The Romney Factor?

There's a new myth circulating: that Romney, if elected, will abolish health care reform. As they say, don't believe everything you hear. The truth of this matter is more than likely quite the opposite. Abolish or accelerate?

The confusion originates with an old failure, the failure to distinguish between health care reform and health insurance reform. Obamacare is about health insurance reforms. Who gets covered and who pays? How? When? You know, the usual menu when it comes to money. That's very different from the basic tenets of health care reform: transparency, portability, interoperability, higher quality at lower cost. These are shared values that players and parties tend to agree on more than they differ.  

As for the money side of the equation, we would naturally expect a Republican president to replace Obamacare with something like "Romneycare", right? Something's going to happen to redefine and rebrand the program. But what will those changes be?

Here's what the American Academy of Family Physicians had to say following last week's presidential debate (see the full statement here):

“Regardless of the election outcome, health care reform will continue. The AAFP calls for reforms that ensure Americans’ access to health care by building the primary care physician workforce, laying a path that enables all Americans to have health care coverage, and improves the quality and lowers the cost of health care services.”

Would you believe that, rather than abolish the reform movement, a new government could expedite it? How so? In reality, it's the federal government that is keeping the pace of change moving as slowly as it is. You've seen the delays: stage 1 certification was released months later than planned, now stage 2 is delayed (until October 2014) far behind the original schedule. The switch to ICD-10 codes has been postponed. By and large, the reasons are good ones, giving time for more public input, allowing room for industries to adapt.

An important pilot project in which the AAFP is deeply integrated - the Comprehensive Primary Care Initiative - involves both private and public payers. CPCI is a 2-year initiative at the behest of CMS. Were it up to the private payers, this project would wrap up in about 6 months.

More or less across the board, private industry would drive change much faster than government agencies permit. Without the political process and federal agencies applying the brakes, reform measures would accelerate not dissipate.

Alistair Jackson, M.Ed.
Jim Grue, O.D.

Getting personal about Health Care Reform

On August 13, Medscape News Today published a rather worthwhile read: Healthcare Reform: It is Getting Personal by Steven D Shapiro of UPMC. Here's the outline:

• Abstract and Introduction
• Patient-centered Accountable Care
• Evidence-based Care Pathways & Clinical Effectiveness Research
• Molecular Networks
• Targeted Therapy for Cancer & the Cost–benefit Equation
• Scientific Approach to Personalized Medicine
• The Electronic Health Record & Analytics
• Conclusion
• Future Perspective

Don't let the number of topics fool you; it's not an overly lengthy article. Outside of molecular networks and cancer therapies, Shapiro covers many of the same themes we articulate here on EMRlogic Live, most of which come down to understanding the essentially predictable tides of change in healthcare, forsaking expensive and ineffective fee-for-service models and moving to a new era of patient-centered care that leverages the power available through health information technology.

In his Future Perspective, Shapiro wraps up with: 

"Sharing of data is another hurdle. This includes both patients' willingness to share their personal genetic information, as well as physician and scientist willingness to work together. .."

Let me add to that the willingness of health systems to share data. Shapiro advocates that "Medical centers should strive for a central data warehouse" ... providing "a 'single source of truth'. In a perfect world, data repositories could be powerful tools. To the degree however that the warehouse is controlled (knowledge is power) or information kept for economic gain, we shoot ourselves in the foot.

Since it's getting personal, let's not do that.

Alistair Jackson, M.Ed.

You asked about ACOs - Part 2, Team Delivery of Care

... continued from last day. For a brief discussion of ACOs and Communications, see Monday, August 13.

Team Delivery of Care

We clearly see a corollary in the development of team-based care delivery: the purists would like to see a system where all providers could form into teams to deliver care in the most efficient and cost-effective ways and in which all providers could participate in shared savings accounts. Large health systems want to maintain their dominance and even extend their control over the delivery system. What we are seeing arise is a number of programs that represent the gamut between these two extremes.  

On the one extreme are ACOs which revolve around a myriad of regulations to the point that it is difficult even to understand exactly what ACOs can and cannot do. The bottom line is that this complex set of regulations restricts ACOs to relatively large health systems in order to fulfill all the requirements. This, of course, favors health system domination and, in fact, was pushed as a complex system by the large health systems.

On the other end of the spectrum is the new Comprehensive Primary Care Initiative, which was effected largely by the designers of health care reform and pushed by the Office of the National Coordinator. These stakeholders want to see competition in the health care marketplace and access by providers at all levels.  

From an eye care perspective, we believe it is important for every eye care provider to have a general understanding of ACOs and health information exchanges, knowing that both are too complex and too diverse to be fully understood in terms of what they can and cannot do. Every eye care provider, on the other hand, should have an intimate knowledge of how DIRECT works and the significance of the Comprehensive Primary Care Initiative, as these are the two programs that most parallel the original goals of the health care reform movement. They also show how providers may work together, through coordinated care, to provide the highest level of care within a structure that openly communicates patient health information between providers. Seeing the significance of shared savings when controlled by primary care is a key to understanding the importance of team care delivery and reimbursement.  

