The HIT Transition Weblog

New HIPAA Standards Clear Regulatory Hurdle, Approach Flaming Commentary Hoops

Tired of the ambiguities and outdated constraints of the electronic claim, remittance advice, eligibility and other X12 transactions? Help is on the way.  Or at least it's coming into view.

The enabling regulation to adopt a new version of those standards has cleared the Department of Health and Human Services and has been passed on to Office of Management and Budget for final review. OMB has 30 days [OOPS! Meant to verify this before posting. In truth the rule of thumb is 90 days for the review; insiders say it is on a fast track, though. -Ed.] to approve it (with or without revisions negotiated with HHS) or reject it.

I was fortunate to have the opportunity to participate in some of the X12 workgroups that built the new standards, and am certain that the new standards will improve efficiency and reduce the number of customizations and workarounds.   We won't be able to say goodbye to those nasty Companion Guides, but at least they will be thinner.

Besides reducing ambiguity in hundreds of passages -- saying when NOT to send data as well as when to send it, for example -- the updates incorporate a number of issues currently vexing implementers:

• Unambiguous instructions for consistent implementation of National Provider Identifier submissions across all transactions and all payers.
• Intrinsic support for the Present on Admission data, rather than the K3 stopgap introduced last year.
• Support for the ICD-10 codeset, not available in the current 4010A1 standards.
• Better, clearer remittance advice instructions and standards, including mandatory utilization of the Remark Codes segment.

The standards were developed over a period of months and published back in 2004 and 2005. First the draft guides were released for public comment, then the workgroups responded to each of comments and finalized the implementation guides (now referred to as "Technical Report 3's" or TR3's) and submitted them for approval via X12's consensus process.

It has taken three years for HHS to put together the regulatory language to adopt them.

And once that draft regulation is released will come another comment period.

Um, what was that?

X12 is anxious about this. Tagging a regulatory comment period on to the standards development comment period brings a lot of new participants out of the woodwork. While techically this may improve the end result, it also stands to send the standards folks back to their own review/comment/edit process, further delaying implementation.

Last time this happened, it was under the deadline for adoption of the original HIPAA standards -- the finished 4010 guides got hurriedly updated with the A1 Addendas, and the industry has had to work out of two sets of books ever since. (I recommend purchasing the Combined Guides for those who have difficulty reading out of two volumes at once. They're not "official" but they will keep you from making a lot of errors or at least getting a lot of headaches. Go to www.wpc-edi.com and check out the HIPAA link.)

I haven't been able to participate in X12 for awhile, but I know they are all over this. I hope that some of their collaboration with the regulators produces both better standards and better adoption processes.  We soon shall see.

Prepping for CCS

Last fall, I reported about how much fun I had at the Collaborative Communications Summit. Not "fun" as in golf outings and spa appointments, but "fun" as in meeting some really interesting and influential people, and being surprised at just how much some executives at the top tiers of the healthcare industry actually know about health IT. But CCS is not just about IT, it's about IT-enabled healthcare, which is a different spin from the typically techy-wonky conferences I traditionally attend.

And I didn't just like it enough to go back; I liked it enough to help make the next one happen. [Disclosure: HITTG is a media sponsor for this event. But we don't sell blog endorsements to anybody.]

Multisyllabic Session Title #1
On Tuesday, I'll be moderating a session called, "Unified Vision with the Consumer and Provider through HIT." I've got an incredibly qualified -- and incredibly broad -- array of panelists:

• Carolyn M. Clancy, MD, Director, Agency for Healthcare Research & Quality
• Michael E. Singer, President, Revolution Health Investments, Revolution Health Group
• George Chedraoui, Global Well-being & Health Benefits Leader, IBM
• Grad Conn, Senior Director, Health Solutions Group, Microsoft Corporation

And before you jump to any conclusions, no this is not a PHR vs. PHR smackdown with a government referee. First, you should note that Mr. Chedraoui has a largely HR perspective -- he's on the boards of both the Leapfrog Group and Bridges to Excellence, recently serving a term as the latter organization's chair. So he's bringing IBM-as-employer mojo, not just IBM-as-programmer-to-the-world. And I don't expect Conn is showing up just to shill for HealthVault, since Microsoft's entire health sector -- personal and enterprise -- reports to him.  Singer has a doctorate from the London School of Economics, which means I will probably buttonhole him first and ask if he's ever met Mick Jagger. I think he's working on some sort of portal these days. Singer, that is.

