The Centers for Medicare & Medicaid Services announces a delay of meaningful use, and on Dec. 6, 2013, proposed an extension of Stage 2 through 2016 and beginning Stage 3 in 2017 for those providers that have competed at least two years in Stage 2.
In a post on its site, Robert Tagalicod, CMS’ director of Office of E-Health Standards and Services and Jacob Reider, MD, acting national coordinator for Health Information Technology of ONC, the goal of the change is two-fold: “First, to allow CMS and ONC to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2; and second, to utilize data from Stage 2 participation to inform policy decisions for Stage 3.
“The phased approach to program participation helps providers move from creating information in Stage 1, to exchanging health information in Stage 2, to focusing on improved outcomes in Stage 3. This approach has allowed us to support an aggressive yet smart transition for providers.”
The two also point out that the timeline allows for enhanced program analysis of Stage 2 data to inform to the improvements in care delivery outcomes in Stage 3, the primary goal of the extension, to give all involved more time to prepare for the future of the reform.
Guest post by James Hofert, Roy Bossen, Linnea Schramm and Michael Dowell, all partners with Hinshaw & Culbertson.
New federal healthcare legislation and implementing regulations, seek to exert control over multiple aspects of patient care. The Health Information Technology for Economic and Clinical Health Act (“HITECH”)[i] with staged implementation through 2016, seeks to not only promote implementation of electronic health record systems (“EHR”), but also regulate electronic communications of health information by and between the patient, physician, hospitals and other healthcare institutions so as to enhance care quality, care coordination and reduce costs.
HITECH further envisions implementation of clinical decision support algorithms for the diagnosis and treatment of disease both during admission and after discharge. The Hospital Readmission Reduction Program[ii], effective October 1, 2012, consistent with the objectives of HITECH seeks to financially penalize hospitals for higher than standardized readmission rates for heart failure, acute MI and pneumonia. The Center of Medicine and Medicaid Service (“CMS”) intends to expand application of the program to readmission for COPD, elective total hip arthroplasty and elective total knee arthroplasty in 2015[iii]. Consistent with preventative care goals so as to mitigate further health care problems as found in HITECH, CMS has refused to adjust the re-admission penalty program to account for readmissions unrelated to the patient’s initial hospitalization even though the readmission could be considered to be outside the hospital’s or physician’s control[iv].
Guest post by Ken Perez, healthcare policy and IT consultant.
When he was leaving his post as the head of the Centers for Medicare and Medicaid Services, Dr. Donald M. Berwick famously said that 20 percent to 30 percent of healthcare spending is waste that yields no benefit to patients.
Given that large amount of waste, surely then, one would have thought that almost all of the original 32 Pioneer ACOs—many of which are generally considered the most sophisticated healthcare organizations in the nation—should have been able to shave a few percentage points off their costs during their first year in the program and therefore, meet or beat their expenditure benchmarks.
As we know from a July 16 press release from CMS, that was not what happened. While all of the Pioneer ACOs successfully reported the required quality measures, a majority—60 percent failed to produce shared savings, missing their cost-reduction (or more accurately, cost curve bending) targets. Moreover, two of the pioneers incurred sufficiently large losses requiring penalty payments to CMS.
In a new report that’s been gaining quite a bit of attention in recent weeks, CMS faces several obstacles in overseeing the meaningful use incentive program.
Here’s what OIG found in its assessment:
“CMS faces obstacles to overseeing the Medicare EHR incentive program that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the report states. “Currently, CMS has not implemented strong prepayment safeguards, and its ability to safeguard incentive payments post payment is also limited. The Office of the National Coordinator for Health Information Technology (ONC) requirements for EHR reports may contribute to CMS’s oversight obstacles.”
Essentially, OIG has concerns that the ONC is simply giving away money without verifying whether those who have attested actually completed the process properly. I think it’s a valid concern, though, given the number of hurdles physicians face and the degree in which their meaningful use systems must undergo to become certified, I think it’s probably a little far fetched that an overwhelming number of practices are going to bilk the system (though it could happen).
What follows are the recommendations for the administration of the meaningful use program, per OIG:
First, it is recommended that CMS:
Obtain and review supporting documentation from selected professionals and hospitals prior to payment to verify the accuracy of their self-reported information and
Issue guidance with specific examples of documentation that professionals and hospitals should maintain to support their compliance.
OIG wants CMS to conduct occasional spot audits prior to payment for them to receive their money. It won’t happen. After all of the work and time invested at the practice level, there is going to be too much push back to administer an audit cycle of this magnitude, and CMS doesn’t have the time nor resources to undertake it as an action item.
Frankly, this seems like a point made for the sake of making a point. This is big government we’re talking about. Everyone feels the need to participate in a conversation just to they look important while doing it. These may be some valid points, but OIG comes off a little out of touch in doing so.