Once again, we believe the way that independent eye care providers are going to be most successful is to understand ACOs and exchanges generally but DIRECT and the Comprehensive Primary Care Initiative specifically. The latter pair illustrate well how the emerging system is supposed to function. Then, being involved in the local community as the care delivery structures are being formed is the most important step.  To that end, the National Eye Care Communications Project, while sponsored by EMRlogic, is offered as a vendor-neutral gathering where providers can share their learnings, their experiences and assist all participants in understanding the cultural changes necessary for business success in health care reform.

Jim Grue, O.D.
Alistair Jackson, M.Ed.

More on ACOs is available in Archives. See Categories: Accountable Care Organizations.

You asked about ACOs - Part 1, Communications

One of the participating doctors in our National Eye Care Communications Project asked for more insight into ACOs, as what some have called "the real rising power" in health care reform.  

In our attempts to understand national-scale bills or movements, such as health care reform, we must acknowledge a conceptual level where the creators and influencers would like to see things go, and also a practical level involving the passing of regulations, legislation and policy.  These two levels rarely align.  And this was never more true than in the case of health care reform.  Let’s consider two parallel situations – communications and team delivery of care – in which we see clearly this difference between how a system is ideally designed and what was necessary to put it in place on a practical basis.

Communications

In the area of communications, we see two distinct programs emerging: the first is the health information exchanges being established in almost all states; the second is the national DIRECT communications network.

From a conceptual standpoint, the purists in health care reform would like to see a system in which every provider has equal and secure access to patient health information. From a practical standpoint, health systems see an advantage in being the central hub with information easily flowing in and where they have control over what flows out. The result is the first category of exchanges, repository-type HIEs, being developed by large health systems that tend to dominate the process in their states. The health systems share patient health information through the exchange, and independent providers send information into the exchange. Independent providers however, for the most part, only have access to view patient information through portals rather than easily receive information from the exchange.

In addition to the health information exchanges, we also see the emergence of the DIRECT system, which is being resisted in many states by the large health systems. DIRECT however is being pushed by the National Coordinator of Health Information Technology and also by some state HIE adminstrators as a way of granting to all providers equal access to patient health information. This is the system that gives independent eye care providers equal access to patient health information.

To be continued ... join us next day for part 2, Team Delivery of Care.

Jim Grue, O.D.
Alistair Jackson, M.Ed.

More on ACOs is available in Archives. See Categories: Accountable Care Organizations.

Taking the long view ... again.

HITECHAnswers has published another worthwhile read for those of us who like to think big picture. It's First Glimpse at Stage 3 Meaningful Use Measures by Mary Mosquera, Senior Editor, Government Health IT. 


I'm intentionally keeping my comments short today in the hope you'll click the link and read what Ms. Mosquera has to say. If you've been following the long-term trends, you already knew that clinical decision support would be the crown jewel of Stage 3 certification. No surprise, the Health IT Policy Committee confirmed that direction at its August 1 meeting.


To date however, most talk of CDS centers around drugs: drug-drug interactions; drug allergy alerts, and so on. And, in this area, an authoritative resource is sought, versus every vendor coming up with its own rules. Great concept! That might leave vendors a place still to set themselves apart - for example, helping with the everyday decisions made by providers that are not medication related yet lead to better patient outcomes.


In the meantime, read Mary Mosquera and maybe a related post or two. Enjoy!


Alistair Jackson, M.Ed.

A scary pilot program!

If only we could say all news of health care reform was good news! Modern Healthcare recently announced a rather scary kind of pilot program: a RAC demo program. RAC, what's that? Recovery Audit Contractors. 


The infamous RACs have been around for years already. Typically, they've gone into practices to do Medicare audits, primarily checking to see that patient records substantiate past Medicare claims. In many cases, records were found not to substantiate the claims, and significant penalties or "clawbacks" have resulted. This program was so successful in getting big dollars back into Medicare coffers that CMS could do nothing other than multiply its army of auditors. Now, CMS has taken it to a whole new level.

"After an eight-month delay, the CMS has set Aug. 27 as the date for the start of a demonstration program that will allow Medicare recovery audit contractors in 11 states to review the medical necessity of claims before the providers are ever paid. 

The demonstration program, called recovery audit prepayment review, will focus on certain types of claims that the CMS says are prone to high rates of improper payments. The reviews will focus on seven states with providers prone to errors and fraud (California, Florida, Illinois, Louisiana, Michigan, New York and Texas) and four with large volumes of short inpatient hospital stays (Missouri, North Carolina, Ohio and Pennsylvania)."

