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22 posts from June 2007

June 28, 2007

Coordinated care vs. primary care: what's the problem and what's the solution?

Over at CommonHealth this week, Debra Geihsler proposes a coordinated care model as a solution to the looming PCP crisis.  (Debra is CEO of Harvard Vanguard Medical Associates, which, for those of you not from around here, is the not-for-profit medical group that used to be the staff part of former part-staff-model HMO Harvard Community Health Plan; the HMO is now Harvard Pilgrim Health Care.)

This sounds like an intriguing idea, but the solution seems to be constructed from the perspective of the provider and payor (lack of PCP resources, high cost of chronic care) rather than the public (though she does note the access issue -- i.e., lack of timely access to PCPs).

I wonder, to what extent has HVMA implemented this approach?  To what extent can it do so without changes in payor contracts?

I'd be interested in hearing more about what HVMA means, exactly, by coordinated care.  As described by some other provider organizations, it sounds to me just like what the function of a good PCP is supposed to be.

My own care through HVMA seems to be coordinated through my PCP, through annual physicals and advice about things like diet and exercise, as well as through encounters with the system between annual physicals.

In the face of a PCP-MD shortage, does coordinated care mean that I will eventually have an NP/PA but not an MD as my primary care provider?  What approaches will be put in place to be sure that the care is more coordinated, rather than less coordinated, in the absence of a PCP?

As always, the devil is in the details.

Update 6/29/07:  More on the problem:  The Center for Studying Health System Change released today a study on the drop in numbers of primary care physicians.  The Center says:

An exodus of men from primary care practice is driving a marked shift in the physician workforce toward such specialties as cardiology and dermatology, reinforcing concerns about a looming shortage of primary care physicians, according to a new national study released today by HSC.

Two factors have helped mask the severity of the shift from primary care -- a growing proportion of female physicians, who disproportionately choose primary care, and continued reliance on international medical graduates (IMGs), who now account for nearly a quarter of all U.S. primary care physicians, according to the study.

See the study and press release.

-- David Harlow

June 27, 2007

News of first HIPAA security audit trickles out

While neither the federales nor the hospital in question has confirmed the story, an Atlanta hospital has reportedly been the target of a HIPAA security rule audit.  This month, Computerworld reproduced the laundry list of inquiries and document requests presented by the feds.  An instructive list, and worth the attention of other covered entitites.

HIPAA enforcement continues to gather steam.

Based on a recent government-funded study, it appears that many covered entities have been experiencing some confusion about the precise nature of their obligations under HIPAA.  In the face of heightened scrutiny and enforcement, compliance becomes an even more important priority.

The Harlow Group LLC, together with its affiliated experts in complementary disciplines, stands ready to assist covered entities with compliance audits, planning and implementation of their HIPAA compliance strategies.

-- David Harlow 

June 26, 2007

Beach Blawg at Idealawg

Stephanie West Allen co-hosts this week's sizzling Blawg Review at Idealawg.  Her co-host is Julie Fleming-Brown, of Life at the Bar.

-- David Harlow

IRS offers further clarification of EHR safe harbors

The IRS recently issued a Q&A document clarifying a handful of questions raised by the memorandum on the EHR safe harbors issued last month

One of the Q&A's seems to represent significant backpedaling by the IRS from its earlier guidance, which said docs had to provide hospitals access to PHI except as prohibited by law.  Now the IRS recognizes that the physician may have contractual obligations to patients and that the hospital and physician may negotiate terms and conditions of access.  It's the fifth of six points set forth in the latest guidance:

Q5 -- What type of restrictions, if any, may a medical staff physician impose on the hospital’s access to electronic medical records created by the physician using the Health IT Items and Services subsidized by the hospital?

A5 – A physician may deny a hospital access to such records if that access would violate federal and state privacy laws or the physician’s contractual obligations to patients. Also, the hospital and physician may agree on reasonable conditions to the hospital's access. For example, their agreement could allow the hospital to access a patient’s medical records only when that patient becomes a patient of the hospital, and could deny the hospital access to nonmedical information such as billing, insurance eligibility, and referral information.