Taking the Moderation out of "Moderator?"
And, just to make sure the conversation is lively, I've given them all a daunting task.

"Engage me."

As a tough-but-interested, enthusiastic-but-skeptical, chronic-conditioned-but-disclosure-averse patient with a checkbook, I could be your best -- or worst -- customer. 

Engage me.

(And yes, I will be nice. I promise. After I set up the challenge.)

Multisyllabic Session Title #2
As if that isn't enough fun, I get to host the second day's "High Performance Leadership" session. This is the slot made famous by last year's CEO roundtable, where athenahealth's Jonathan Bush, Allscripts President Lee Shapiro, Andrew Eckert, CEO of Eclipsys, and Jeff McCaulley, CEO of Wolters Kluwer Health made such an impression on me, I wrote it up as a TV pilot, which was eventually re-cast and optioned as an animated short for the HIMSS conference.

Can we outdo that august assemblage this year? Looks like we'll give it a run. Here's our roster.

• Duncan James, Group President, Health Systems Market, McKesson Provider Technologies
• Oran Muduroglu , CEO, Healthcare Informatics, Philips Healthcare
• Graham Hughes, MD, GM of Product Strategy, GE Healthcare IITS

Like last year, it will be short prepared statements (keep your PowerPoints in their holsters, please, gentlemen!),  followed by a lively Q&A from the assembled C-suiters and opinion leaders in attendance. Last year, the atmosphere by the end of the second day was both congenial and charged with energy. There weren't any yawners or whiners in the group, and you could actually see ideas being connected by people who were very much able to take the next step and make something happen.

Why Wait Until Nomination Time? Let's Get Partisan!
Oh, and if that wasn't enough, the organizers have got healthcare policy advisors for all three presidential candidates to agree to show up at the same time for a pleasant little chit-chat.  I thought they were really reaching when they said they would set aside time for such a forum, but they pulled it off. I guess you'd have to call that a coup.

Just got the lineup today, so it might not be posted on their website yet.

• Tom Miller, Healthcare Policy Advisor Senator McCain
• Chris Jennings, Healthcare Policy Advisor, Senator Clinton
• Dora Hughes, Legislative Assistant Senator Obama

They were too smart to put me in with that crowd. Instead, eHealth Initiative's Janet Marchibroda will get to wear the zebra suit and blow the whistle if they get out of hand. Janet's much more diplomatic than I am, so I think they'll play nice. I'd hate for her to have to pull out a Yellow Card.

But Seriously
I probably said "fun" too many times to say, now, that it would be a wise investment of your time and energies to roll up for a conference that's barely a week away. But if you're in the DC area -- or are looking for a good excuse to be in the DC area -- you might want to check it out. Monday and Tuesday, May 5 and 6 at the Mandarin Oriental.

Best Care, Lowest Price Under Attack

The Wall Street Journal offers a doomy, gloomy perspective on the state of primary care in the US: Primary Health Care Needs Fixing Before Universal Care Can Work

We don't train enough, we don't pay enough, and adding more patients to the load is not going to work, either at the state level or the national level.

I agree with the author, Dr. Benjamin Brewer, but I'm afraid he doesn't know the half of it. High deductible health plans are eating PCPs for lunch, and they don't even realize it yet.

Right about now, the final adjudications for January's billing will be coming in. That means the millions of new HDHP enrollments that shifted over on the calendar year are starting to move from claim-to-payer to patient-responsibility.

And patients, as we know, are deadbeats. At least collectively. And collections is going to become an even bigger component of the non-healthcare business of the PCP's business.

First In, Worst Off
There's a wierd sort of non-standardized "preventive care" benefit that is allowable (but not mandated) under HDHP, but as low-dollar, first-seen physicians, PCPs are going to be eating deductibles way out of proportion to both their number and their revenue.

Think about a broken wrist -- $10,000 according to my wife's recent unfortunate experience. ER gets paid by the payer (mostly), then come the hospital and surgeon's bills, along with the anaesthesiologist. That eats up the $2500-5000 deductible -- and then some.  The last providers in the door finally start to get paid by the health plan. Physical therapists, as the caboose on the train of care, have it made (except if the health plan declares them out of network and disputes the number of visits -- that's another story!).

