In healthcare, it seems that nothing is easy — technology, regulation, privacy, and security. And now, pricing. Efforts are underway to make prices more transparent; this is a tentpole issue for the Trump administration, which wants hospitals to begin posting “shoppable” prices online in 2020.
According to reports, some hospitals are facing some challenges for doing so and are trying to figure out how they’ll be able to meet the requirement.
The Centers for Medicare & Medicaid Servics (CMS) offered the proposed rule, which mandates that hospitals publish their payer-negotiated rates for “shoppable services” starting on the first of the year. This is part of CMS’ outpatient payment rule. The proposed rule is expected to be finalized by November 2019.
To read my full report on this pricing transparency battle, check out my article on MultiBriefs here.
During her trip to HIMSS19, Center for Medicare & Medicaid Service administrator Seema Verma spoke with registered members of the media to preview her keynote speech and answer questions about her department’s newly released proposed interoperability rule. The rule dictates that data generated by patients while in the scare setting is theirs to own, transfer and share with caregivers. It also would require healthcare providers and plans to implement open data sharing technologies to support transitions of care as patients move between these plan types.
In a statement released prior to her meeting with the media, Verma said that ensuring patients have easy access to their information, and allowing that information to follow them on their healthcare journey “can reduce burden, and eliminate redundant procedures and testing, thus giving clinicians the time to focus on improving care coordination and, ultimately, health outcomes.”
During her meeting with the media at HIMSS, Verma started by discussing CMS’ “why” — why CMS is moving toward enhanced patient empowerment – as well as her and the administration’s focus on the improving the sustainability of the healthcare community.
Patient empowerment remains front and center for the agency, she said. For example, from the patient perspective, everyone has their own experience of going to the healthcare system and not being an empowered patient, she said, and not having access to data decreases patient engagement. CMS is working to change that, now.
When people understand their health and participate in their health, this has the ability to improve care outcomes, she added, and through complete access to their healthcare records, patient care can be more complete. Ultimately, she said, with every detail of a person’s health information in one place — and accessible to the patient — will kick start the digital health data revolution.
On Feb. 12, 2019, CMS Administrator Seema Verma held a session with some members of the healthcare media (this reporter attended the session) at HIMSS19 in Orlando in which she previewed her keynote remarks at the conference. During the briefing, and later during the actual keynote, Verma provided insight into the recently released Interoperability Proposed Rule as well as spoke directly about the Center for Medicare and Medicaid Services (CMS)’ efforts for empowering American patients.
During each session, Administrator Verma highlighted specific actions her agency is taking to ensure Americans have access to their medical records in a digital format. She also profiled some of the steps for setting the stage to increase seamless flow of health information, reducing burdens on patients and providers, and fostering innovation in healthcare through the unleashing of data for researcher and care innovation.
The Administrator took a strong tone to support patient access to their health information and ownership of patient data. “One thing that I want to make very clear for the entire healthcare system is that the data belongs to the patient. It’s their data. It doesn’t belong to the provider. It doesn’t belong to the EHR company. It belongs the patient.”
Thank you Jared (Kushner) for that kind introduction. It has been an honor to work alongside visionaries like you; somebody who really understands at a very personal level as I do, the need and potential of innovation to better serve Americans. Having the Office of American Innovation involved is critical, and I’m grateful for Jared’s involvement, his hard work, and his leadership. It’s an honor to serve with him, and I am grateful for his service to our country.
We have procedures that we couldn’t have imagined a generation ago that are saving thousands of lives.
Precision medicine has opened the door to a new world of therapies specifically tailored to a patient’s unique genetic code.
We can now treat retinal disease that causes blindness.
Robotic technology is making surgeries less invasive, and we are on the verge of having the world’s first artificial pancreas.
3D training tools are enabling doctors to learn anatomy without a cadaver.
Telemedicine is also improving access to care and empowering CMS beneficiaries to lead healthier lives.
And it doesn’t stop with traditional healthcare innovators. The automobile industry is partnering with leading technology companies to perfect driver-less cars that may one day give independence to our nation’s elderly and people with disabilities. And through smart phones and wear-able technology, we are compiling health information every second, and Americans are using that information to track activity, calories, and heart rates. Innovators are even developing ways to monitor chronic illness with electronic watches. The list of innovation is endless.
But while all of this technology is changing every area of our lives, we face enormous challenges in healthcare, and the value that we are receiving for the amount of money that is being spent.
Last year CMS released a report showing that the rate of growth in healthcare spending is not slowing down. Despite all of the changes and regulations over the past decade, healthcare continues to grow more quickly than the overall economy. By 2026, we will be spending one in every $5 on healthcare.