Also, according to the report, CMS did not concur with OIG’s first recommendation, stating that “prepayment reviews would increase the burden on practitioners and hospitals and could delay incentive payments.”
Finally, OIG recommended that ONC:
Require that certified EHR technology be capable of producing reports for yes/no meaningful use measures where possible
Improve the certification process for EHR technology to ensure accurate EHR reports.
ONC concurred with both recommendations, which I think are beside the point.
Perhaps the most “intriguing” element of the report, though, is its actual title. Let’s take a look: Early Assessment Finds that CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program.
Is it me or can the title be any more vague? Seriously? CMS face obstacles? That’s a pretty bland statement given the scope of meaningful use, and (perhaps I’m reaching) that seems to diminish the validity of the entire report, which brings me back to my previous point: Is OIG inserting itself into a conversation in which, at this point, it really has very little to say?
With the patient engagement quandary hanging its head over the next phase of meaningful use, healthcare leaders of all kinds continue to wrestle with how to meet mandates that are beyond their control.
Previously, the assignment was simple: do this, get that. But here, in stage 2, there’s a little outlier – required patient engagement – that has some physicians worried about how they are going to handle their second attestation.
Even though there are rumblings that CMS may look the other way when dealing with patient engagement, or decides not to enforce it, at least in the beginning, or chooses not to audit this measure, it’s still a mandate and it’s being taken seriously for all providers seeking the second set of financial incentives.
Some practices are taking measures that they haven’t had to in the past or at least with as much passion as they are now. They are marketing and advertising directly to patients, even if the campaign extends only to the interior of their own practices.
Such is the case for Dr. Stephen Bush, of Fox Valley Women and Children’s Health Partners in St. Charles, Illinois.
The first step in the process, Dr. Bush said is the implementation of a patient portal, which is though to help get the practice’s patients engaged or, in the very least, getting them more involved in their care protocols.
“The problem is, patients have to sign up to use the portal,” Bush said. His worry, though, is when pushing patients to engage, that if patients are pushed too hard, patients push back and essentially disengage.
“We receive significant push back from patients who get upset when trying to engage too much,” Bush said. Examples include posting too many times on Facebook or posting too many tweets to Twitter. According to Bush, patients will stop liking the practice on Facebook and stop following on Twitter if they feel the practice too involved socially.
Bush said his practice is working to implement new marketing and educational strategies to prepare for the patient engagement mandate, just to be safe, even though there’s little that can be done to audit how often patients use the portal after they have signed up.
There also may be too much attention put on patient portal’s capabilities, he said.
“They are not education tools, and they’re not meant to provide better healthcare, and in no way does it educate the patient,” he said.
Despite the patient engagement portion of the Stage 2, Bush said meaningful use is needed and ultimately, will help patients become more informed and get them involved in their care, which may help reduce costs overall. “The management of healthcare for patients is important, and can make lives better and healthier,” he said.
“All physicians are concerned about their patients are being taken care of and informed. Meaningful use gets patients involved. Patients now deal with things when there is a problem occurs rather than managing a healthy lifestyle.”
Physicians are trying to engage patients, and always have. Eventually, a change will come to the landscape, but as long as patients remain laissez-faire, there will be some push back when they are pushed.
Perhaps one of the easiest ways to engage patients in the patient engagement process, especially as it relates to meaningful use Stage 2, is to let them know that you are trying to engage them.
Since CMS announced the patient engagement requirement as part of meaningful use, physicians and practice leaders who hope to attest and receive federal incentives have voiced their concern over the requirement since it’s the one element beyond their control.
“The push back from providers is because it’s the one thing they can’t control; they can’t make patients ask for a patient summary and force them to download it,” said Amit Trivedi, healthcare program manager at ICSA Labs, which is a vendor-neutral testing and certification firm that works with EHR vendors. “Originally, I thought it would be upheld. I still don’t think they’ll drop it, but it’s possible they (CMS) may modify it or choose not to audit it.”
Essentially, the patient engagement portion of Stage 2 most likely won’t be dropped, but, according to Trivedi, enforcement of the mandate may not happen right away.
Still, Trivedi says the healthcare community shouldn’t walk away from the patient engagement debate simply because patients don’t seem interested in or accessing their health record. On the contrary, now is the time to begin moving in the direction of creating more awareness with the consuming public.
By taking the approach that if patients don’t ask for something because they don’t want it is faulty, Trivedi said. The same arguments were made by technology vendors prior to meaningful use who he said claimed certain enhancements just were not important to physicians and their patients. However, once incentives were announced and mandates issued, vendors quickly jumped on board to upgrade their systems to meet the new need.
Patient portals are an example of one such tool. Prior to meaningful use, they were considered Cadillac-like add ons that were wanted only by a few practitioners. With meaningful use, they are necessary and required component of the systems.
“You may never be able to make patients download their records, but you have to advertise and make the data available” said Trivedi.
Healthcare is entering the age of a new demographic and though there may be little desire to engage with the current generation, upcoming users are not going to be so patient in seeking their health information. For many, having access to their records will be a right, Trivedi said. Making data available to the public and encouraging patients to access and use it is nothing more than a cost of business.
Other than advertising to patients about the capabilities, Trivedi suggests taking the message to those who truly need access to it, for example, parents of young children and caretakers of the elderly. Though there’s simply no way that a majority of consumer patients will be engaged patients, at least in the short term, it’s much more likely that targeting specific population sets, like those mentioned, will help move the population forward and get people to take greater ownership of their care (or at least the care of those they are caring for).
After all, even with all the data collection and its analysis, its potential for improving greater health outcomes across the population and the move toward structured and transportable data, it ultimately we won’t find the results we’re looking for if the patients are not engaged.
Help me understand, if you will, where the soul of meaningful use lies. I’ve seen the rules that have been made final and I’ve heard the stories of folks in the field that have had their lives and practices changed because of it.
But all of this just doesn’t seem to lead to a very innovative end.
Sure, the technology is needed in healthcare as the antiquated use of paper continues to overwhelm, but what’s the real proposition here? As far as I’m concerned, some of the real questions remain unanswered, and I am slightly suspicious as to why the feds are so heavily involved.
Granted, I shouldn’t be surprised given all the money that’s been spent in numerous non-government areas (like cars, banking and solar), but let’s peel back here a little and ask why the industry really needs the incentives. Let’s agree that on its own, the healthcare industry would have adopted the technology and was doing so; the incentives just moved adoption along much more quickly. So, why are the feds involved? Agree with me or not, they want our data.
This is the coup d’état. Collected data leads to predictive analysis and evidence-based treatment protocols. This leads to the dissolution of independent care protocols and removes independent will and turns healthcare into committee care.
Getting care is going to be similar to applying to government grants and scholarships. I’m oversimplifying the matter here, but please, let’s admit that there is a price that’s going to be paid for the federal incentives.
That said, my soap boxing out of the way, I’m back to my original question: Where is the soul of meaningful use?
Let’s take a look at the upcoming Stage 3. In large part it’s a lot of increased measures and new “patient engagement” provisions such as: giving patient the opportunity to request amendments to their records online, requiring electronic health records to receive, generate or access appropriate immunization recommendations, and requiring EHRs to be able to query other entities for outside records.
(Yawn.) (Wipe my eyes.)
These are valiant efforts and worthy of exploring, certainly. But, where is the real innovation that we’re supposed to be seeking? Where’s the game-changing approach to healthcare information that blows our minds? This is a technology based process after all and I think we need to begin demanding more of the technology we employ.
The technology is not holding us back, either. It’s us and our continually lowered expectations. If we’re going to take some risks then those risks need to be real risks and not some marketing speak for a data grab slight of hand.
From my perspective, about 90 percent of the technology vendors in the space do just enough and nothing more. Their investments are in sales teams, not in research and development.
But how can you blame them when the one leading body of the mandated changes is asking so little of the community.
What this is beginning to feel like a bunch of self-appointed “decision” makers trying to affect change of a program that’s been in place for decades, in the end, no matter the tinkering, may be nothing but waste having been accomplished.
The fact that mandatory Stage 2 patient engagement is considered one of the largest meaningful use hurdles should come as a surprise to no one. If it is, that’s somewhat similar to saying that the day before a presidential election you still haven’t decided who you are going to vote for.
I think at this point it’s pretty short sighted to disregard this fact. Healthcare reform does not (yet) reform patients; it’s still a set of mandates for those in the field, practicing in the field and drawing money from the system.
Meaningful use is meaningless as far as patients are concerned. In almost every case they don’t know what it is nor do they care. They’ll only care when one of two things happen. You can take this to the bank: 1.) they are forced to pay or contribute financially in some way or 2.) you take away their right to care (in other words, you mandate them to do something in some way.)
I speak from experience gained from my time leading communication programs for a mandated statewide health insurance program.
If we want to hold patients responsible for their health outcomes, we need to either take away their right in some regard or tax them for their behavior. This is also commonly known as a sin tax. You smoke and you pay the tax on cigarettes.
I’m being a bit overly dramatic on purpose and I don’t recommend either of the two points above, but we should be fully aware that putting meaningful use in the hands of the patients are going to produce disappointing results for every physician and practice hoping to achieve Stage 2.
