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158 posts categorized "CMS"

January 29, 2015

Better, Smarter, Healthier: Medicare and Value Based Purchasing

EvolutionThe big announcement this week from Medicare -- setting forth specific targets for a historic shift away from fee-for-service reimbursement in order to reduce costs and improve quality -- is less than it seems.

Medicare has been talking about value based purchasing for decades now, and thus far has taken baby steps towards implementation. Even the strides taken in recent years, and the targets laid out this week for the future, don't really leave FFS medicine in the dust. ACOs and other MSSP innovations don't entirely move away from FFS reimbursement; they just add cost and quality kickers as part of a retrospective reconciliation.

CMS identified four categories of payment and targets related to each of these categories.

  • category 1—fee-for-service with no link of payment to quality
  • category 2—fee-for-service with a link of payment to quality
  • category 3—alternative payment models built on fee-for-service architecture
  • category 4—population-based payment

Continue reading "Better, Smarter, Healthier: Medicare and Value Based Purchasing" »

November 13, 2014

Telemedicine: CY 2015 MPFS reportage and dangers of the echo chamber

Station-grungeMany of us are waiting with bated breath for CMS to broaden its coverage of telemedicine services. Upon the release of the CY 2015 MPFS, the American Telemedicine Association got a little ahead of itself in the excitement over some changes in the physician fee schedule, and announced that CMS had added payment for remote patient monitoring of chronic conditions (99091). In fact, CMS's response to the proposal that this and other E&M codes should be payable if provided via telemedicine was: "These services are not separately payable by Medicare. It would be inappropriate to include services as telehealth services when Medicare does not otherwise make a separate payment for them." (79 FR at 67600.)

Continue reading "Telemedicine: CY 2015 MPFS reportage and dangers of the echo chamber" »

May 23, 2014

The Affordable Care Act: How Provider Organizations Can Succeed Under Health Reform

The Affordable Care Act has triggered many changes in the health care delivery system. Learn about the health reform-inspired approaches to redesigning care that work (or don't work) for management of chronic conditions, including diabetes -- from ACOs to bundled payments to patient centered medical homes.

I recently had the opportunity to present to the domestic affiliates of Joslin Diabetes Center on this topic.

Continue reading "The Affordable Care Act: How Provider Organizations Can Succeed Under Health Reform" »

February 07, 2014

SGR Fix - Can This Really Be Happening?

MagicianThe Sustainable Growth Rate mechanism creating a zero-sum game for Medicare Part B reimbursement rates (dropping rates as volume picks up) has long been unsustainable, and so Congress has been messing around with short-term SGR fix legislation for years now. Every six to twelve months we've been hearing about the impending 20% or 30% Medicare pay cut about to hit physicians' pocketbooks, and the likely exit of physicians from the rolls of participating providers. However, the stars are now aligned in such a way that real progress seems likely: multiple powerful Congressional committees have signed off on a deal to replace the SGR rule with something more workable: A unified approach to financial incentives to physicians and other medical professionals who are Medicare participating providers intended to promote quality and enrollment in alternative payment arrangements.

The full text of the bill will be available here: It's H.R. 4015. Check out the SGR fix section-by-section-summary and the websites of the House Energy & Commerce Committee and the Senate Finance Committee too. The substance of the proposal is discussed below.

How has this happened?

Continue reading "SGR Fix - Can This Really Be Happening?" »

September 23, 2013

HIPAA Rights, Expanded: Opening the Door to Patient Access to Lab Results

MC900389390We're inching closer to promulgation of final regulations that will likely make all lab test results more easily accessible to patients, by making them subject to the HIPAA rules ensuring patient access. (Currently, lab test results and psychiatric notes are the two lone categories of patient data not subject to HIPAA; however "in-house" labs drawn at a health care facility or medical practice are already accessible to patients under HIPAA.) This change is significant in no small part because there was no change in the law that prompted the change in regulation -- the only thing that changed was the rising voice of patients insisting on access ... and a more receptive set of ears in Washington. The proposed change in the regulation was first published two years ago. As I wrote then in a post on lab test results and proposed changes to the HIPAA rules:

This carveout of lab results from patient-accessible records has long been a thorn in the side of the e-patient.  This month, the federales announced that they would step forward as Androcles to the e-patient lion (to jumble a reference or two), and pull out the thorn, by proposing to amend both the CLIA regs and the HIPAA regs.  The HIPAA regs include the exception described above: all records must be made accessible upon request except labs and a couple others.  The lab results exception will be deleted from the HIPAA regs if the change is finalized.  The CLIA regs prohibit lab delivery of results directly to patients.  The proposed amendment says that the labs “may” release the results directly to patients.  The net effect is that patients will have the right to request the results, and since labs will be permitted to release them, they will have to do so.

