are the primary policy and technical changes that could help?

Ann O'Malley: First, the creation of incentives for providers to coordinate care and to communicate with one another would be helpful. This includes not just financial incentives, but breaking down some of the existing systematic barriers to coordination that are present in the fee-for-service system. Next, improving the basic care processes around coordination and the infrastructure to support those processes, such as improved health information technology capabilities important to coordination tasks, could be quite helpful.

HTN: You identified many opportunities to take advantage of current technology. Which of these were likely to have the biggest impact on care coordination?

Ann O'Malley: Interoperability between EMRs is key so that clinicians in different offices or across inpatient and outpatient settings can exchange patient data in a secure way that promotes coordination.

HTN: You also identified areas for EMR improvement. Which of these were likely to have the biggest impact on care coordination?

Ann O'Malley: It's hard to say at this point in HIT development. But among the clinicians we spoke with, the exchange of medication lists, problem lists, and communication around referrals and consultations as well as shared care plans were quite important.

HTN: ONC has published the rules by which eligible professionals will be receive incentive payments to be meaningful users of a certified EHR. Where are these rules on the mark, and where do they fall short in terms of facilitating coordination of care?

Ann O'Malley: They are appropriately taking an incremental approach because there is such variation in terms of EMR implementation among U.S. practitioners.

HTN: You interviewed clinicians and leaders that are working every day with EMR technology. What's their general "temperature" related to the state of Health IT and EMR's?

Ann O'Malley: In general, most clinicians would not go back to paper. They felt EMRs were an improvement for care provided within their office. For those outside of integrated delivery systems however, EMRS were not felt to be helpful as they currently are designed and used for coordination of care across offices or settings.
_____________________________

Ann S. O'Malley MD, MPH is a senior health researcher with the Center for Studying Health System Change. She conducts quantitative and qualitative research on a wide range of topics related to quality and access. She is particularly interested in primary care delivery, its intersection with specialty care, and the coordination of care from both the patient and provider perspectives. O'Malley completed her pediatrics internship at Georgetown University Medical Center and a residency in preventive medicine at the University of Maryland Medical Center. She received her master's degree in public health from Johns Hopkins and then completed a National Research Service Award fellowship in primary care research. She is board certified in preventive medicine and is a fellow of the American College of Preventive Medicine.

Improving Care Coordination Through Health IT - Part I

Coordination of care is a significant problem in part due to the large number of specialists involved in patients’ care and a perverse payment system that rewards the most expensive care, doesn’t reimburse for proactive health management, and drives fragmentation of care delivery.

Into this web, steps Dr. Ann O’Malley and a research team from the Center for Studying Health System Change (HSC), asking how care coordination can be improved through health IT. Their findings are published in The Journal of General Internal Medicine, “Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices”.  For their study, they interviewed physicians and staff with at least two years of experience with commercial ambulatory EMRs in place, along with CMO’s from Health IT vendors and national thought leaders on health IT.

'The study reports that a gap exists between policy makers' expectations that current commercial electronic medical records (EMRs) can improve coordination of patient care and clinicians' real-world experiences with EMRs.

Current commercial ambulatory care EMRs facilitate care coordination within a practice by making information available at the point of care but are less helpful for exchanging information across physician practices and care settings, according to the study supported by the Commonwealth Fund.

Clinicians identified many areas where both the design of EMRs might be altered, and office care processes modified, to improve EMRs' support for tasks involved in coordinating patient care.

Additionally, while current commercial EMR design is driven by clinical documentation needs, there is a heavy emphasis on documentation to support billing rather than patient and provider needs related to clinical management, the study found. And, current fee-for-service reimbursement encourages EMR use for documentation of billable events, office visits, procedures—and not for care coordination, which is not a billable activity.

"There's a real disconnect between policy makers' expectations that current commercial electronic medical records can improve care coordination and physicians' experiences with EMRs," said HSC Senior Researcher Ann S. O'Malley, M.D., M.P.H., coauthor of the study with HSC Senior Researcher Joy Grossman, Ph.D.; HSC Research Assistant Genna R. Cohen; former HSC Research Analyst Nicole M. Kemper, M.P.H., and HSC Senior Researcher Hoangmai H. Pham, M.D., M.P.H.

Excerpts from their findings that can be used to inform future EMR improvements include:

• EMRs may have unintended consequences for care coordination, such as creating information overload that complicates providers’ efforts to discern key clinical information. And, managing information overflow from EMRs is a challenge for clinicians.