But most patients don't spend $10K in a year. They get sick, they go to their PCP. They never meet their deductible. PCPs will take a disproportionate share of the hit as HDHP deductibles turn inevitably into bad debt.

UHC, Ingenix and...Hillary????

It's not like UnitedHealthcare needed any more bad news. First they and their Ingenix software division get the business-headline perp walk in New York Attorney General's investigation of the intentional skewing of "usual and customary" fee calculations that govern millions of Americans' out-of-network payments.  Then some uppity blogger points out that Cuomo planted his flag a the top of a very hefty deductible-sinking iceberg.

Then, adding insult to inquiry, they flat out lose a national popularity contest among hospital administrators. And they didn't lose by a little -- they doubled the score of their nearest competitor, Wellpoint.

Orangemen Take Football, Go Home
You'd think today's story would just be a minor piling-on thing, to look at it. Everybody wants to smack the gorilla when he's down, right? So, the lost business represented by University Hospital's decision to leave the UHC provider network over $1.5 billion in unpaid bills (okay, that's per the hospital's account, so I should say "allegedly unpaid bills" -- but why don't we ever read such disclaimers when the payers shout about the billions in fraud and abuse, when "abuse" is being determined unilaterally by the payers themselves? I digress.)

Other than the fact that I was born in or near that hospital (I was quite young at the time and haven't been able to follow the institutional mergers and acquisitions in the years since), this wouldn't have been much of a blip on my radar.

Why Let Readers Comment, Anyway?
But then alert reader Cyndee Weston, Executive Director of the American Medical Billing Association, sent me a note suggesting I read the story. And right under the press account, I found a comment from someone who had found a smoking gun tying presidential candidate Hillary Clinton to UHC.

When campaign finance reports first started coming out,  I wasn't too thrilled to hear that Hillary was accepting campaign donations from the insurance industry in disproportionate measure to the other candidates. Remember, though, that not all health care insurers are against universal care, and we at HITTG think that's the number one priority. So, I thought I'd judge her health care policy on its merits first, then dig for skeletons in her closet before I rendered judgment on the accusations that she was sleeping with the enemy.

I didn't realized she was the enemy.

Mathlete to the Line
According to the report she filed last June 15, and published at opensecrets.org, Ms. Clinton owns some stock in UnitedHealth Group, parent to UHC and Ingenix. I'm no accountant, nor am I a political snooper of much acumen, but the way I read page 38 of that report it looks like she checked the box under "Assets" in the $100,000 - $250,000 column, and the box under "Income" in the $50-100,000 with a "CG." Now, that CG looks like it might be referring to Capital Gains. So if the capital gain was at least $50,000 during the period covered by the report, then somebody with better financial brains than I have might be able to say whether that spread is closer to $100,000 than $250,000.

Can We Make Those Numbers Look A Little Better?
But for the sake of fairness, let's suggest it's right at the bottom and say, as far as we know, she owns merely $100,000 in UHG stock.  Heck, that's just 20 years worth of deductibles for a family on a HDHP plan.  Or, if you use a customized database to adjust the patient's payments, you can boost that $5K deductible to as much as $12,987 and whittle that down to a mere 7.7 years of deductibles (that's $100,000 divided by the $12,987 a family would actually have to pay to satisfy their annual deductible, using our proprietary U&HC deductible-skewing engine. Change the deductible amount from $2000 to $5000 when that spreadsheet loads and watch the magic happen!).

There's Nothing to See Here, Mister
So, when you do the math just right, she really only owns about 8 families-worth of unpaid claims, in the what hospitals say is the worst healthcare payer in the country. (Hey, don't shoot the messenger! I love UHC!).  And that's only if someone in the family gets really, really sick. What kind of story is that?

No story, really. But where she got the stock? That might be a story.

Luckily, this is a healthcare IT blog, and we don't do politics. The one time we tried, it really came out badly.

What's that? I seem to have some overdue editorial on curing the systemic economic failure that drives up healthcare costs. That's more up my alley than tracing individual money trails.

Are Cuomo's Estimates Too Low?

