HealthBlawg

Connected Health Symposium 2009 Wrap-up

I attended the Connected Health Symposium last week in Boston and got a healthy dose of the past, present and future in health care connectivity, connectedness and connections.  As always, I enjoyed connecting in person with a whole host of folks I know online -- including those who know my twitter handle, @healthblawg, better than my name.

The conference was kicked off by Stuart Altman, who regaled us with tales of his days with the Nixon Administration, and made a couple of key points:

• The health care spending crisis is cased by rising prices, not rising utilization
• Any federal health insurance reform will cause cost-shifting to the privately insured, the states, the young
• Therefore the key to successful reform lies in reforming the payment system as well as the delivery system; otherwise we're "trying to grow flowers in a toxic environment."
• Value-based purchasing (P4P), gainsharing, global payments are reasonable options for payment reform
• Incentives for providers to use home-based systems will help heal the system at large, and promote connected health, which in turn promotes quality and efficiency

(But n.b.: while remote monitoring and home care will improve quality and reduce cost overall, it is not necessarily cost-effective for every patient.)
 
The conference closed the next afternoon with the official launch of the Journal of Participatory Medicine, presented to the group by members of the editorial board, re-emphasizing the need expressed in the intervening two days of sessions for clinicians to include patients in all aspects of managing their own care.  (On this theme, see the JOPM kickoff on-line conference from earlier in the week, including e-Patient Dave's webcast How Great EHRs Empower Participatory Medicine; free registration required). 

In between these two sessions, we heard from a wide range of speakers, panelist and vendors.  I offer here an idiosyncratic sampling of some of the many overlapping sessions.  (Please see the archived tweetstream from the conference, a couple of audio recordings of panel discussions on EHRs and PHRs, and please post links to other blog posts about the conference in comments below.) 

Ed Markey, via videolink from DC, preached to the converted that the health care system needs CPR - connectivity, privacy and research (as the Center for Connected Health's Director, Joe Kvedar, tweeted, Markey has a terrific speechwriter).  Markey has been delivering, having had a hand in building the national broadband network from his seat on the telecom committee, and in beefing up HIT privacy and security in the HITECH Act.

Jim Mongan, CEO of Partners, made the poignant comment that liberty, on the one hand, and justice for all, on the other hand, may be at odds with each other, and the unsurprising comment (from his perch atop a large IDS)  that large IDS's are the way to go.

"It's the Network." Verizon's Rajeem Kapoor pitched his company's big entry into health care connectivity, noting that of 100,000 preventable errors per year in the US, 20% are due to the lack of immediate access to patient data.

A recurring theme: health care plans are designed by negotiation between payors and providers ... they need to include patients. 

Tom Lee, also from Partners, said that payors and providers are engaged in co-evolution, and that they need to work together or else chaos will result.  Lee also said: Global payment isn't about bending the cost curve, it's about enhancing value -- a different perspective than Altman's, but not unexpected from a large delivery system representative.  The "alternative contract" offered by Blue Cross Blue Shield of Massachusetts is a global payment contract with risk adjustments, quality bonuses, and other bells and whistles, per Andrew Dreyfus (from BCBSMA) designed to fairly compensate and avoid perverse incentives for providers.  The global payment system to be rolled out in Massachusetts over the next five years (maybe) is intended to separate insurance risk (not to be passed onto providers as it was in capitation's bad old days) and performance risk, or quality risk, which lies appropriately with the providers.

Since the current health care system is straddling the past and future, fee for service reimbursement in an age where a more holistic approach to care is recognized as preferred, Partners is paying physicians participating in a medical-home-like program a management fee to replace some of the lost FFS income.  A panel on patient incentives yielded the observations that silos within health insurance companies lead to irrational decisions: a cost to one division could yield a many-times-larger savings to another division, but the first has no incentive to incur that cost.