Works for me.

-- David Harlow

June 25, 2007

Thoughts on potential new directions in Medicare

Over at Let's Talk Health Care, Charlie Baker has been musing about how to wrestle with the intractable problems of Medicare, citing a WSJ piece by a Sloan-Kettering doc who observed, in Charlie's words: "Care is more ongoing and multi-disciplinary than it’s ever been, and Medicare has no way of recognizing this new fact, or aligning with it financially."

Fast forward through the comments, and we have Charlie concluding that the learning from Medicare demonstration projects

[doesn't] find [its] way into the larger platform that the baseline program operates on. This makes me wonder if the only way to go at this would be a statewide demonstration (I can’t believe I’m saying this - MA had something kind of like this back in the late 1980s when the state set all hospital rates, including Medicare rates). Might be worth considering - as a way to get everyone in MA on the same page.

Initially, I couldn't believe he was saying this either, but upon reflection it seems to me that this is yet another way that CMS could expand the sandbox, so to speak.  The federales have been pretty actively throwing a lot of stuff against the wall to see what might stick, including the Senior Care Organization demonstration here in Massachusetts for dual eligibles (Medicare and Medicaid).  It would, in fact, be interesting to see a statewide Medicare demonstration incentivizing providers to take more of a collaborative, patient-centered approach to care.

-- David Harlow

June 21, 2007

More on minute clinics in Massachusetts and elsewhere

Retail clinics are being reimbursed for services by payors -- and CIGNA added a new retail clinic provider to its network recently, according to the WSJ Health Blog.

Paul Levy continues to ruminate about local opposition to retail clinics, dissecting part of the comments filed by opponents of retail clinics in Massachusetts in connection with the Department of Public Health's review of licensing requirements for retail clinics here in Massachusetts.

-- David Harlow

Flying down to RHIO

Some good news and some bad news.  The bad: Northeast Pennsylvania RHIO bites the dust; the most recent casualty.  Tip of the hat to Gary Levin at Trusted.MD's RHIO Monitor, who notes:

The failure of most RHIOs lies in the repetitive cycle of relying on establishing non-profit entities and reaching for a grandiose goal of regional and or national connectivity.  Babies must take baby steps.

Gary thinks NEPA RHIO will be resurrected in some form or another.

Many commentators have observed that successful RHIOs need to focus on building a shared vision (not just among the technogeeks, but among all the stakeholders) before beginning to build the IT infrastructure.  And, clearly, it can't be done without big bucks. 

So on to the good news (well, I think it's good): the California health facilities bond agency has conditioned its approval of Sutter Health's nearly $1 billion bond issue on Sutter's ponying up nearly $10 million for the California RHIO -- to build some IT infrastructure for the RHIO and for rural providers.  That sort of creative arm-twisting strikes a familiar chord for me (as a former regulator) and could go a long way towards jump-starting RHIOs.  It's more opportunistic than planned, but hey, $10 million is $10 million.

Now let's consider the funding question further: Should the provider community bear the cost of rolling out a RHIO?  Shouldn't them that realize a monetary benefit shoulder the burden?  That would mean contributions from payors -- as has happened in Massachusetts, with significant funding for MAeHC coming from payors -- and even liability insurance credits for the wired provider.  Who else should be tapped for contributions?

-- David Harlow         


June 19, 2007

Medblogger code of ethics, anyone?

I was pointed to the Health Care Blogger Code of Ethics blog by my friend Dr. Ben (whose newish blog, by the way, is an excellent resource on pediatrics, infectious disease and quality improvement).  The undertaking seems to be getting up a good head of steam post-Flea, and under the tutelage of Revolution Health's Dr. Val.  Hmm, wait a minute, what's RevHealth's angle here . . . ?

Truth is, I'm not sure there's a need to reinvent the wheel.  HON's code (for example) includes the HCBE principles and is similarly free and self-enforcing (or, rather, community-enforced).  It also clearly requires an up-front assessment, which HCBE hasn't yet clearly committed to requiring.