Read more here: CMS sets start date for RAC demo program | Modern Healthcare 

So what does this have to do with eye care? As is the case for all manner of change arising from health care reform, it has everything to do with eye care. It's only a matter of time before any aspect of the transformation of healthcare comes home to roost in your practice. 


A primary concern for eye care as a profession is that we're second only to radiology in the volume of imaging used for diagnostic purposes. Imaging is a primary target for RACs since they're notoriously poor at showing what the claim says they show, especially if the images are kept as paper records. 


A big lesson we see in just the brief quote above is that audits are now occurring statewide and across defined groups. How far a leap is it to move from provider groups "prone to errors and fraud" or that demonstrate "short inpatient hospital stays" to specialty provider groups? These examples prove that the analysis of broad-based provider data is alive and well at CMS. Do we think CMS has not yet identified or cannot easily spot professions or provider groups that claim every billable specialty test in order to maximize revenue? 


The bad news here is the catch-all nature of the new RAC process. Once a group is identified, it matters no longer that you're the exception. By virtue of association, you've effectively failed the audit before it starts ... akin to guilty until proven innocent. Even if the verdict is favourable, going through the process is ugly.


Our message here is more for the eye care profession and significant provider groups within it than to individual providers: it's time to pay heed to the pilot program developments in healthcare. Too often we still hear, "that's down the road" or "we'll do that once it's important. Sometimes those are foolish words from sleeping giants.


Alistair Jackson, M.Ed.

Patients with Direct addresses?

Last week, I joined in on a LinkedIN discussion about patients having Direct addresses. (You can find it here.) Should they, shouldn't they? Despite the pro and con comments, the fact is that some patients do already have Direct addresses. Here's one person's comment:

As someone who's occasionally a patient myself, I've already created my own personal Direct address (for free) via my Microsoft HealthVault account (also free). And, while I'm eagerly awaiting the day when my own PCP's patient portal (Epic-based) gets upgraded to allow for more efficient and effective 2-way messaging between me and my doctor, I'm especially looking forward to eventually being able to expect him and the other providers I see to routinely send my health information -- using CCD/CCR and other relevant PHI attachments -- to my @direct.healthvault.com address, so that I'll be able to maintain ownership and control of ALL of my own health information in one place without having to be tied to a single ambulatory practice's EMR system. Until MU Stage 2 becomes a reality, though, my HealthVault PHR is mainly just a nice place for me to be able to find all of my recent pharmacy records and lab results in a structured way (thanks to the HealthVault apps that CVS, Quest Diagnostics, and LabCorp have made available), and some self-reported PHI as well, and share this information with the various specialists I see.

The writer is obviously not your average patient. He's too well informed not to be involved directly in healthcare. But he's a patient nonetheless. Those "some patients" to whom I referred above will soon become "many patients" and eventually "most patients".


How about you? If you're following this blog, you're also not your average patient ... but a patient nonetheless. Do you have a personal @direct address? How about a personal HealthVault account? Both are free. Why not jump in on that game? I suspect it'll help you be ready to understand what's going on when "Joan" asks you to send her health information to averagepatient@direct.healthvault.com. 


Alistair Jackson, M.Ed.

PCPs, your new best friends!

No matter how large or small your professional network, it's time to improve communications with the Primary Care Physicians in your community. Why? For years, healthcare in the USA has been specialty-centric. That is, in the M.D. world, specialties have made a lot more money than primary care. Healthcare Reform is changing that balance of power ... and payment.

Perhaps you've already read our comments about the Comprehensive Primary Care Initiative, even noticed or attended meetings in your state or city. The bottom line is that PCPs are being heavily incented to take on care coordination and to develop their practices as medical homes or medical communities. Given that care coordinators will take over the total care of the patient, we need to understand that PCPs are being placed at the power core of reformed healthcare. Not only will they coordinate every aspect of patient care, they will assemble the care team. Primary Care Physicians will play a key role in choosing the specialty providers who are able and available locally to most efficiently get the job done. Those team doctors (specialists) will need to be both available and valuable. So, when it comes to the eye care needs of the patient, will the PCP's eye care provider of choice be you?

We'd like to suggest that, more often than not, the Eye Care Practioner (ECP) of choice will be someone within the PCP's network, such as employee of the local hospital where the primary care physician already has admitting privileges and working relationships. Why? Expediency. 

If that seems discouraging, it's probably time to think hard about being an independent eye care provider. No, this is not simply the same old same old. It's not the way it's always been. In years gone by when patients chose you based on your local reputation, there was no highly incented and highly paid care coordinator in the local doctor's office taking over the scheduling of their eye care visits. 

The new realities of health care reform call for a proactive stance. YOU must step up and be counted. As we've seen in the last six posts, you have to be in the EHR game, you have to be ready for communications, you have to offer your value-add services to the local PCPs with whom you want to work. 

We'll alert you, prod you, raise the red flag, advise and help you. In the end, you have to get busy at the grass-roots level and make things happen.