In a panel discussion called The Futurists, Jay Sanders of WellDoc said we need to bring the exam room to where the patient is, and to personalize medicine (i.e., normal for me is not normal for you).  Roy Schoenberg of American Well described his company's next step, plans to allow PCPs to bring specialists into the in-person patient visit; he also cited a Gartner prediction: By 2013, 25% of all health care encounters that can happen virtually, will.  We also heard about implantable wireless sensors that will be able to transmit a stream of data and household robots from Microsoft. 

In an interesting back-to-the-future answer to the question: What's the killer app? we heard this answer from Paul Williamson of Cambridge Consultants: Family-provided, wireless-enabled care.  This vision of the future was echoed later in the day by Joe Kvedar, who posited as an ideal a world in which the patient coordinates self-managed care with a clinician as coach and an employer as enabler.  A related recurring theme: The need to move to more of a team approach to care.

Some of the toys in the exhibit hall (some called it vaporware) seemed more geared to the futurists (e.g., Intel's offering, a wired home hub for communication among providers, case managers, family members and patients, now being put through its paces in a few demos), but some are ready to go now, sporting tags signifying their compliance with Continua connectivity standards (the Continua Alliance is a standards organization jump-started by Joe Ternullo, assistant director of the Center for Connected Health, who, along with director Joe Kvedar and the Center's staff, put on a terrific conference) -- and some are positively old warhorses already in widespread use, like Honeywell's offering, with interfaces for automated home monitoring and communication of data directly into interoperable EHRs or standalone software.
 
The Myca/HelloHealth presentation highlighted the robustness of the Myca platform (employee health programs -- Qualcomm was featured at length; are there others?), medical home programs for small physician practices with "fractional use" of physician extenders -- a new twist on the Vermont and South Carolina medical home pilots), PHR integration already there or on the way, lab results integration coming soon (Quest); reiterated the slow rollout of HelloHealth (12 practices so far); and demonstrated (in part via BCBS Ventures' investment in the company) that Jay Parkinson & Co. may not be able to put as much space between themselves and third-party payors as they may like.  (This issue is not limited to HelloHealth, of course; the retail clinic sector, also founded on the premise of dissociation from third-party payors, has had to retrench; and some of the speakers also pointed to insurance companies as players not to be overlooked, due to the Willie Sutton factor . . . that's where the money is.)

Linda Magno, head of demonstration projects at CMS highlighted experiences with some demos and shared the podium with a couple of physician demo sites.  Key takeway from her presentation was that payors (beyond government payors) are just not willing to pay more for improved quality.  (Putting the Medicare managed care program / fiasco in the best possible light, her comment is consistent with the dismantling of that program, which pays higher prices, theoretically in exchange for more comprehensive care, because it was costing more than traditional FFS Medicare.)

Mark Bard, of Manhattan Research, shared some of his data re: physician internet use (doubled on-line work hours in past five years, and 2/3 of docs use smartphones in their practices -- using apps 15-20 times a day), and patient use of "Health 2.0" tools (doubled to 80 million in past two years).  This demonstrates that moving health care to the cloud will not leave all providers and patients behind. 

More than one speaker concluded that we need to subsidize healthy choices as well as tax unhealthy ones (e.g., tax the Big Mac and subsidize the salad). 

John Halamka and John Glaser presented interesting personal counterpoint on the issue of changing behavior, Halamka saying he easily chose diet and exercise over putting "poison" (Lipitor) into his body, Glaser saying he went for the stent and still enjoys his hamburgers.

Other keynoters:

Nicholas Christakis (looking at obesity as a social network epidemic, using Framingham Heart Study data - see NY Times magazine treatment), offered a couple of terrific analogies: First, carbon makes coal, graphite and diamonds - the difference depends on the interconnections between carbon atoms.  Second, the form of the network yields its function: are you finding the mastodon, or killing the mastodon?  As Christakis was winding down, I tweeted: "Unanswered Q: How do we design health care interventions to leverage IRL social networks?"  The immediate, slightly tongue-in-cheek, response from @cascadia (Sherry Reynolds), tweeting from the Pacific Northwest: "Ask women with actual friends."

Jason Hwang (co-author of The Innovator's Prescription, applying principles of disruptive innovation to health care) spoke about technology as enabling decentralization in health care as in other industries, through commoditization of historically valuable and expensive expertise, and the need to replace the hospital-centric model with new types of networks.  This shift is already under way, of course.

Bottom line: Given the crushing cost of hospital-based health care services, the current and growing primary care physician shortage, and the expectation of high-quality health care services accessible to all, the Center for Connected Health is letting us all know that the road to the future is the information superhighway, paved with intelligent payment reforms -- but that the nodes in the network will always be human beings.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

HITECH Act security breach rules now effective; federales give a six-month pass. Now's the time to kick compliance efforts into high gear

Two key Son of HIPAA rules mandated by the HITECH Act are now effective.  Both the FTC and HHS have finalized their security breach notification requirements and have assured the regulated community that they have six months to get their collective houses in order.

Please take the time to peruse both the HHS Son of HIPAA security breach notification rule and the FTC Son of HIPAA security breach notification rule.  I discussed the impact of the breach notification rules and their enforcement when they were issued as "guidance" and draft regs in April at HealthCamp Boston and will be posting more information about them in the near future.

A few points to consider for now:

• The HHS breach notification rule layers encryption standards -- how to render health information "unusable, unreadable or indecipherable" -- for data at rest, data in use and data in motion, on top of the HIPAA privacy and securty rules.
• Encryption is not required, but a security breach with respect to non-encrypted data triggers public notice requirements (i.e., alert the media) in addition to data subject notice requirements.
  
• The FTC rules widen the net, imposing HIPAA-"covered-entity"-like obligations on business associates including, e.g., PHR vendors and other non-covered-entity repositories of health information. 
• As an aside, greater regulation of other business associates under HIPAA will be effective in February; business associates will have to implement policies and procedures similar to those now required only of covered entities.
• Enforcement will be ratcheted up after six months.  Greater sanctions are available for regulators to impose, and the FTC is a tougher enforcer than HHS has been on the HIPAA front to date.

With all this in mind, now is the time to examine policies and procedures, update them to comply with new rules -- Son of HIPAA rules and related/overlapping FTC Red Flag Rules (effective November 1) and state data security rules -- train staff to follow the policies and procedures consistently, and communicate commitment to these standards to your various consituencies: patients, other health care providers, business partners, etc. 

The Harlow Group LLC stands ready to assist covered entities and PHR providers in assessing the regulatory landscape, conducting an audit of current policies and procedures, and moving from a gap analysis to developing a fully compliant program and staying ahead of the curve going forward.  Please be in touch to learn more about our approach.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Red Flags Rule: The FTC piles on, because HIPAA, ARRA and overlapping state laws just weren't enough

Update 11/3/09:  The FTC announced that implementation of the Red Flags Rule will be delayed once more, this time until June 1, 2010.  The announcement came on the heels of losing a court case to the American Bar Association -- the court ruled that the rule does not apply to lawyers -- and on the heels of a legislative attempt to bar its applicability to small health care, accounting and legal practices.  Stay tuned.  

Update 7/29/09:  The FTC announced today that implementation of the Red Flags Rule will be delayed once again, this time til November 1, 2009.  The agency promises to roll out additional information targeted at low-risk entities covered under the rule.  Thus far, nothing has changed with respect to the rule and its ultimate effect, so organizations subject to the rule should take the extra time to assess their compliance needs and implement their plans in advance of November 1.

After a couple of delays, the FTC Red Flags Rule will be effective August 1, 2009.  This rule requires "creditors" under certain "covered accounts" to maintain a heightened alertness to numerous categories of "red flags" that may indicate that the consumer who is the rightful account holder is the victim of identity theft.  If a red flag is triggered, the creditor must take steps to notify the consumer and correct any inappropriate information included the creditor's records.

As you probably already know, the FTC is extending its reach with this rule (among others) into the health care sector.  (Cf. the FTC's role in enforcing certain Son of HIPAA provisions.)  The AMA has all but dropped a draft complaint on the FTC's desk, citing assorted legal precedents in its correspondence with the FTC arguing that the Red Flags Rule should not apply to physician practices.  The FTC is unmoved -- except to the extent that it has been willing to delay the effective date twice (from November 2008 to May 2009 to August 2009).