When we read the coverage of NY Attorney General Andrew Cuomo's accusation that Ingenix, United Healthcare and a host of other payers had systematically underestimated the "Reasonable and Customary" fees used to calculate reimbursements for out-of-network services, one frequently-repeated statement caught our eye:

Lacewell said, in one example, the office's investigation showed that when $200 was a fair market rate for a 15-minute doctor's visit for a common illness, Ingenix determined it was $77. Therefore, United would pay $62 when it should have paid $160, leaving the consumer with a $138 bill. [Emphasis added.]

Actually, the United would probably not pay a dime. The patient would have to pay the entire $200 bill -- at least until the deductible was satisfied. That got us thinking about deductibles, so we took our question over to the AskLeslie group -- those coding and billing folks that handle all those claims for providers and their patients.

We asked this question: When a non-participating plan estimates a U&C price lower than the actual fee, which value gets applied to the patient's deductible -- the actual payment, or just the discounted amount? The response was overwhelming: The patient only gets credit for what the plan says they "should" have paid for the service, not the amount of the check they actually had to write.

Be Careful What You Solve For...
So today, when I read where the Ingenix execs Andy Slavitt and David Ostler say, "We believe that the issue of how to calculate out-of-network charges and reimbursement is an important one, but we also believe that it is a small part of a larger issue: improving the healthcare system by improving the quality and quantity of information available to its participants," I thought maybe I would apply some rules of basic algebra to the "improve the quality and quantity" of information at hand.  To wit: How does such fee repricing affect annual expenses?

Wisconsin Wishes for RHIO Clarity; Tooth Fairy Alerted

Wisconsin has withdrawn its RFP for a statewide health information exchange, issued in December. Apparently, some of the major partners thought that the Request for Proposals hadn't nailed down just exactly how the HIE would be implemented and paid for. Well, those folks in Wisconsin know a lot about cows, but you won't find many cowboys. It takes a real buckaroo to haul off and whip up a RHIO. This here is uncleared land, partner.

Bury the Hillary Campaign at Yasgur's Farm

Well, I came upon a Child of God
He was walking along the road
And I asked him, where are you going
And this he told me
I'm going on down to Yasgur's farm

I was in a fine snit this morning.  Michael and Allie noticed right away.  "What's the matter, honey?" Allie asked.

"I was listing to my Pandora station.  You know, 'It's a Beautiful Day?'" I had tuned my personal music channel to play the old psychedelic stuff that was always on my siblings' turntables during that boisterous era. Years after any incipient fog had long since lifted, I continue to find the melodies and optimism uplifting.

"I was doing fine until it played 'Woodstock,' then I got really mad."

"But you love that song!" she protested.

"I know.  But it made me mad. Mad at Hillary." I said.  I wasn't finished. Not nearly.

Worst in the World. Again.

It hurts me deeply every time the American healthcare profession is knocked around by researchers. And here it comes again: Among 19 developed countries, the U.S. ranks worst in deaths that could have been prevented by healthcare says new research published in the Jan/Feb issue of Health Affairs.

How bad is it? If we had performed as well as France, Japan and Australia, 101,000 fewer Americans would have died unnecessarily in 2003.

Researchers Ellen Nolte and Martin McKee state in their report "Measuring the Health of Nations: Updating an Earlier Analysis" that while other nations made strides and saw these types of deaths decline by an average of 16% between 1997 and 2003, the U.S. experienced only a 4% decline. All other countries had improved substantially except the U.S. They add that

It is difficult to disregard the observation that the slow decline in U.S. amenable mortality has coincided with an increase in the [U.S.] uninsured population.

The study did not ferret out causes (Was it access to care? Quality? Mistakes? Timeliness?). Rather than placing blame, the study simply reports the horrible news: In 1997–98 we ranked 15th out of 19 countries on the "mortality amenable to health care" measure; by 2002–03 we had fallen to last place. Based on our poor performance improvement (4% compared with 16% global declines in mortality), the U.S. is falling woefully behind.

Karen Davis of The Commonwealth Fund, supporter of the research, makes the message clear:

Our failure to cover all Americans results in financial barriers that are much more likely to prevent many U.S. adults from getting the care they need, compared with adults in other countries.