Continue reading "HIPAA Rights, Expanded: Opening the Door to Patient Access to Lab Results" »

August 26, 2013

Leverage: Preventable readmissions and a recent OIG advisory opinion

MM900323824Medicare's excess readmission penalty policy (up to a 1% ding in IPPS Medicare payments to hospitals that have excess readmissions for acute myocardial infarction, heart failure and pneumonia in FFY 2013, going up to 2% in 2014 -- and adding in measures for hip and knee replacements and acute episodes of COPD patients -- and 3% thereafter) has resulted in some hospitals experiencing multimillion-dollar pay cuts. Over the next couple of years, the potential exposure will triple, upping the ante from the relatively low stakes hospitals have faced thus far.

The excess readmission penalty program (if the penalties are high enough) will force hospitals to become enmeshed in post-discharge care to a degree not hitherto seen in the FFS world. This is of a piece with leverage exerted by other health reform innovations. For example, the cost and quality improvements called for in the ACO program will lead health systems to apply changes to management of all patients' care, not just Medicare patients' care (because running multiple parallel systems is impractical). In essence, by design or otherwise, various aspects of health reform and financial incentives attached to them require greater integration of effort across previously more-disjointed elements of the health care "system," as well as departures from the traditional FFS mode of thinking and acting.

Continue reading "Leverage: Preventable readmissions and a recent OIG advisory opinion" »

August 13, 2013

The RUC (again): Is there a light at the end of the tunnel? A conversation with Brian Klepper

Tunnel of Light TJ Blackwell Flickr CC http://www.flickr.com/photos/tjblackwell/3362987463/ Recently, there were a couple of breathless articles about the RUC (Relative Value Scale Update Committee) published in The Washington Post and The Washington Monthly, reporting as news the state of affairs that has prevailed for years in the realm of re-setting the relative values of physician services annually for purposes of the RBRVS -- which is at the heart of the Medicare Physician Fee Schedule (MPFS) and which affects physician reimbursement well beyond Medicare, since the RBRVS is used as a touchstone in determining payment levels under commercial payor agreements as well.

I thought this confluence of publications was a good excuse to call up Brian Klepper, who is an expert critic of the RUC, to discuss the latest stories and talk about the prospects for meaningful reform.

Have a listen to our conversation (about 30 minutes long):

Brian Klepper on RUC HealthBlawg Interview with David Harlow 07262013

Brian Klepper - RUC - HealthBlawg

A transcript is appended to this post.

Continue reading "The RUC (again): Is there a light at the end of the tunnel? A conversation with Brian Klepper" »

June 18, 2013

Alternative Quality Contract with Blue Cross Blue Shield of Massachusetts: A model for ACOs?

Managed Care Magazine recently ran a story on the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which serves as a model for the ACO program under the Affordable Care Act. Check it out: Bay State Blues Combine Global Payment With Quality Metrics. The author of the piece, Joe Burns, contacted me as well as others in Massachusetts for comment.

My take, drawn from the story:

David Harlow, a health care lawyer in Newton who writes the HealthBlawg, agrees [that the early findings are encouraging], calling the AQC a significant development for two reasons. First, it is an alternative to fee for service.
“That’s appropriate because there is a need to change the incentives of health care providers in the system,” he adds. Second, the AQC is important because it has served as a model for the federal Centers for Medicare & Medicaid Services’ accountable care organizations.
“The problem with past attempts to control health care spending is that adequate quality standards were not in place,” Harlow says. “It was all about keeping costs down. While this model represents an improvement over other models, the amounts at risk are relatively trivial and, standing alone, will not bend the cost curve.
“Nevertheless, the AQC is different because no provider group can earn a quality bonus unless the physicians and hospitals achieve or exceed the quality standards.”

As I've written before, I think the focus should be on long-term planning for a wholesale shift away from fee-for-service medicine rather than trying to expose and rationalize payment levels. Global payments (a euphemism for that dirty word, capitation), a bonus structure tied to performance against quality benchmarks pegged at a level sufficient to change provider behavior, and dedicated funding within the global payment system for nurse case managers and other elements of the medical home model, are the key elements of the solution we are looking for.