Just because a practice implements a patient portal doesn’t mean patients will use it. I have used my doctor’s patient portal. Even as a technology enthusiast and healthcare writer, I don’t particularly find it fun to use nor do I find it really helps me engage with my physician. Sure, I can send some emails and pay some bills through it, but that’s just the case. To me, it’s more of a bill pay system and I’m sure I’m not alone here. How many of you enjoy using your credit card company’s online bill pay system?
The only good news on this front is that Centers for Medicare and Medicaid Services might have finally figured this out and may allow for an exception to the ill-conceived requirement, despite Kathleen Sebelius’ insistence that a measure of patient engagement be included in the Stage 2 requirement.
But, I’m not holding my breath that what’s best for physicians in regard to meaningful use attestation will be upheld, though, when the only response to physician frustration over the requirement because patients are not showing any interest is for physicians to “push” their users to use it.
In principal, that response is a lot like breaking a toothless law. Sure a law is on the books, and you broke it, but there’s nothing that you can do about it.
And, as anyone who works in communications understands, push communications only goes so far in the 21st century and not nearly as far as it may have 15 or 20 years ago.
Push and pull; now that’s the kind of conversations that engage. You give, you take; you speak, you listen.
Anything else is nothing but mandatory arrogance from political forces far from the field of actual care.
For all of you info nuts, I discovered a fascinating repository of healthcare trivia facts collaborated by Rock Health.
There’s some pretty terrific and wonderful information here, and some pieces of trivia that I would never have imagined.
For example, this may be a softball, but, think America has got it all? Apparently not. It’s the only wealthy, industrialized nation that doesn’t have a universal health system. Speaking of wealthy, we Americans spend about $8,000 per capita on healthcare. That’s twice the amount of our next closest competition. That’s heavy.
We’re also a heavy nation. Nearly 70 percent of all adults are obese. And as “advanced” as we are in our healthcare, our life expectancy is at about 79 years. That’s 50th globally. Maybe the mortality rate has something to do with the obesity rate.
Perhaps it has something to do with the number of medical error deaths each year: between 50,000 and 100,000.
For those of us in otherwise non-final stages of life, there’s a good chance we’re living with a chronic condition. One in two Americans suffer some form of chronic illness. That’s a lot of pain.
Moving on, what do we spend our healthcare money on? Give yourself a pat on the back if you know some of these figures. Shocking.
Total healthcare dollars spent in 2010 was $2.6 trillion. Nearly all of that is spent on personal care, at $2.2 trillion. No wonder we spend so much time talking about the subject. That’s a lot of dough changing hands. By the way, in case you’re keeping track, the rest of the money was spent on health insurance admin and public health, according to CMS. Thanks to Rock Health for also pointing out that of the $2.2 trillion spent in personal health care expenditures, Medicare and Medicaid finance $525 billion and $400 billion respectively, or more than 40 percent of health care. That’s a lot of public assistance.
If you’re involved with healthcare IT in any matter, you probably already know that 17 percent of our nation’s gross domestic product was spent on healthcare. That’s more than any other developed nation.
Hospital care, physician and other clinical services make up about 51 percent of all health spending at $1.3 trillion, according to CMS, with prescription drugs making up about 10 percent of all health spending ($259B)
More than 30 percent of all healthcare spending is wasted.
How about this one? And don’t shake your head like it’s a shame when you might be part of this problem: 75 percent of all healthcare dollars are spent on patients with one or more chronic conditions, many of which can be prevented including diabetes, obesity, heart disease, lung disease and high blood pressure. You do your part, I’m doing mine.
In the care setting, 35 percent of U.S. hospitals have adopted electronic health records, and 57 percent of office-based physicians have adopted the systems. According to Rock Health, the number of hospitals using health information technology has more than doubled in the last two years, and the number of health IT jobs in the U.S. is expected to increase by 20 percent from 2008 to 2018. Maybe not for PR folks like me, but I wish you the best if you’re in sales, R&D and training and support.
For you mobile folks, and there are a lot of you, perhaps you’ll take comfort knowing that there’s strength in numbers. Apparently, there are more than 104 million folks in the U.S. that own smartphones. Fifty percent are app users and download them regularly. More that 142 million will use them by 2016.
For you doctors, apparently about 84 percent of you use tablets in your daily work. Very mobilely progressive of you.
Now for a little health on the web. More than 80 percent of Internet users, or 59 percent of U.S. adults, look online for health information. About 25 percent of Internet users have consulted online reviews of particular drugs or medical treatments.
And, nothing shocking here, 18 percent of Internet users of adults, have gone online to find others who might have health concerns similar to theirs. People living with chronic and rare conditions are significantly more likely to do this. Who hasn’t done this?