110 American deaths per 110,000 population. Lives lost because we can't get healthcare right in the wealthiest (at least for the time being) country in the world.

http://hittransition.com/flashpoint/ad.htm

Marty's HIT List 2008

Here's my official list of prognostications for 2008.  In 2006 and 2007, I didn't call them predictions, so I probably don't deserve any credit if anything I said came true.  If you agree -- or not -- you can give me your own scorecard by clicking here.  Give your feedback by January 23 and I'll post the results (and any interesting comments) in a blog at the end of the month. As far as we know, we're the only industry analysts that give you, our valued reader, this critical "You're Full of..." HIT response tool.

Why Quality Doesn't Matter

Oops. I meant that headline to read, "Why Quality Scoring Doesn't Matter."  Oops.  My bad.

I've maintained a skepticism about the value of so-called "quality transparency" scores when it comes to comparing one hospital/clinic/lab/doctor to another. My queasiness is mostly related to the problems of measurement and sample selection: Won't the toughest cases get routed to the best doctors and facilities?  And if so, won't that be reflected in higher mortality rates relative to those who take the more mainstream cases?  Yeah, I know about acuity adjustments, etc., but when it comes to life and death situations, I'd rather rely on the professional opinion of someone I trust -- say, the family doctor I've had for the last ten years -- than rely on my own reading of a spreadsheet with unknown risk adjustment tweekage criteria.

The Flying Fickle Finger of Fate
And further, I see the "foam finger" reduction of even those impressive tables and charts into marketing one-liners: "We're Number One! (with an asterisk)."  (So if your comparing trauma units, do you look for "Number One with a Bullet?")

Now Matthew Holt points out another, perhaps more compelling, weakness: The numbers themselves aren't significant.  As in "statistically significant."

It turns out that only for CABGs (coronary artery bypass grafts) are there enough cases performed to have statistical confidence that a hospital has that poor a record compared to the national average.

Holt cites a presentation by Joe Newhouse of Harvard Medical School, who pulls data from a 2004 JAMA article by Dimick, et al. 

Adder Up
Okay, so if we've known these statistics are crap for three-going-on-four years, what's all the fuss about using these quality numbers to drive policy, even revenue?  Holt suggests that even bad numbers can lead to improvements, sort of like college linebackers comparing Basket Weaving grades.

I'm not so sure. If I were a hospital administrator, I'd want to bank my paycheck on a more reliable team...

RHIO Riposte

My response to the flurry of premature RHIO obituaries has been included in today's Health 2.0 blog.  I was grateful they accepted my request to guest author, even though there are probably a lot of Health 2.0 types who would prefer the industry pursue a commercial model for health information exchange.  Maybe even their commercial model.

I'm actually a very 2.0 kinda guy -- pushing out a collaborative intranet site in the late nineties, publishing various blogs since aught-one and even scheming to accelerate HIT standards adoption with a hare-braned collaborative environment of my own design.  I even ran an industry collaborative project on 2.0-ware without telling anyone until it was over.

Cripes.  It's been four years since I gave that 2.0 testimony.  Maybe I better get busy again.  Sounds like people are paying attention now.

Meanwhile, to show that 2.0 might work even for nonprofits, put your comments over on the H20 version of my editorial.  You don't even have to agree with me.  In fact, it's sorta better if you don't.  "Me too" is so 1.0, ya know?

How Much Would Universal Coverage Save?

Earlier this morning I made a point that has been clear to me for a long time: Universal coverage will cost less.  This opinion has evolved over a long period of time, starting with my college studies in economics, which were focused on another domain impacted by the interactions of individual, societal and natural forces: the environment.  My career in healthcare, particularly in its focus on business operations and financial interactions, made it clear that the cost-shifting shell game we play in America is what is causing the system to spiral out of control both in terms of economics and quality: Letting people get sick costs more than helping them stay well.

Sometimes the urge to put this all into a single analysis is paralyzing, distracting me from my "real job" of merely trying to help the industry do health IT right.

Thank goodness someone appears to have done it for me.  They even put a price tag on the profligate ways of our dysfunctional "free market" (NOT) system: $1.5 trillion.

That's what the Commonwealth Fund's Commission on a High Performance Health System report, Bending the Curve: Options for Achieving Savings and Improving Value in Health Spending, says we can save over 10 years by covering everybody and making wise, systemic changes to the way the elements of the healthcare system interact.  I'm just popping it open now, but it seems they are not "anti-market," but rather seek to employ market forces within the context of correcting known dysfunctions, for instance, by setting prices based on outcomes rather than on procedures, using collective purchasing power to drive down drug prices, etc.  Pharma's just going to love this one.