At any rate, the August 1 effective date is around the corner, and affected health care entities need to develop and implement compliance plans now, if they haven't already.  (Even the AMA says so, and has published guidance and a sample policy for members.)

A few more general comments before stepping back and examining the language of the rule and its applicability to health care providers.

The federales are taking something of a common-sense approach here, recognizing that a compliance plan needs to be tailored to the specific entity, the nature of its "covered accounts" and its operations.  Bank of America, N.A. and Springfield Medical Associates, P.C. will have very different compliance plans, because their potential red flags and the potential risks are vastly different.

Affected health care providers need to understand that the Red Flag Rule requirements overlap with HIPAA and state privacy law requirements (and looming Son of HIPAA requirements in ARRA), but will not be satisfied by implementation of existing privacy policies and compliance plans.  Review of the intersection of existing policies and procedures with the new rule's requirements is the first order of business.

As with any other new regulatory scheme, preparing a compliance plan and putting it on the shelf won't cut it.  The rule calls for regular monitoring of the plan and issues that arise by a senior manager.  Furthermore, best practices would dictate the training of staff to deal with individual issues and, most importantly, with the affected consumers.

Even if not clearly subject to the Red Flags Rule, providers should undertake to comply, for a couple of interrelated reasons:

• Good patient PR.  Data security is top of mind these days.  Much of the effort required under the rule should be expended anyway simply to respond to market pressures calling for improved data security.
• Potential liability.  The creative trial attorney will seek to use the Red Flags Rule as establishing a standard of care for the stewardship of personal information.  The incensed jury will go along.  The health care provider caught in the middle between thieves and victims may be the only perceived deep pocket available.

OK, so what is a "creditor" and what is a "covered account?"

Any entity that accepts payment other than payment in full at the time of service is a creditor.  Health care providers that go the cash-on-the-barrelhead route aren't creditors; all others are creditors.

The FTC Guide defines covered accounts as follows: either

• a consumer account you offer your customers that’s primarily for personal, family, or household purposes that involves or is designed to permit multiple payments or transactions; or

• any other account that a financial institution or creditor offers or maintains for which there is a reasonably foreseeable risk to customers or to the safety and soundness of the financial institution or creditor from identity theft, including financial, operational, compliance, reputation, or litigation risks.” Examples include small business accounts, sole proprietorship accounts, or single transaction consumer accounts that may be vulnerable to identity theft. Unlike consumer accounts designed to permit multiple payments or transactions – they always are “covered accounts” under the Rule – other types of accounts are “covered accounts” only if the risk of identity theft is reasonably foreseeable.

Any creditor with covered accounts must have a red flags rule compliance plan in place with policies and procedures for dealing with "red flags" -- i.e., signs that personal information may have been compromised.  The World Privacy Forum suggests that the following red flags are the ones most applicable in the health care context:

• A complaint or question from a patient based on the patient’s receipt of:
   o a bill for another individual
   o a bill for a product or service that the patient denies receiving
   o a bill from a health care provider that the patient never patronized or
   o a notice of insurance benefits (or Explanation of Benefits) for health services never received.
• Records showing medical treatment that is inconsistent with a physical examination or with a medical history as reported by the patient.
• A complaint or question from a patient about the receipt of a collection notice from a bill collector.
• A patient or insurance company report that coverage for legitimate hospital stays is denied because insurance benefits have been depleted or a lifetime cap has been reached.
• A complaint or question from a patient about information added to a credit report by a health care provider or insurer.
• A dispute of a bill by a patient who claims to be the victim of any type of identity theft.
• A patient who has an insurance number but never produces an insurance card or other physical documentation of insurance.
• A notice or inquiry from an insurance fraud investigator for a private insurance company or a law enforcement agency.

If a situation is flagged, a creditor must take steps to mitigate the risk of identity theft or continued identity theft.  Again, the World Privacy Forum notes:

There need to be uniform but appropriately flexible answers to these questions:

• What do we do when a patient claims fraud is in their files?
• What do we do when a patient says the bills are for services she did not receive?
• What do we do for patients and other impacted victims when we uncover a fraudulent operation?
• When we have a real case of medical identity theft, how can we work with patients to fix the records and limit future damages?
• What do we do when a provider has altered the patient records?
• How do we handle police reports and requests for investigation from victims?

The answers to these questions need to viewed not just from the provider’s perspective, but also from the victim’s perspective, which can differ substantially.

There are a number of useful resources available for health care providers seeking to take stock of their situation, establish Red Flags Rule compliance policies and procedures, and undertake staff training on the subject.  For example, the FTC, the AMA and the World Privacy Forum have all released valuable guidance documents (all linked to above) that would assist any organization with coming into compliance. 

As with any effort of this sort, it is often valuable to have someone outside the organization come in to review existing policies, procedures and workflow in order to highlight potential risks and opportunities for improvement.  The HealthBlawger and members of the HealthBlawger's virtual consulting network are available to come in and assess, plan and help implement compliance strategies for organizations large and small touched by the Red Flags Rule.

Whatever the size or nature of your business, please take a moment to consider how the Red Flags Rule may apply to its operations, and how it may relate to other regulatory schemes such as HIPAA and state laws.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

David Harlow quoted in Medicare Compliance Alert on pre-employment background checks

Take some advice from the HealthBlawger in screening new employees.  Check out some specifics in the current edition of DecisionHealth's Medicare Compliance Alert, offered in point-counterpoint format with tips from my friend Bill Mandell.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Engage With Grace

As patients, as family members, as friends, as health care providers, we have all faced end-of-life issues at one time or another, and we will face them again.  And again. 

This weekend, the "Engage With Grace" message is being broadcast virally, through a "blog rally," at a time when many people are with family and friends over the long weekend.  (Thanks to Paul Levy and Charlie Baker for getting the issue out of the blogosphere and onto page one of the Boston Globe today, too.)  The point is: we all need to have the potentially uncomfortable conversation with people close to us about what kind of treatment we would want, and they would want, if incapable of making or communicating health care decisions.  (If you really want to monopolize Thanksgiving dinner conversation, you could also start the family health history conversation being promoted by the Surgeon General.)

End-of-life decisionmaking has long been an issue of great personal and professional interest to me, and I am proud to have played a role in having out-of-hospital DNR orders recognized in Massachusetts by EMS providers, as an example. 

Download your copies of the Massachusetts health care proxy form or other states' proxy or living will forms -- and add specific instructions about nutrition, hydration, and anything else that is important to you so that everything is crystal clear.  My mom kept a stack of living will forms in the dining room when I was growing up, and was not shy about raising the issue with dinner guests and offering to witness their directives.  Having the conversation is a starting point; we all need to follow through and make sure that our loved ones' wishes are documented, placed in medical records, discussed with physicians and other caregivers, and honored. 

When I have the opportunity to speak to groups of lawyers or health care providers, I often ask for a show of hands: how many of you have health care proxies?  The percentage seems to have increased over time, but it is still not where it needs to be.  If groups that should be above average in this respect are not all raising their hands, then we clearly have a lot to do in terms of educating the general public about the need to have the sometimes difficult conversation with friends and family members.  That's what the Engage With Grace project is all about.  And with that, I turn over this post to Engage With Grace:

*    *    * 

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones "know exactly" or have a "good idea" of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.  But our end of life experiences are about a lot more than statistics. They're about all of us.

So the first thing we need to do is start talking. Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences.

And we're asking people to share this One Slide - wherever and whenever they can.at a presentation, at dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven't had.Here is what we are asking you: Download The One Slide and share it at any opportunity - with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team)

*    *    *

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

David Harlow quoted on CMS recovery audit contractor (RAC) initiative

The Medicare recovery audit contractor (RAC) initiative is moving from pilot phase to national implementation, in stages.  See my earlier post on the RAC initiative, the CMS report on RACs issued in February, other CMS materials on RACs, and also a recent article in which I'm quoted, in the April issue of Orthopaedic Practice Management -- which appears in a slightly different form as the lead article in the May issue of Managed Care Contracting & Reimbursement Advisor. 