The AQC is a good start. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

May 19, 2013

Hospital Chargemasters and Open Data from CMS -- The conversation continues

MH900059592When CMS recently released hospital chargemaster and payment data for the 100 hospital codes most frequently billed to Medicare, there was much written and said about the significance of the data release.

Some found this to be significant; others (including your humble HealthBlawger), not so much.

Leonard Kish summed up and addressed the critiques of the value of the CMS open data, and others whose judgment I also respect found that the release was overall a good thing. Gilles Frydman, for one, in a listserv exchange, opined that the release was a net positive because it thrust the irrationality of hospital pricing into the public eye, and that "[i]f enough people get angry, a public push for more transparency will follow."

I can accept the proposition that data will be valued differently by different parties. However, I want to throw something else into the mix: We are collectively trying to move away from fee-for-service medicine. As the saying goes: the future is already here; it just isn't evenly distributed. Some are further down the path than others. I think that our time and effort is better spent on ensuring that value-based purchasing systems are up and running, rather than on improving the pricing transparency of FFS medicine.

Eighty-two percent of health plans responding to a recent survey consider payment reform a ‘major priority.’ Nearly 60 percent forecast that more than half of their business will be supported by value-based payment models in the next five years. And, of those, 60 percent are at least mid-way through implementation, according to a study published May 9 by Availity, a health information network.

The Health Plan Readiness to Operationalize New Payment Models study delves into the progress of the country’s commercial health plans, as they migrate from fee-for-service to value-based models of compensating physicians, according to a news release by Availity. The study highlights the consensus among plans that information sharing with physicians must be automated – primarily in real-time – for these models to achieve success.

HealthcareIT News.

On the Medicare front, ACO development and other initiatives of the Center for Medicare and Medicaid Innovation are moving the system away from FFS medicine as well.

There's a system-wide bet that's been placed on value-based payment. Historical amounts charged and paid shouldn't really enter into the construction of this framework, and that's part of what underlies my negative reaction to the release of the chargemaster and payment data. We should be more focused on things like: revaluing primary and preventive care, global budgeting for episodes of care, adoption and refining of meaningful quality measures and quality-based payment systems (even though not all VBP schemes are working) -- all to the same end as the end sought by those who have been cheering the release of the charge and payment data: transparency and a clear connection between payment and delivery of value.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting  

April 23, 2013

Response to ONC RFI on advancing interoperability of EHRs and HIE

Open DoorAt last weekend's #healthfoo I proposed that one unconference session be devoted to preparing a comment letter responding to the ONC RFI on Advancing Interoperability and Health Information Exchange.

We discussed three possible sub-regulatory changes (which is what ONC asked for), and reiterated the value of a specific regulatory change that would not require a new rulemaking process, because it may be incorporated into the final rule on patient access to lab results (draft rule released in 2011, no final rule yet).

Specifically, we proposed:

  • Leverage existing regulatory requirements by building meaningful use of EHRs and HIE into the lexicon of the health care facility surveyor; a Meaningful User should be cited with a deficiency specifically citing the EHR use or misuse or non-use if proper meaningful use would have eliminated the root cause of the deificency.
  • Advance provider directories to support HIE by using the attestation process to link a provider's Direct address with other contact information in the National Plan and Provider Enumeration System (NPPES, NPI system).
  • Increase patient access and use of EHR information by developing patient education programs as well as improving usability of the patient interface.
  • Increase standards-based electronic exchange of lab results; see Keith Boone's reg change proposal and my reply to Farzad Mostashari's tweet ("Lawyers: Would this work?") about Keith's post.

Here is the Health Foo letter to ONC on its EHR interoperability RFI.

The discussion that yielded this comment letter followed hard on the heels of a discussion about Meaningful Use Stage 3 facilitated by Claudia Williams of ONC, so we certainly hope that ONC is listening.

(Click on the image above to see Regina Holliday's painting, Open Doors, painted over the course of the unconference.)

I was also involved in the preparation of the ONC comment letter filed by the Society for Participatory Medicine, which covers most of the same ground, and also promotes adoption of Blue Button Plus as a means to empower patients to a degree that current systems do not allow.

These letters are addressed both to ONC and to CMS, in response to their joint request for information. This collaboration within HHS is encouraging, and it may well point to greater interest in leveraging EHRs within CMS. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting