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.

Know Your Community: Accountable Care Organizations

My colleagues Dr. Chuck Haine and Alistair Jackson have written previously about Accountable Care Organizations. (See the Archives for Chuck's post from December 23, 2011 and Alistair's from February 17, 2012.) My question for you is, have you taken the time to see if there is an ACO in your area?  ACO’s represent a new patient referral and reimbursement system whereby the ACO receives a bundled payment for the care of the patient instead of each provider being able to bill fee-for-service to Medicare. The ACO then becomes responsible to distribute payments to the providers involved in the care of the patient. This in turn means two things: one, that the ACO chooses the participating providers and, two, that the ACO controls access to patients.

My point today is this: if you don’t learn how to become part of this new delivery system, it will affect your access to patients.  You owe it to yourself at least to be finding out if you have an ACO in your locality, or if any of the health systems in your area are working toward forming one.  


There are many ACO's functioning now already. Another group will begin getting bundled payments from Medicare on July 1, 2012, then another on Jan 1, 2013.  Since many ACO's are still at the formative stage, it's the perfect time for you to get involved.  Once they're functioning, it may be too late to open the door for your participation.


ACO's are a good example of how health care reform doesn't apply only to providers who take Medicare. You may not be concerned about stimulus incentives since, based on your current Medicare volume, your eligibility is low. Correspondingly, you may be even less concerned about  a small Medicare penalty. But what if, by virtue of the fact that you do not have certified EHRs and cannot communicate as required with other health care providers, you do not qualify to participate on a chronic care team? Losing access to patients is certainly a more serious matter than a 2% Medicare penalty. This is why we have maintained that the EHR Incentives program is really not about the money - it's about the survival of your business. Know your community and get involved in its healthcare programs. They're going to affect your business for better or for worse. It's within your grasp to make it for the better.


Jim Grue, O.D.

Know Your Community: Beacon Community Projects

Is there a Beacon Community project near you?  If you don’t know, you might want to Google "Beacon Community Project" and find out.  


There are 17 projects across the country and all involve large health systems. These are government demonstration projects that are establishing the way all health care resources in a community will work together. Beacon Community projects are determining the clinical research to be used in future meaningful use and health care reform legislation. If this is happening in your community, it is certainly in your interest to know about it and also to be part of it. 


If programs being driven by a large health system seem irrelevant to your eye care practice, be sure to ask yourself, "Do I want a model program being established in my community, one that's going to drive the future delivery of health care, including eye care, and not be part of it?"


Jim Grue, O.D.

A meaningful attitude

Many eye doctors see meaningful use (MU) as a list of extra tasks to be done if (and only if!) one wants to qualify for stimulus dollars. This being the case, you would probably overlook the advantages and opportunities those MU tasks offer.  The CCD is a great example of a new requirement with a hidden punch. You need to give it to your patient at the end of the exam, and also must make it available to the patient in an electronic format.  Sure, you can provide the CCD as a minimum requirement to "get the money", or you can see beyond and also realize that this document brings a significant benefit for your business. 


If you have to provide the CCD then so does every other health care provider who sees your patient. If you ask patients to provide your office with an electronic copy of the CCD from their physician, the electronic CCD can completely populate your EHR's problem list, medication list, allergy list and lab tests. Instantly, almost 10 minutes of data-entry work goes away. You no longer need the patient to arrive early to fill out health forms in your waiting room, and you no longer have to pay a staff person to enter the data. It's all done for you and you need only confirm the information is accurate. At a time when most doctors are worried that EHRs will slow them down in the exam lane, here is a clear example of how certified EHR technology will speed you up.


How are you handling meaningful use? As they say, "attitude is everything". Be assured, there are other opportunities you haven’t previously recognized and of which you can still take advantage.


Jim Grue, O.D.

Key Changes to the ONC HIT Certification Program

You probably already know that the current EHR certification program is a temporary certification program. The anticipated sunset of the temporary certification program is expected to occur upon the effective date of a final rule for the stage 2 proposed rule. At that time, the permanent certification program would become effective and known as the “ONC HIT Certification Program”. 

Proposed changes for stage 2 aim to increase regulatory transparency and add flexibility for the HIT community. ONC is proposing changes to the certification processes for EHR Modules that remove certain certification requirements and provide clear direction for certifying to proposed new certification criteria. The revised process would provide flexibility to quickly utilize newer versions of “minimum standard” code sets. Also proposed is an increase in certification transparency and clarity by making publicly available the test results used to certify EHR technology and clearly representing EHR technology that has been certified. Public comment is also invited on full cost transparency for certified Complete EHR and EHR Module.

Here's another interesting request for public input, a statement that corroborates our recent post on EMR switching. ONC writes in its Stage 2 Fact Sheet, "Data portability (including the migration from one EHR to the next) is a key factor in the EHR technology market where agility and innovation is necessary. We request public input on ways to improve data portability, including comment on a proposal to improve data portability for providers."

A final note: our discussion of Stage 2 is based on the proposed rule making. The 2014 Edition EHR certification criteria are opening for public comment through May 7. Only after this date will a final rule be published.

Alistair Jackson, M.Ed. 

Acronyms of Change, Part 8 (CEHRT)

Here's another acronym I couldn't resist sharing: CEHRT: Certified EHR Technology. The Office of the National Coordinator is looking to revise the definition of CEHRT, based on feedback from stakeholders and the recommendations from the HIT Standards Committee. The new definition would take effect beginning with the EHR reporting periods in 2014, and would provide more flexibility for eligible health care providers. 

The proposed revised definition of CEHRT would require eligible health care providers to have a "Base EHR" that includes fundamental capabilities all providers would need to have, as well as the additional EHR technology necessary to meet the meaningful use objectives and measures for the stage of meaningful use that they seek to meet and to capture, calculate, and report clinical quality measures, but not more than necessary to meet those objectives. A Base EHR would include such fundamental capabilities as:

1. the ability to provide clinical decision support; 
2. the ability to support physician order entry; 
3. the capacity to exchange health information with other sources; 
4. and the capacity to protect the confidentiality, integrity and availability of health information stored and exchanged. 

The revised definition of CEHRT would also enable eligible providers to upgrade and adopt EHR technology certified to the 2014 Edition EHR certification criteria as early as 2012 if they so choose.

That's the information piece. Now, what are the takeaways? 

1. There's nothing more constant than change. Expect continuous change as we move through the transformation of healthcare. That's not a bad thing. In fact, it's a good thing. Change means someone is listening and adapting.
2. Note well the repetition of clinical decision support. It's an incidental mention here but make no mistake, it's a key underpinning showing what is expected of CEHRT.
3. Note also the frequency of exchange language. The transformation of healthcare is all about taking us outside the four walls of our practice to the wider community. Exchange means the portability of health information, locally, at the state level and, in due course, nationally.
4. Just as healthcare at large is continuing to evolve, stay after your own change process. If you've implemented EHRs already, don't stop there! Keep moving on. And the next step is your state Health Information Exchange. Find out more from your state association and check back here; we'll soon be talking about an eye care demonstration project for a state HIE.

Alistair Jackson, M.Ed.