This matters to each and every one of us because this increase in spending will continue to crowd out funding for other priorities, such as roads and schools, as well as national defense. Not to mention it means higher healthcare spending for each and every one of us. We’ve already seen our costs go up, with health insurance premiums, co-pays and deductibles.
And yet, this national increase in spending has not addressed many of America’s healthcare challenges. Entire communities have been ravaged by the opioid epidemic, and we rank poorly compared to other countries when it comes to preventing premature births, infant mortality and chronic diseases. It’s clear that when it comes to the most consequential measures of health and wellness, we need to get much more for our money.
The system we have is unsustainable, and it cannot continue. And President Trump agrees.
Last year, the President announced an Executive Order: Promoting Healthcare Choice and Competition Across the United States. Through his executive order the President made clear that he wants his administration working to change the rate of growth of healthcare spending so that competition can be fostered in healthcare markets, so that patients, and the American people, may receive better value for our investment in healthcare.
Secretary Azar and I are working for competition and better value by moving away from a fee-for-service approach, to a system that is value-based – and that rewards value over volume. This means paying providers on the outcomes they achieve, making people healthier rather than how many procedures they perform. Now many of you have heard this all before.
But, I’ve always been struck by how seldom the patient is mentioned in discussions around value-based care. Let me be clear, we will not achieve value-based care until we put the patient at the center of our healthcare system. Until patients can make their own decisions based on quality and value health care costs will continue to grow at an unsustainable rate. This administration is dedicated to putting patients first, to be empowered consumers of health care that have the information they need to be engaged and active decision-makers in their care. Through this empowerment, there will be a competitive advantage for providers that deliver coordinated, quality care, at the best value, to attract patients who are shopping for value.
I have spent a lot of time talking to Americans from all walks of life, and they are demanding more accountability from the health care system. As they are paying more through higher premiums and higher deductibles, they want to know how much services are going to cost, and they want to shop around for the best price. They don’t want to be paying for duplicate tests, or unnecessary care, and they are demanding a higher level of service and efficiency from the healthcare system.
In every other area of our lives, we are receiving better services that leverage innovation in technology. We can take our ATM card to any bank across the globe, and that bank can access our accounts. We can track every credit card purchase, and every phone carrier honors our cell phone number, and we receive ads for products we were only thinking about buying – or so it may seem.
So it should be no surprise that Americans have the same consumer friendly demands for healthcare. Americans are demanding that when they go to the doctor, the doctor spends more time with them, and less time on paperwork or typing into a computer.
To that end, in our drive towards value-based care, CMS adopted an approach that we call “Patients Over Paperwork.” Patients Over Paperwork is a direct result of President Trump’s Cut the Red Tape initiative, which aims to restore patients as the priority of everything we do, and eliminate burdensome regulations that have outlived their purpose.
We have held meetings in cities across America, and received thousands of letters. And one of the most common complaints we have heard from both patients and providers has been the inefficiency of Electronic Health Records – or EHRs, and the inability of providers to effectively coordinate care for their patients.
Now tremendous progress has been made in the adoption of EHRs. The technology for data sharing has advanced, and data is often shared effectively within a given healthcare system, with inpatient and outpatient doctors in the same provider system able to share and edit the same clinical record.
Despite this progress, it is extremely rare for different provider systems to be able to share data. In most cases there is not yet a business case for doing that – it’s in the financial interest of the provider systems to hold on to the data for their patients.
The Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) today released final rules that simplify requirements and add new flexibilities for providers to make electronic health information available when and where it matters most and for health care providers and consumers to be able to readily, safely, and securely exchange that information. The final rule for 2015 Edition Health IT Certification Criteria (2015 Edition) and final rule with comment period for the Medicare and Medicaid Electronic Health Records (EHRs) Incentive Programs will help continue to move the health care industry away from a paper-based system, where a doctor’s handwriting needed to be interpreted and patient files could be misplaced.
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement. By 2018, these rules move us beyond the staged approach of ‘meaningful use’ and focus on broader delivery system reform,” said Dr. Patrick Conway, M.D., M.Sc., CMS deputy administrator for innovation and quality and chief medical officer. “Most importantly we are seeking additional public comments and plan for active engagement of stakeholders so we take time to get broad input on how to improve these programs over time.”
HHS heard from physicians and other providers about the challenges they face making this technology work well for their individual practices and for their patients. In recognition of these concerns, the regulations announced today make significant changes in current requirements. They will ease the reporting burden for providers, support interoperability, and improve patient outcomes. Providers can choose the measures of progress that are most meaningful to their practice and have more time to implement changes to program requirements. Providers are encouraged to apply for hardship exceptions if they need to switch or have other technology difficulties with their EHR vendor. Additionally, the new rules give developers more time to create user-friendly technologies that give individuals easier access to their information so they can be engaged and empowered in their care.
As part of today’s regulations, CMS announced a 60-day public comment period to gather additional feedback about the EHR Incentive Programs going forward, in particular with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which established the Merit-based Incentive Payment System and consolidates certain aspects of a number of quality measurement and federal incentive programs into one more efficient framework. We will use this feedback to inform future policy developments for the EHR Incentive Programs, as well as consider it during rulemaking to implement MACRA, which we expect to release in the spring of 2016.
Guest post by Crystal Ewing, senior business analyst and manager of regulatory strategy, ZirMed.
Denial management is an industry-wide challenge—and despite traditional approaches intended to reduce denial rates, it’s one that continues to grow. Frankly, this is absurd.
I say that because, despite the recent announcements from CMS regarding changes to how they will process ICD-10-coded claims for the first year, denials will likely still increase under ICD-10—and that’s something healthcare providers don’t need to suffer in full, because it is possible to reduce their denial rates before ICD-10. Ultimately this will be more impactful than any denial management program specifically targeting ICD-10-related denials, because the “everyday” denials will otherwise endure and continue to delay A/R long after whatever disruption ICD-10 causes has long faded into distant memory.
Here are two simple truths:
90 percent of denials are preventable
More than 60 percent of denials are recoverable
So where does this leave healthcare organizations seeking to decrease denials ahead of ICD-10, a change that—despite recent announcements from CMS—is nonetheless likely to bring with it a spike in denials?
Exactly where they’ve always been—in need of straightforward best practices that actually help them drive down everyday denials that create A/R delays, back-office backlogs, and an unreliable revenue cycle.
Step 1: Thoughtful Automation
Let’s step through a common process for working denials, just to clarify why it’s such a headache.
Here are some time-study figures—per each denial, staff spend:
4 minutes identifying the denial and routing it appropriately
+ 10 minutes gathering information
+ 30 minutes compiling and filling out appeal letter and materials
+ 5 minutes just documenting all their activity related to the denial
and visit/log in to the associated payer’s website for 25 percent of denials
That is unacceptable—which is an opinion. But it’s also unnecessary, and that’s a fact. Each of the time-consuming manual processes mentioned above can be eliminated or significantly reduced through thoughtful automation and workflow-focused software development.
Reducing research time and enabling staff to easily resubmit denied claims are two of the biggest denial management time-savers—period.
Guest post by Ken Perez, vice president of healthcare policy, Omnicell.
Since the passage of the Patient Protection and Affordable Care Act, most of the health reform activity in the Medicaid arena has primarily been about expansion of coverage. According to the Centers for Medicare and Medicaid Services (CMS), as of February 2015, 70.5 million people—more than one in every five Americans—were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), which represents an increase of almost 40 percent from the number enrolled at the end of 2009.
However, on May 26, CMS aimed its sights on improving the quality of care delivered by Medicaid, issuing a 653-page proposed rule to “modernize the Medicaid managed care regulations,” which have not been revised in a decade. The proposed rule faces a public comment period that will continue thru July 27.
The changes presented in the proposed rule would align the regulations governing Medicaid managed care with those of other major sources of coverage, including Medicare Advantage (MA) plans and Qualified Health Plans (QHPs), which are offered thru health insurance exchanges (marketplaces). CMS has said that the proposed Medicaid measures will emphasize evaluating health outcomes and the patient experience enrollees have with private plans. In addition, the proposed rule mandates public reporting of information on quality of care, as well as the use of financial incentives to reward Medicaid managed care plans that meet quality measures, a la Medicare Advantage Star Ratings.
CMS’s announcement has been met with mostly favorable responses. “It was about time for the changes” has been a common refrain, with the revisions viewed as a natural, logical progression.
How big is the market that will be impacted by the changes? Per CMS, Medicaid managed care organizations (MCOs) have grown from handling 8 percent of Medicaid beneficiaries in 1992 to about 70 percent of the 70 million Medicaid enrollees today—almost 50 million people. That figure compares with 17.3 million MA enrollees as of January 2015.
At Health Datapalooza, the acting Centers for Medicare & Medicaid Services (CMS) Administrator, Andy Slavitt, announced a new policy that for the first time will allow innovators and entrepreneurs to access CMS data, such as Medicare claims. As part of the Administration’s commitment to use of data and information to drive transformation of the healthcare delivery system, CMS will allow innovators and entrepreneurs to conduct approved research that will ultimately improve care and provide better tools that should benefit healthcare consumers through a greater understanding of what the data says works best in health care. The data will not allow the patient’s identity to be determined, but will provide the identity of the providers of care.