Just another fascinating day out in the Wild West of medblogging.

-- David Harlow

June 18, 2007

CMS finally puts the kibosh on Medicare Advantage private fee for service plan marketing

A halt to marketing by the half-dozen or so private plans that cover the Medicare Advantage (MA) private fee for service (PFFS) waterfront (the top seven plans that account for 90% of the market) was announced late last week -- a "voluntary" arrangement agreed to by the health plans.

About a month ago, Pete Stark held hearings on the subject of PFFS marketing, and said:  "Given that half of the projected Medicare Advantage growth" is in the area of private fee-for-service plans, "we need to immediately evaluate its value before it gets unmanageable."  He'd like to steer some of the MA PFFS dough to SCHIP funding.

The problem raised by the PFFS plans is that they receive a significant premium above traditional Medicare FFS rates, with little or none of the care management that is the theoretical basis for the bump up in payment.  The issue has been aired in a number of forums, including Health Affairs.

MA PFFS has brought health plans into the Medicare business in markets they had previously avoided.  They were applauded by the NAACP for doing so, but, hey, traditional Medicare was there first and was doing just fine, thank you -- and the NAACP eventually backpedaled its support on roughly those grounds.  (See Bob Laszewski's post for some history and context on PFFS and funding issues.  In a more recent post, he says the health plans can sell PFFS plans during a limited open enrollment period anyway, except to someone who's just turning 65, so this voluntary ban dosn't really ban anything just now.)

Rural health experts, pulled together in an HHS National Advisory Committee on Rural Health and Human Services, included MA PFFS in their annual report issued in January. The issues and recommendations concering MA PFFS are discussed here, and start off with this stark statement:

The Committee's concerns, laid out in detail below, focus on a myriad of instances in which the substitution of MA for traditional Medicare may have the effect of stripping from many of the rural providers critical financial supports embedded in traditional Medicare as a result of more than 20 years of efforts by policymakers to create a stable health care environment in rural areas. CMS needs to monitor the impact of these plans on rural providers closely to assure that they continue to exist and provide access to care for Medicare beneficiaries in rural areas.

The Committee is concerned that if MA is implemented in a manner that is not sensitive to the rural context, it could adversely affect the health care delivery system in rural communities. Medicare payments can account for as much as 80 percent of in-patient revenues for small rural hospitals.

Against this backdrop of need and concern come the sales forces of the major health plans.  Given the fact that MA PFFS enrollees are more profitable to the insurance companies, it is not surprising that individuals are steered into them by sales agents whose commissions for MA PFFS sales are several times higher than commissions for other products -- some of which may well be more suitable for the enrollees.  (Click here for more PFFS information from the patient advocacy perspective.)

Some folks, including Michael Catron at Health Care BS, see the retrenchment precipitated by the "blunders" of the health plans in question as a step backward for future market-based Medicare reform.

This episode certainly hurts that cause, and there are things that need to be attended to, pronto.  The government needs to focus on recalibrating the program so that there is concrete value realized in return for any premium above and beyond Medicare FFS rates (e.g., case management), rationalization of sales commissions, and limits on profit-taking by the private sector on what is quintessentially a public sector program.  Without these fixes at a minimum, beneficiaries are better off with traditional FFS Medicare.

-- David Harlow   

June 14, 2007

IRS releases draft revisions to form 990 - annual report for tax-exempt entities including hospitals

The IRS issued proposed revisions to Form 990 today, including a new schedule for hospitals which

Requires organization to report aggregate community benefit for all facilities, and certain information regarding billings, collections, and joint ventures; requires list of facilities and description of type of services provided at each facility; requires reporting of certain policies and activities to communities served by the organization.

See the IRS press release and the IRS web page on the proposed revisions to Form 990.  The comment period is open for 90 days.

I suppose this could count as the response called for in the letter from Senators Grassley and Baucus to Treasury last month.  Think the IRS had a heads-up on the Senators' letter?

Wipe off those spectacles and prepare for a little more transparency.

-- David Harlow