OPM is a publication of Oakstone Medical Publishing; MCCRA is a publication of HCPro.

As I noted in the article, RACs focused on hospital claims during the demo phase (since that's where the big bucks are) but now that the gloves are off, physician practices will feel the pinch more acutely.  The CMS materials outline the rollout schedule for national implementation.

Bottom line: implementing a comprehensive compliance plan will go a long way towards avoiding having to deal with the RACs.

-- David Harlow

Providers chafing under Medicare Recovery Audit Contractors

Under MMA Section 303 (text towards end of this MLN article), CMS was authorized to roll out a demonstration project in three states, for three years, engaging RACs to review potential overpayments (and underpayments) to Medicare providers and suppliers.  The RAC contracts are permitted to be contingency-based, and they are, reportedly, entirely contingency-fee-based.  (Another side of pay for performance . . . .)

CMS picked -- surprise, surprise -- California, Florida and New York as its three demonstration states.  These three states account for over 25% of all Medicare expenditures.  (See 2007 CMS report on national health expenditure data -- most recent data from 2004).

The program is to be expanded nationwide this year, and industry groups are objecting to the way it's being run: 

[The program] recouped $247.4 million in overpayments in fiscal year 2007.

The program relies on private-sector auditing firms to examine claims filed by hospitals and other medical providers and then pays them contingency fees based on how much money they save the government. In FY 2007, auditors identified $357 million in overpayments, $17.8 million or 7.1% of which were overturned on appeal, according to CMS. Payments for contingency fees and other administrative expenses totaled $77.7 million. Auditors also found $14.3 million in Medicare underpayments.

While supporters of the program say the contingency fees serve as an incentive, critics say it encourages auditors to rely on a "'bounty hunter' payment mechanism."

Kaiser Network Daily Health Policy Report, based on Wall Street Journal reporting.

Update 1/29/08:  In fact, a bill calling for a one-year moratorium on RAC activity was filed in the fall.

Contingency fees have long been decried as a cause of aggressive collection tactics.  CMS could mollify its critics in part by adopting a blended compensation formula for its RACs: part fixed, part contingent.  It has already addressed a related concern and has instituted contingent fees for RAC-identified underpayments as well as overpayments.

To my mind, a more significant issue is that, per the Kaiser Report, CMS has been saying that only once the program

is expanded nationwide, auditing firms will be required to have a medical director and medical-coding experts, [and] return contingency fees for claims upheld on appeal.

First of all, the enabling legislation requires use of qualified personnel -- folks with "appropriate clinical knowledge of and experience with the payment rules and regulations under the Medicare program."  Even if it didn't, one would hope that CMS wouldn't entrust a program of this magnitude to anyone not expert in the intricacies of Medicare coverage and billing.   Second of all, the notion that it's so hard to shake loose contingency fees in cases where the contractors' denials are overturned is inexcusable.

Here's hoping the privatization of government functions doesn't allow contractors to continue to stray quite so far off the reservation.

-- David Harlow

CMS announces home health pay for performance demonstration

P4P is moving into the home health arena.  Later this month, CMS plans to roll out a two-year HHA P4P demonstration project in seven states: CT, MA, AL, GA, TN, IL and CA.  The key indicators to be tracked as part of the demo are drawn from standard quality measures already included in the CMS HHA Outcome-Based Quality Improvement (OBQI) data set.  They are:

• Incidence of Acute Care Hospitalization
• Incidence of Any Emergent Care
• Improvement in Bathing
• Improvement in Ambulation/Locomotion
• Improvement in Transferring
• Improvement in Status of Surgical Wounds
• Improvement in Management of Oral Medications

Payments will be tied to both high performance (a la HQID) and performance improvement.  Unlike other P4P demonstration projects (e.g., the gainsharing demos), for this project, there's talk of random assignment to control vs. study groups.  Also, payment will be conditioned on reduced overall Medicare spending.  Thus, unlike participants in the gainsharing demos, HHAs will not be put at financial risk by implementing higher-cost program modifications designed -- but not guaranteed -- to yield performance improvement and/or cost savings.