• Clinicians believe current EMRs have limited ability to capture dynamic planning and the medical decision-making process in a way that supports future coordination needs—present EMRs focus on linear (moment-in-time) documentation while care coordination is dynamic and ongoing.

• Maximizing the potential of an EMR for coordination involves ongoing evolution of clinical care processes as well as clinician input on EMR design modifications and standards for data exchange to support those processes.

• Modifying reimbursement to encourage coordination of care by clinicians will likely drive clinicians to demand better EMR functioning to support coordination.

• Simply creating incentives to adopt EMRs as they currently exist, given the confines of the current payment system, may result in EMRs being designed for billing purposes primarily rather than for clinical relevance to patients and care coordination.'

The team identified EMR features that contribute to care coordination and areas for improvement.

In Part II of this article, HTN interviews principal investigator Ann O'Malley.

Obama: Up or Down on Reform

President Barack Obama presented his arguments for health care reform and called for an up or down vote on the proposed legislation.  Backed by physicians, PA's and nurses, Obama made his case:

"We began our push to reform health insurance last March, in this room, with doctors and nurses who know the system best.  And so it’s fitting to be joined by all of you as we bring this journey to a close.    

Last Thursday, I spent seven hours at a summit where Democrats and Republicans engaged in a public and very substantive discussion about health care.  This meeting capped off a debate that began with a similar summit nearly one year ago.  And since then, every idea has been put on the table.  Every argument has been made.  Everything there is to say about health care has been said and just about everybody has said it.  So now is the time to make a decision about how to finally reform health care so that it works, not just for the insurance companies, but for America’s families and America’s businesses.

Now, where both sides say they agree is that the status quo is not working for the American people.  Health insurance is becoming more expensive by the day.  Families can’t afford it.  Businesses can’t afford it.  The federal government can’t afford it.  Smaller businesses and individuals who don’t get coverage at work are squeezed especially hard.  And insurance companies freely ration health care based on who’s sick and who’s healthy; who can pay and who can’t.  That's the status quo.  That's the system we have right now.

Democrats and Republicans agree that this is a serious problem for America.  And we agree that if we do nothing -– if we throw up our hands and walk away -– it’s a problem that will only grow worse.  Nobody disputes that.  More Americans will lose their family's health insurance if they switch jobs or lose their job.  More small businesses will be forced to choose between health care and hiring.  More insurance companies will deny people coverage who have preexisting conditions, or they'll drop people's coverage when they get sick and need it most.  And the rising cost of Medicare and Medicaid will sink our government deeper and deeper and deeper into debt.  On all of this we agree. 

So the question is, what do we do about it?

On one end of the spectrum, there are some who've suggested scrapping our system of private insurance and replacing it with a government-run health care system.  And though many other countries have such a system, in America it would be neither practical nor realistic.

On the other end of the spectrum, there are those, and this includes most Republicans in Congress, who believe the answer is to loosen regulations on the insurance industry -- whether it's state consumer protections or minimum standards for the kind of insurance they can sell.  The argument is, is that that will somehow lower costs.  I disagree with that approach.  I'm concerned that this would only give the insurance industry even freer rein to raise premiums and deny care.

So I don't believe we should give government bureaucrats or insurance company bureaucrats more control over health care in America.  I believe it's time to give the American people more control over their health care and their health insurance.  I don't believe we can afford to leave life-and-death decisions about health care to the discretion of insurance company executives alone.  I believe that doctors and nurses and physician assistants like the ones in this room should be free to decide what's best for their patients.

Now, the proposal I put forward gives Americans more control over their health insurance and their health care by holding insurance companies more accountable.  It builds on the current system where most Americans get their health insurance from their employer.  If you like your plan, you can keep your plan.  If you like your doctor, you can keep your doctor.  I can tell you as the father of two young girls, I would not want any plan that interferes with the relationship between a family and their doctor.

Essentially, my proposal would change three things about the current health care system.  First, it would end the worst practices of insurance companies.  No longer would they be able to deny your coverage because of a preexisting condition.  No longer would they be able to drop your coverage because you got sick.  No longer would they be able to force you to pay unlimited amounts of money out of your own pocket.  No longer would they be able to arbitrarily and massively raise premiums like Anthem Blue Cross recently tried to do in California -- up to 39 percent increases in one year in the individual market.  Those practices would end.

Second, my proposal would give uninsured individuals and small business owners the same kind of choice of private health insurance that members of Congress get for themselves -- because if it’s good enough for members of Congress, it’s good enough for the people who pay their salaries.

The reason federal employees get a good deal on health insurance is that we all participate in an insurance market where insurance companies give better coverage and better rates, because they get more customers.  It's an idea that many Republicans have embraced in the past, before politics intruded. 

And my proposal says that if you still can’t afford the insurance in this new marketplace, even though it's going to provide better deals for people than they can get right now in the individual marketplace, then we'll offer you tax credits to do so -- tax credits that add up to the largest middle-class tax cut for health care in history.  After all, the wealthiest among us can already buy the best insurance there is, and the least well off are able to get coverage through Medicaid.  So it's the middle class that gets squeezed, and that’s who we have to help. 
Now, it is absolutely true that all of this will cost some money -- about $100 billion per year.  But most of this comes from the nearly $2 trillion a year that America already spends on health care -- but a lot of it is not spent wisely.  A lot of that money is being wasted or spent badly.  So within this plan, we’re going to make sure the dollars we spend go towards making insurance more affordable and more secure.  We’re going to eliminate wasteful taxpayer subsidies that currently go to insurance and pharmaceutical companies; set a new fee on insurance companies that stand to gain a lot of money and a lot of profits as millions of Americans are able to buy insurance; and we're going to make sure that the wealthiest Americans pay their fair share on Medicare.

The bottom line is our proposal is paid for.  And all the new money generated in this plan goes back to small businesses and middle-class families who can't afford health insurance.  It would also lower prescription drug prices for seniors.  And it would help train new doctors and nurses and physician assistants to provide care for American families.

Finally, my proposal would bring down the cost of health care for millions -- families, businesses, and the federal government.  We have now incorporated most of the serious ideas from across the political spectrum about how to contain the rising cost of health care --- ideas that go after the waste and abuse in our system, especially in programs like Medicare.  But we do this while protecting Medicare benefits, and extending the financial stability of the program by nearly a decade.

Our cost-cutting measures mirror most of the proposals in the current Senate bill, which reduces most people's premiums and brings down our deficit by up to a trillion dollars over the next two decades -- brings down our deficit.  Those aren't my numbers; those are the savings determined by the Congressional Budget Office, which is the Washington acronym for the nonpartisan, independent referee of Congress in terms of how much stuff costs.

So that's our proposal.  This is where we've ended up.  It's an approach that has been debated and changed and I believe improved over the last year.  It incorporates the best ideas from Democrats and Republicans --- including some of the ideas that Republicans offered during the health care summit, like funding state grants on medical malpractice reform, and curbing waste and fraud and abuse in the health care system.  My proposal also gets rid of many of the provisions that had no place in health care reform -- provisions that were more about winning individual votes in Congress than improving health care for all Americans.

Now, despite all that we agree on and all the Republican ideas we've incorporated, many -- probably most -- Republicans in Congress just have a fundamental disagreement over whether we should have more or less oversight of insurance companies.  And if they truly believe that less regulation would lead to higher quality, more affordable health insurance, then they should vote against the proposal I've put forward.
Now, some also believe that we should, instead of doing what I'm proposing, pursue a piecemeal approach to health insurance reform, where we tinker around the edges of this challenge for the next few years.  Even those who acknowledge the problem of the uninsured say we just can't afford to help them right now --- which is why the Republican proposal only covers 3 million uninsured Americans while we cover over 31 million.

The problem with that approach is that unless everyone has access to affordable coverage, you can't prevent insurance companies from denying coverage based on preexisting conditions; you can't limit the amount families are forced to pay out of their own pockets.  The insurance reforms rest on everybody having access to coverage.  And you also don't do anything about the fact that taxpayers currently end up subsidizing the uninsured when they're forced to go to the emergency room for care, to the tune of about a thousand bucks per family.  You can't get those savings if those people are still going to the emergency room.  So the fact is, health reform only works if you take care of all of these problems at once.

Now, both during and after last week's summit, Republicans in Congress insisted that the only acceptable course on health care reform is to start over.  But given these honest and substantial differences between the parties about the need to regulate the insurance industry and the need to help millions of middle-class families get insurance, I don't see how another year of negotiations would help.

Moreover, the insurance companies aren't starting over.  They're continuing to raise premiums and deny coverage as we speak.  For us to start over now could simply lead to delay that could last for another decade, or even more.  The American people, and the U.S. economy, just can't wait that long.  So, no matter which approach you favor, I believe the United States Congress owes the American people a final vote on health care reform.