CMS will begin accepting innovator research requests in September 2015.
“Data is the essential ingredient to building a better, smarter, healthier system. The announcement is aimed directly at shaking up health care innovation and setting a new standard for data transparency,” said acting CMS Administrator Andy Slavitt. “We expect a stream of new tools for beneficiaries and care providers that improve care and personalize decision-making.”
Innovators and entrepreneurs will access data via the CMS Virtual Research Data Center (VRDC), which provides access to granular CMS program data, including Medicare fee-for-service claims data, in an efficient and cost effective manner. Researchers working in the CMS VRDC have direct access to approved privacy-protected data files and are able to conduct their analysis within a secure CMS environment.
“Historically, CMS has prohibited researchers from accessing detailed CMS data if they intended to use it to develop products or tools to sell,” said Niall Brennan, CMS chief data officer and director of the Office of Enterprise and Data Analytics. “However, as the delivery system transforms from rewarding volume to value, data will play a key role. We hope that this new policy will lead to additional innovation and insights from the CMS data.”
On Apr. 23, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and rates for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and the IRF Quality Reporting Program (IRF QRP). The FY 2016 proposals are summarized below.
Proposed Changes to IRF payment policies and rates:
Changes to the payment rates under the IRF PPS. CMS is proposing to update the IRF PPS payments for FY 2016 to reflect an estimated 1.9 percent increase factor (reflecting a new IRF-specific market basket estimate of 2.7 percent, reduced by a 0.6 percentage point multi-factor productivity adjustment and a 0.2 percentage point reduction required by law). CMS is proposing that if more recent data are subsequently available (for example, a more recent estimate of the market basket or multi-factor productivity adjustment) such data would be used to determine the FY 2016 update in the final rule. An additional 0.2 percent decrease to aggregate payments because of updating the outlier threshold results in an overall update of 1.7 percent (or $130 million), relative to payments in FY 2015.
No changes to the facility-level adjustments. As stated in the FY 2015 IRF PPS final rule (79 FR 45872, 45882 through 45883), CMS froze the facility-level adjustment factors at the FY 2014 levels for FY 2015 and all subsequent years, unless and until we propose to update them again through future notice and comment rulemaking. For FY 2016, CMS will continue to hold the facility-level adjustment factors at the FY 2014 levels as we continue to monitor the most current IRF claims data available to assess the effects of the FY 2014 changes.
ICD-10-CM Conversion. In the FY 2015 IRF PPS final rule (79 FR 45872), CMS finalized conversions from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for the IRF PPS, which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF?PAI submissions. CMS reminds providers of IRF services that the implementation date for ICD-10-CM is Oct. 1, 2015.
Seems all the chittering was right: The meaningful use Stage 3 proposed rule has been released prior to the annual HIMSS conference, to give all conference goers and government officials in attendance something to talk about.
The news of the rule’s release now comes as no surprise.
The feds like to make these kinds of splashes, to be the bearers of news – any kind of news – especially at big venues where they’re likely to get lots of ink and face time with those in attendance, and the supposed powers that be.
The same thing happened last year at HIMSS when officials, peppered with questions, were vehement that the ICD-10 roll out deadline would not be delayed. Only a few weeks later, federal officials had to walk that back and, untimely, wound up changing the deadline.
These are apples and oranges, I understand, but the grandiosity of the occasion (HIMSS15) means that everyone attending the conference really does need to “bring it.” Vendors, presenters, the feds. At HIMSS, to capture hearts and minds, this is a simple truth — we need to bring it no matter who “we” are.
I’m not trying to be cynical about the announcement or the timing of the proposed Stage 3 rule, but there seems to be something about the nature of its timing that seems suspect. It’s as if CMS wants the news about meaningful use to be relevant. But, as we know, on its own, it is relevant; we all know this.
It’s as if CMS is trying to secure the legacy of a failing program – where as of January 0nly 4 percent of eligible professionals had met meet Stage 2 requirements. It’s sort of like the agency, to make people talk about a once relevant product, is bursting through the HIMSS gates like a has-been celebrity and is announcing, “Don’t worry, we’ll be there.”
How could we forget?
We know you’ll be there, we know we’ll be looking to you for guidance, we know what you have to say is important to us because it impacts the very professions in which we have built our lives.
CMS will make their claims, get us to talk then they’ll ride off into the sunset like Shane.