Abt Associates has been in involved in the demo design, and an Abt presentation at an HHA P4P open door session is up on the CMS website (click on open door ppt download).

The HealthBlawger stands ready to assist HHAs with the demonstration application process, as I have with hospital and physician group clients in the MMA 646 and DRA 5007 demos. 

-- David Harlow

Creative approaches to caring for seniors in less restrictive settings

Last year, Massachusetts amended its Medicaid laws to require that beneficiaries headed to nursing facilities be screened to see if they could be placed instead in less restrictive settings. The Commonwealth then applied for a so-called Section 1115 waiver from Medicaid rules in order to reallocate federal funds ordinarily devoted to health care facility based care to community based care. The Massachusetts program is called Community First.

This sort of thing is clearly better for beneficiaries, and easier on the public fisc. It also echoes a longstanding effort to keep seniors in community settings, where they can be more active, and to resist medicalizing the normal aging process. The PACE program (aka the Program for All-inclusive Care for the Elderly, begun at the On Lok community health center in San Francisco a couple decades ago) graduated a few years ago from a waiver/demonstration program to a regularly recognized program for federal funding purposes. PACE keeps seniors who are eligible for nursing facility placement out of nursing facilities, arranging for all needed services through community health centers (adult day health, home health, etc.).

Assisted living facilities also sprang up over the past couple of decades as an alternative, or in some cases way-station to, nursing facilities.

There are also programs designed to keep health care facilities from being too much like health care facilities: viz. the Green House model of homelike nursing facilities.

The latest entrant in this field of alternatives to traditional nursing facilities is the Going Home program in Massachusetts, highlighted in today's Boston Globe story about a four-resident home in West Peabody operated by North Shore Elder Services, which plans to add additional sites. The home provides a residence, a live-in aide, meals, and other services as needed. Per the Globe,

Services cost another $3,600 to $4,000 per person a month at West Peabody, covered through the Medicaid and Medicare programs, because the residents have medical and physical conditions that would otherwise qualify them for government-paid nursing home care. The total cost per day is less than the $187 average state payment for nursing home care, but more than the state pays for the least-ill nursing home residents.

The story continues:

Because the houses are not subject to state regulation like nursing homes, some question whether residents would be adequately protected. There have been occasional abuses in state-funded homes for the mentally ill.

Organizers say there are multiple checks and balances in the way the houses are run. One of the regular duties of the elder service agencies is to investigate abuse and neglect for the state. The agencies' staff monitors the care provided in the houses. And other professionals, obligated to report abuse, are regular visitors.

The market for these services is likely robust and it will be interesting to follow the growth of this initiative in Massachusetts and elsewhere.

-- David Harlow

CMS releases 2008 Medicare home health services payment regulation

Pay-for-reporting, the precursor to pay-for-performance (P4P), continues to roll through Medicare payment rules for various provider types.  Yesterday the home health rule went on display.  It is slated for Federal Register publication by the end of the month. 

The rule includes a 2% holdback for them that don't report on NQF measures. The CMS press release says:

This final rule adds two new National Quality Forum (NQF) endorsed measures, Emergent Care for Wound Infections, Deteriorating Wound Status and Improvement in Status of Surgical Wound, to the 10 measures that are currently reported for a total of 12 measures to be reported by HHAs in CY 2008.

The press release also announces:

The home health market basket increase for CY 2008 is 3.0 percent, which results in $430 million in additional payments to home health agencies in CY 2008.

Not so fast!

Dig a little deeper, and we learn that there's a nearly 3% negative payment adjustment for each of the next three years to account for past upcoding transgressions.  This little gift is due to the fact that CMS has now determined that 92% of the case-mix increase from 2000 to 2005 was unrelated to actual increased patient acuity.  (I'll leave it to someone else to moan about the potential for misplaced punishment here.)  Case-mix calculation for propsective payment determination is also being tweaked accordingly.

-- David Harlow