Alistair Jackson, M.Ed.

Jim Grue, O.D.

Bundled payments ... ubiquitous change!

I'm a big believer that trends flow to their logical conclusion. If we look at the initiatives under way today in coordinated care, it should be no surprise that changes in the delivery model will flow to changes in the reimbursement model.


Look at this background statement for the Bundled Payments for Care Improvement initiative, from the CMS Innovation website:

Medicare currently makes separate payments to providers for the services they furnish to beneficiaries for a single illness or course of treatment, leading to fragmented care with minimal coordination across providers and health care settings. Payment is based on how much a provider does, not how well the provider does in treating the patient. 

Research has shown that bundled payments can align incentives for providers – hospitals, post acute care providers, doctors, and other practitioners– to partner closely across all specialties and settings that a patient may encounter to improve the patient’s experience of care during a hospital stay in an acute care hospital, and during post-discharge recovery.

As expected, most health care reform initiatives are contextualized in the hospital setting and flow from there into ambulatory care settings. It's important, therefore, that you, as an independent health care provider recognize Accountable Care Organizations (ACOs) as the bridge between these two worlds.

ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  

While the statement above comes from CMS, recognize that today there are more commercial ACOs than Medicare ACOs. It is a dangerous gamble to segregate CMS initiatives from those of other payers and pretend the trends don't matter because you don't see many Medicare or Medicaid patients.

In a similar vein, we still encounter the equally harmful gamble that "this is all going to go away" in the supposed defeat of Obamacare. Not so. While some aspects of payment reform (health insurance reform) will survive and others won't, health care reform is here to stay. It is not the object of the pending Supreme Court decision. For the well being of your business and private-practice profession, look back then look ahead. Ubiquitous change. Are you preparing for what it means to you? Are you participating alongside your colleagues to ensure that independent eye care providers have a place in the emerging models of health care, both delivery and reimbursement?

Alistair Jackson, M.Ed.

Coordinated care leads to bundled payments

Coordinated care is by no means a new concept or recent buzzword but it does flag some important developments in the ongoing transformation of health care. In our discussions with eye care providers it is not yet apparent that many have grasped the significance of press releases like the one on June 6 from CMS entitled, “CMS Announces Private-Sector Commitments to Improve Primary Care for Patients, Save Money for Medicare: Eight States will test unique investment in coordinated care”. 

“In a strong show of support for more effective, more affordable, higher quality health care, 45 commercial, federal and State insurers in seven markets today pledged to work with the Centers for Medicare & Medicaid Services (CMS) to give more Americans access to quality health care at lower cost.”

The announcement goes on to explain a new initiative that impacts the business of every eye care provider from coast to coast, even though it specifies pilot projects in only eight states. Why is this important to you as an ECP? Because pilot projects like these signal ubiquitous change. If we understand the big picture, we can see that coordinated care spells the eventual demise of fee-for-service care billed directly by you to CMS or any other payer. To the extent that you don’t bill much to CMS, look past Medicare and Medicaid. See the private-sector commitments and public-private partnerships. Ubiquitous change.

“Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services. Simultaneously, participating commercial, State, and other federal insurance plans are also offering an enhanced payment to primary care practices that provide high-quality primary care. 

"We know that when we support primary care, we get healthier patients and lower costs," said Acting CMS Administrator Marilyn Tavenner, "This initiative shows that the public and private sectors can come together to meet the critical need for these services."

Insurers in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Oklahoma signed agreements with CMS to participate in this initiative. The markets were selected based on a diverse pool of applicants from commercial health plans, State Medicaid agencies, and self-insured businesses who hoped to work alongside Medicare to support comprehensive primary care. 

In order to receive the new care management fee from CMS and insurers, primary care practices must agree to provide enhanced services for their patients, including offering longer and more flexible hours, using electronic health records; delivering preventive care; coordinating care with patients’ other health care providers; engaging patients and caregivers in managing their own care, and providing individualized, enhanced care for patients living with multiple chronic diseases and higher needs. 

Approximately 75 primary care practices will be selected to participate in the Comprehensive Primary Care initiative in each designated market ...

The Comprehensive Primary Care initiative is a four-year initiative administered by the Innovation Center. Applications will be accepted until July 20.

For more information, please go to: http://www.innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html”

Takeaways for you as an independent eye care provider:

1. Getting connected with primary care is imperative to the survival of your business.
2. Coordinated care management fees mean that qualified entities will take over the complete care of the patient, including assigning their eye care provider.
3. Enhanced services include using EHRs, delivering preventive care (that’s you!) and coordinating care with patients’ other health care providers (that’s team-based care).
4. Chronic care is defined as two back-to-back billings by a provider for the same condition or diagnosis (that’s everyone, all your patients in due course).
5. Coordinating care with other health care providers means electronic communications … exchanging CCDs and other forms of patient information.
6. The National Eye Care Communications Project is focused precisely on helping you meet these requirements. 
7. The CMS Innovation website is a tremendous resource for understanding where the transformation of healthcare is taking us. We strongly recommend that you go there and read up on ACOs, Bundled Payments and the Comprehensive Primary Care Initiative. Links to all three topics are available in the bottom section of the home page.
8. Join us next day for more on the logical conclusion of coordinated care ... bundled payments.