We have debated this issue thoroughly, not just for the past year but for decades.  Reform has already passed the House with a majority.  It has already passed the Senate with a supermajority of 60 votes.  And now it deserves the same kind of up or down vote that was cast on welfare reform, that was cast on the Children's Health Insurance Program, that was used for COBRA health coverage for the unemployed, and, by the way, for both Bush tax cuts --- all of which had to pass Congress with nothing more than a simple majority.
I, therefore, ask leaders in both houses of Congress to finish their work and schedule a vote in the next few weeks.  From now until then, I will do everything in my power to make the case for reform.  And I urge every American who wants this reform to make their voice heard as well --- every family, every business, every patient, every doctor, every nurse, every physician’s assistant.  Make your voice heard.

This has been a long and wrenching debate.  It has stoked great passions among the American people and their representatives.  And that's because health care is a difficult issue.  It is a complicated issue.  If it was easy, it would have been solved long ago.  As all of you know from experience, health care can literally be an issue of life or death.  And as a result, it easily lends itself to demagoguery and political gamesmanship, and misrepresentation and misunderstanding.

But that’s not an excuse for those of us who were sent here to lead.  That's not an excuse for us to walk away.  We can’t just give up because the politics are hard.  I know there’s been a fascination, bordering on obsession, in this media town about what passing health insurance reform would mean for the next election and the one after that.  How will this play?  What will happen with the polls?  I will leave it to others to sift through the politics, because that’s not what this is about.  That’s not why we’re here.

This is about what reform would mean for the mother with breast cancer whose insurance company will finally have to pay for her chemotherapy.  This is about what reform would mean for the small business owner who will no longer have to choose between hiring more workers or offering coverage to the employees she has.  This is about what reform would mean for middle-class families who will be able to afford health insurance for the very first time in their lives and get a regular checkup once in a while, and have some security about their children if they get sick.

This is about what reform would mean for all those men and women I’ve met over the last few years who’ve been brave enough to share their stories.  When we started our push for reform last year, I talked to a young mother in Wisconsin named Laura Klitzka.  She has two young children.  She thought she had beaten her breast cancer but then later discovered it had spread to her bones.  She and her husband were working and had insurance, but their medical bills still landed them in debt.  And now she spends time worrying about that debt when all she wants to do is spend time with her children and focus on getting well.

This should not happen in the United States of America.  And it doesn’t have to. 

In the end, that's what this debate is about.  It's about what kind of country we want to be.  It's about the millions of lives that would be touched and, in some cases, saved by making private health insurance more secure and more affordable.

So at stake right now is not just our ability to solve this problem, but our ability to solve any problem.  The American people want to know if it's still possible for Washington to look out for their interests and their future.  They are waiting for us to act.  They are waiting for us to lead.  And as long as I hold this office, I intend to provide that leadership.  I do not know how this plays politically, but I know it's right.  And so I ask Congress to finish its work, and I look forward to signing this reform into law.

Thank you very much, everybody. Let's get it done."

Certification Programs NPRM Issued

David Blumenthal announced the release today of the notice of proposed rule making for Certification Programs for Complete EHR's and EHR Modules.  Excerpts from the ONC's summary include:

Certification of EHR Technology will provide assurance to purchasers and other users of health IT that an EHR system offers the necessary technological capability, functionality, and security to meet meaningful use criteria.

The Notice of Proposed Rulemaking (NPRM) proposes establishment of two certification programs for the purposes of testing and certifying health IT, one temporary and one permanent.

NIST is developing a test method and infrastructure that will be used by testing laboratories in the testing component of both certification programs.

Certified EHR technology is a requirement for providers to receive incentive payments for the adoption and meaningful use of EHRs under the Medicare & Medicaid Incentives Program. 

An initial set of standards, implementation specifications, and certification criteria for Complete EHRs and EHR Modules was also published in a related Interim Final Rule.

The temporary certification program provides for ONC to authorize organizations to test and certify Complete EHRs and/or EHR Modules.  The goal is to assure availability of Certified EHR Technology prior to the reporting period in which health care providers may seek the incentive payments available under Medicare and Medicaid.

The second proposal establishes a permanent certification program to replace the temporary certification program. The permanent certification program would separate the responsibilities for performing testing and certification, introduce accreditation requirements, establish requirements for certification bodies authorized by the National Coordinator related to the surveillance of Certified EHR Technology, and would include the potential for certification bodies authorized by the National Coordinator to certify other types of health besides Complete EHRs and EHR Modules.

The temporary program ends once the permanent certification program is established and at least one certification body has been authorized by the National Coordinator.

The public comment period for the temporary certification program will be open for 30 days after publication. The public comment period for the permanent certification program will be open for 60 days after publication.

While two certification programs are described in this proposed rule, ONC anticipates issuing separate final rules for each of the programs.