Alistair Jackson, M.Ed.

Jim Grue, O.D.

Communications, Connected Care and Beacon Communities

What is the Beacon Community Program? 

The Beacon Community Cooperative Agreement Program is part of a larger health care improvement revolution that demonstrates how health IT investments and Meaningful Use of electronic health records (EHR) advance the vision of patient-centered care, while achieving the three-part aim of better health, better care at lower cost. The HHS Office of the National Coordinator for Health IT (ONC) is providing $250 million over three years to 17 selected communities throughout the United States that have already made inroads in the development of secure, private, and accurate systems of EHR adoption and health information exchange. Each of the communities, with its unique population and regional context, is actively pursuing the following areas of focus:

• Building and strengthening the health IT infrastructure and exchange capabilities within communities, positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years; 
• Translating investments in health IT in the short run to measureable improvements in cost, quality and population health; and;
• Developing innovative approaches to performance measurement, technology and care delivery to accelerate evidence generation for new approaches.

Why are Beacon Communities relevant to our Eye Care Communications project? 

The above description is taken from the Office of the National Coordinator of Health Information Technology website.  The basic task of the Beacon Community Program is to look at the total health care resources of these 17 selected communities and see how they can most effectively work together to get the best community-wide health care outcomes at the lowest cost. Their challenge is to develop innovative ways for health care providers and resources to work together to optimize patient outcomes, to develop ways of consistently delivering the highest quality care.  If you go to the link above and scroll down, you'll see a description of what each community project is asked to do. One of the broad goals of the Beacon Program is also to determine what items “bundled” payments must cover.

The results of the three-year project (2011 through 2013) are providing important information at the national level for developing health care policy.

Getting independent eye care providers involved in Beacon Community projects is a goal of the National Eye Care Communications Project.  Participation is essential if independent eye care is to be part of the developing model of care, and especially if independent eye care is to be included in the reimbursable services included in the bundled payment system.


Alistair Jackson, M.Ed.
Jim Grue, O.D.

Looking "outside", seeing the road ahead

Our December 19, 2011 post was entitled, "To understand eye care, look outside!" We talked about the infamous crystal ball, which no one seems to have, and why it's not actually needed if we simply look outside eye care ... at the hospitals. If we follow hospital news, we'll see the road ahead for eye care, really for the domains of care of all independent practitioners.


Today's look at Becker's Hospital Review reveals yet another new healthcare model: the integrated care model, or network. Two have been announced in the last week, one in Central Georgia and the other in Western New York. Let's look at the one in New York since it involves a BCBS partnership. The bolded words are mine, for emphasis.

"BlueCross BlueShield of Western New York and Kaleida Health of Buffalo, N.Y., announced plans to partner and form an integrated care model, the first of its kind in the Buffalo region.

The model includes a network of Western New York physicians partnering with health system Kaleida and health insurer BCBS to create a physician-led organization. It's a first of its kind healthcare delivery model for the Buffalo region in that it combines a health plan, health system and group of physicians providing patient-centered care.

It's essentially a commercial accountable care organization. Kaleida Health refers to it as a "strategic partnership" intended to "assure accountability for both the clinical outcomes of the patients and the costs of the care delivery model."

Are we drifting off into aspects of health care reform that don't apply to ECPs? Absolutely not. Admittedly, we still feel the need to point to the evidence that says (a) health care is transforming, and (b) the very changes we're seeing today in the hospitals are the changes we'll see in your practice tomorrow. If we're harping on HIEs and ACOs, it's because these entities matter for you. This is not about stimulus money, neither grants nor penalties. It's about the survival of your business.


Action items for ECPs:

1. Find out about your state HIE and how you can get connected to it.
2. Inquire about local ACOs and what it takes to belong to a care team.
3. Ask your software vendor about their readiness to offer you ONC Direct. (We have written a number of posts recently on HISPs and ONC Direct. See those for more details.)
4. At the bottom of this post, see "Comments and Reactions". If you have a question, click on that title and type away. We'll be more than happy to respond.

Alistair Jackson, M.Ed.



  

More patients, less time, forever.

In a global sense, I'm an advocate of the transformation of health care. Of course, it's not all good and certainly not all easy. One of the sad pressures of our times is that doctors must see more patients in less time, and do that forever. We might blame that on health care reform but it's more likely an inescapable reality no matter what the system. A paper-based model demands the same but offers no hope for survival. We've all heard it said that insanity is repeating the same thing and expecting a different result. So, change we must.

I came across a blog post today (American Academy of Optometry - LinkedIn discussion group), entitled "See More Patients by Having Them Return Less Often. Huh?" In a nutshell, the discussion is about patient compliance, matching your recall efforts with patient patterns and expectations. You can recall your patient every year but if the numbers show they actually come back on average every 28 months, maybe you're wasting your marketing dollars. Maybe you'll see more patients return if you recall them closer to when they think it's time to see the eye doctor again.

Regardless of how you reconcile that difference - and I don't suppose there's just one answer for all - the fact is that the HITECH Act is driving all kinds of new technologies into health care, including patient communications. Consumer technology is driving some of this change on its own but health care reform is making it official, and that means everyone must play ball.

Good EHRs will take care of the "less time" issue by driving speed and efficiency in the patient visit. When it comes to educating your patients and improving compliance, you'll be assisted in whole new ways by the evolving technology of health care. Last week, for example, I learned from our e-prescribing partner (DrFirst/Rcopia) that we'll soon see a patient advisor module added to the mix, functionality that will include patient education, coupon offers and recalls, all able to be sent via email or text message. Does this type of service exist already? Of course it does, but as separate services. And how tired are we all of having multiple bills to pay, one here, one there, a seemingly endless array of third-party solutions. 

My point is that the transformation of health care is like the tide coming in. When the tide comes in, all ships rise. The bar is being raised all over healthcare and it's bringing hope, new possibilities, new integrations. It's by embracing the power of integrated technology solutions that we can hope to survive in a more-for-less-forever world.

Alistair Jackson, M.Ed.

The law of unintended consequences

Perhaps you remember when infant safety seats were mandated to be placed in the back seat of the car not in the front passenger seat. Made sense, right? So why did this action lead to a dramatic increase in child injuries from automobile accidents? The unintended consequence of the law was to cause parents to turn around while driving. Less attention to the road, more accidents.

The Affordable Care Act of 2010 is intended to bring about cost reductions on many levels in health care, and part of that is helping patients see clearly into cost and quality matters. The intended consequence of health care Transparency is to help consumers choose low-cost high-quality providers. But what if consumers believe more care is better and low cost means low quality? It's another great example of how our assumptions don't always lead where we expect them to go. 

Unintended consequences don't always mean the original thought was a bad idea. They remind us that change is more complicated than we anticipate, and the more so when many people are required to make changes. It's why public comment periods and the democratic process are so valuable in bringing about a better end game. I personally get impatient with the review process, the criticism, the debate but I have to admit it produces better results.

As we observe the transformation of healthcare over the coming years from fee-for-service to pay-for-performance and from disparate care to connected care, let's take the long view. Give yourself time and space to test assumptions and adapt, and do the same for those who are driving the bus. 

Alistair Jackson, M.Ed.
For some deep and interesting insight on this topic, see the article published on Health Affairs as "Consumers’ And Providers’ Responses To Public Cost Reports, And How To Raise The Likelihood Of Achieving Desired Results" by Ateev Mehrotra, Peter S. Hussey, Arnold Milstein and Judith H. Hibbard.

An epic debate

An epic debate is under way in the Supreme Court. It's about challenging the current health care bill. The results will significantly affect all Americans and obviously all health care providers. Whatever happens with the decision, it is clear that the Supreme Court is following the same discussion going on elsewhere.  That discussion revolves around parts of the bill that may overstep the constitutional right of the federal government to mandate that every individual must purchase health insurance. Parts of the health care bill are favored by everyone on both sides of the political spectrum. Many indicators point to the likelihood that the individual mandate could be declared unconstitutional.  

Of particular interest, the Chief Justices are asking whether such a declaration would make the entire bill unconstitutional, or if there is a way to preserve the rest of it. Justices on both the right and the left are in agreement that, if possible, the rest of the bill should remain in effect, provided there are legal grounds to achieve that end. 

This Supreme Court debate mirrors some of our previous blog posts, that the controversy here lies within the insurance reform part of the bill (who gets covered and how it gets paid) not within the health care reform part, which directly affects how health care is delivered and reimbursed. It will be some time before we know the Supreme Court's formal decision. Whether or not the individual mandate is struck down, there will be significant efforts on both sides of the political spectrum to keep the health care reform process moving ahead. 

So, our message once again to eye care providers (indeed all health care providers) is this: 

• know the distinction between health insurance reform and health care reform;
• understand that, even if the insurance reform portion is eliminated or modified, this does not eliminate the basic tenets of health care reform that are already transforming the way you must practice;
• continue to pursue the EHR technologies delineated within the HITECH Act regardless of your volume of Medicare or Medicaid billing.

Jim Grue, O.D.

Accountability: it cuts both ways

Accountability is a basic tenet of today's transformation of health care. Why? Perhaps because the lack of accountability inherent in a paper-based fee-for-service honor system is the root cause behind the near bankruptcy of Medicare.


Last week, we saw that accountability in health care reform is not just about Providers becoming accountable to low cost and high quality; Payers are also accountable. We've seen fraudulent providers get caught and penalized; now we're seeing unreasonable insurers stopped in their tracks. Secretary Sebelius called on two insurance companies to drop unreasonable rate hikes in nine states.

"Thanks to the Affordable Care Act consumers are no longer in the dark about their health insurance premiums," said Secretary Sebelius.  "Now, insurance companies are required to justify rate increases of 10 percent or higher.  It’s time for these companies to immediately rescind these unreasonable rate hikes, issue refunds to consumers or publicly explain their refusal to do so."

In these nine states, the insurers have requested rate increases as high as 24 percent. These increases were reviewed by independent experts to determine whether they are reasonable.  In this case, HHS determined that the rate increases were unreasonable, because the insurer would be spending a low percentage of premium dollars on actual medical care and quality improvements, and because the justifications were based on unreasonable assumptions.

In light of the March 19 HHS press release and this week's Supreme Court hearings on "health care reform", it's worth re-emphasizing that the Affordable Care Act and many other examples commonly cited in the media as health care reform are more accurately called "health insurance reform". Health care reform and key concepts like accountability, transparency, portability and interoperability are not up for discussion. Like EHRs and the new technology of health care, these basic tenets are here to stay. Expect to see them everywhere, including in your own back yard. And prepare your business for them accordingly.

Alistair Jackson, M.Ed.

Health care reform or connected care?

Ever get so down in the weeds that you lose the big picture? It feels like time to come up for air and remind ourselves what in the health care world is going on. What follows is an excerpt from my second post on EMRlogic Live, 11 December 2011. I hope it'll be a useful reminder. You can read the original posts via the Archives button to the right. Select December 2011 and scroll down to Parts 1 and 2 of "What are you doing about health care reform?"


But before you read on, let me make an important clarification. I suspect that the term "health care reform" may have become a bad word for some. In my last post, I distinguished between health care reform and health insurance reform. Given the debate around ObamaCare, the discussion of health care reform may have become tainted. For myself, I'm re-directing my thinking to a more neutral and potentially more helpful term: connected care. It describes in vanilla terms where we're going ... to a connected community of health care, the likes of which we have never seen. And it's a good thing.

"I asked an optometrist I considered to be a prominent figure in the eye care profession what he was doing about health care reform. Response? “You know, I just don’t believe the feds are going to pull it off.” Unfortunately, that answer belies what I’ve heard all too often. Ostrich syndrome.

Optometry has a problem. Though far from all, too many leaders are playing wait ‘n see. Ophthalmology is not playing that game. Instead, the MDs are running away with the evidence-based medicine that will be critical to the Clinical Quality Measures upon which all eye care pay-for-performance will be established.

In our 2007 white paper, A White Paper for Optometry: Medicare Pay-for-Performance & Value-Driven Health Care, we asked the question, “Is it in the best interests of either the patient or the health care system itself to emphasize surgical and advanced-treatment methods over early intervention and preventive methods?” Then we gave our answer. “Clearly not! Yet this is the natural course of the current trend toward pay-for-performance. Optometry must position itself to gain input into the outcomes selection process.”

My sense about eye care is that we're moving in the right direction. MU attestations (1238 Optometrists and 655 Ophthalmologists in 2011) and the news of so many ECPs receiving their year 1 stimulus payments is encouraging. Surely our colleague above is less convinced today that the feds aren't going to pull it off.


2011 was the year of the EHR. We got over the initial hurdle and many of us are now seriously in the game. But if we've learned anything, it's that it's not over. There are more hurdles. And the 2012 hurdle is the HIE. Your statewide Health Information Exchange is your doorway into true connected care. Watch for more on this in the coming weeks. Remember that the purpose of EHRs was never about recording results - you've been doing that on paper for years already. The true purpose is to blow open the doors, create transparency and connectivity within the system. That's why we call it connected care.

Alistair Jackson, M.Ed. 

Health care reform or health insurance reform?

On February 21, CMS News issued a press release entitled, "Health Reform Expands the Insurance Market, Supports Consumer-Governed Nonprofit Health Plans". My purpose today is not to comment on the specifics of this announcement, rather to draw your attention to an area where we have observed confusion among Eligible Professionals.

The media and "we" generally do not distinguish well between health care reform and health insurance reform. The two are obviously related but are not one and the same. When you hear the political debate over ObamaCare, that's insurance reform. It's the money side of health care. Who's going to pay for what? How will patients be covered or reimbursed? What about shared savings programs? And in the case above, what are health insurance CO-OPs? 

The most unfortunate outcome of our confusion is that many doctors hear the debate and conclude that health care reform must still be up for discussion. They ask, "why should I rush into EHRs? If ObamaCare fails, everything will go out the window anyway." Well, insurance reform is still up for discussion but health care reform is not. Sadly, too many Eye Care Providers are still waiting to see how it all turns out. They're holding back on EHRs thinking they can wait a little longer with their familiar paper charts. They're convinced that EHRs and the Stimulus money don't matter because they don't do much Medicare anyway. Meanwhile, health care is transforming and putting their businesses in greater jeopardy with each passing week.

If health insurance reform is the cost side of health care, health care reform is the quality side of health care. Lower cost, higher quality. Improved patient outcomes. Health care reform is not up for discussion. It has been unfolding for many years already. It is well engrained in the fabric of health care today. It is here to stay. 2011 was the year of the EHR. 2012 is the year of the HIE ... connected care.

The health insurance reform debate is likely to carry on for years to come. The only real question that remains about health care reform is whether you'll be its benefactor or its victim.

Alistair Jackson, M.Ed.

Acronyms of Change, Part 6 (CQM)

Clinical Quality Measures (CQM) are based on specific evidence-based practices that have been shown to give the best results to the most people. To demonstrate meaningful use successfully, Eligible Professionals are required to report clinical quality measures specific to their health care environment. As an Eligible Professional (EP), you must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures. CQM results (numerators, denominators, and exclusions) must be reported to CMS as part of the attestation process. 

You'll recall, I'm sure, the advent of the Physician Quality Reporting Initiative (PQRI) which has now been renamed PQRS. The "initiative" has become the "system". PQRI was what we called spring training or a pay-for-reporting practice run in anticipation of true pay-for-performance. In the sense that reporting of CQMs is now an attestation requirement, you are being paid for it. However, as is common to most elements of Stage 1 certification, the concepts are really just being introduced. Moving to stages 2 and 3, the bar is rising and more  is being required at each step. We are certainly not yet at full-blown pay-for-performance.

Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report CQMs to CMS by reporting them through either the Registration and Attestation System or via participation in the new Physician Quality Reporting System-Medicare EHR Incentive Pilot. 


However, note that you are only able to participate if you are able to report CQMs based on a full calendar year. This likely means you had completed your Year 1 MU Attestation as of December 31, 2011 and were eligible to begin your year 2 as of January 1, 2012. If you started your Year 1 MU period on January 1, 2012 and are prepared to continue with PQRS through December 31, 2012 the participation in the Pilot may also be possible.


For more details on this new program, see its Quick Reference Guide. More details about CQMs are available here on the CMS.gov website. Or, you may read about Core Measure #10 here.


Alistair Jackson, M.Ed.

Acronyms of Change, Part 4B (DIRECT)

In our last blog, Part A of the same topic, Alistair provided a good basic understanding of DIRECT, a term you may not have been familiar with but one that, if you aren’t familiar and aren’t making the right choices now, may cost you dearly in the future.  As the core communication standard chosen by the Office of the National Coordinator of Health Information Technology, DIRECT must now be used by every state Health Information Exchange (HIE) in view of creating an eventual national HIE. DIRECT is worthy of our close attention. 

Why could HIEs cost you a lot of money in the future? First, because there is no long-term money anywhere in health care funding for the ongoing maintenance of the information exchanges. In the national system proposed by the government, DIRECT would be the national standard and would make it possible for all health care facilities and providers to exchange health information using exactly the same recognized and established communications protocols as established early on by the state HIEs.  If this becomes the national functional standard, then it is thought that the cost of using the exchange will be in the range of hundreds of dollars per provider per year. No provider wants to pay this fee, but the alternative is much more costly. Under the government's proposed plan, the financial benefit to be incurred would far exceed the cost paid for using the exchange. Independent or small group providers would realize a net financial gain by using exchanges standardized around DIRECT.

There is competition however, competition that you may easily feel you should support if you aren’t well informed. You may already have been approached by a large health system in your area telling you that patient health information is available through a free web portal, one that lets you simply log in to see all your patient information. Some ODs are already doing this. At first glance, it appears to be a great benefit, very convenient. Unfortunately however, it is the first step in the large health systems trying to take control of the state HIE. The model is to create an information exchange that requires independent providers to access the state and national exchanges through the local health system's communication network. 

There is growing evidence that these networks can indeed support the cost of you accessing patients from within the health system, as it is essentially marketing for the health system and a business plan that can increase referrals into the system. There is also however strong evidence that these same health systems are establishing exchange capabilities that create a profit center for the future. It is likely that, if large health systems successfully control the state exchanges, we will see fees in the thousands of dollars per provider per year to use the exchanges for access to the national system when it involves patients from outside the local health system. 

When your local health system makes a very generous offer to give you a free portal to view patient information, recognize that by doing so you are casting your vote for the future choice that will probably be the most expensive for you. Begin with the end in mind; we recommend DIRECT  Accept a modest fee early on in order to circumvent exorbitant fees later on.


Jim Grue, O.D.