It's not a piecemeal effort by any means, though.  They actually attack the problem at the national level, and identify ways that different policies can work together to control costs.

Nice present to put under your tree.

(Michael says I need to remember, though, that our company is not a non-profit enterprise, so this time I'm going to put in our little ad for the Health IT Grant Resource directories he worked so hard to assemble.)

http://hittransition.com/flashpoint/ad_rhio2.htm

Uninsurance Is a Deadly Sin

In what should be a no-brainer for anyone who has thought deeply about US healthcare, Matthew Holt over at The Healthcare Blog cites some fresh statistics that prove that not having insurance can kill you.  Quoting this new study by the American Cancer Society, he offers a dark truth: "For all cancer sites combined, patients who were uninsured were 1.6 times as likely to die in five years as those with private insurance."

Is it that they can't afford those expensive surgeries and heroic interventions?  Perhaps.  But most of it seems to happen earlier -- they don't get the screenings they need for early detection.

Women without health insurance are about half as likely as those with private health insurance to have received a mammogram in the past two years (38.1 percent of uninsured women versus 74.5 percent of insured women age 40-64), a pattern seen for all race/ethnicities studied (white, African American and Hispanic) at all levels of education.

As a result...

Twenty to 30 percent of uninsured women were diagnosed with late stage (stage III/IV) breast cancer, compared with ten to 15 percent of privately insured patients.

What the study doesn't seem to address is the financial impact, either to the individual or to the nation.  I'll fill you in on something I learned back in my days at the hospital: Sicker patients cost more to treat.

We don't spend more on healthcare despite not covering all our citizens.  We spend more on healthcare because we don't cover all our citizens.  The moral case and the economic case come up with the same answer.

Seeking Sustainable RHIO Forest; View Obscured by Non-profit Trees

Health Affairs just published a study by a team of Harvard researchers that has cast a pall on the sustainability of Regional Health Information Organizations (also referred to as Health Information Exchanges). The report, The State Of Regional Health Information Organizations: Current Activities And Financing, by Julia Adler-Milstein, Andrew P. McAfee, David W. Bates, and Ashish K. Jha, seems to imply that the maladies suffered by RHIO efforts around the country might be fatal, at least if you read the many news stories and blogs that are talking about it.  I say "seems to" because our analysis suggests that the industry echosphere is still missing quite a bit of the big picture.  Let's take this step by step, starting with the Harvard study and moving into the invisible economy and the nature of the RHIO challenge.

First, the "scary facts" presented by the researchers:

• 25% of previously-listed RHIOs seem to be "defunct"
• Only 20% of the remainder reported exchanging significant volumes of clinical data
• Most of the data they were exchanging falls into the categories of lab results, inpatient data and medication history
• A majority reported receiving in-kind donations, about half reported grants or financial contributions and slightly less than half reported no financial contributions

You might look at these factoids and come to the conclusion that the current generation of RHIOs are unsustainable.  The quote lifted from the report that has been frequently cited to support this conclusion says: "if RHIOs are to succeed as small businesses, they must be built around sustainable business models, which requires both profitability and value creation for participants."

Is 5010 a Year?! Why HIT Standards Take So Long...

You thought I was just being clever last week when I quipped, "These umbrage-and-edit timelines rachet out to make the electronic claim standards developed three years ago available for widespread adoption sometime after the the turn of the decade, even with optimistic dependency scheduling."

Oh, no.  I had inside information.  And that information became public this week.  The North Carolina Healthcare Information and Communications Alliance and The Workgroup for Electronic Data Interchange have been working on a real live MS-Project-based timeline to show regulators and industry analysts just how much time is consumed in developing, adopting and implementing HIT standards.  The equation for the 5010 version of the electronic claim and other ASC X12 administrative transaction adds up to 2014 -- that's seven years from now to implement a standard I helped smarter people finalize almost three years ago. 

According to Holt Anderson, Executive Director of NCHICA,

“Our estimate is based on the key assumption that a proposed rule on 5010 will be published in June 2008, and if only minor revisions are made, a final rule will be published in 2010. It is projected that it will take three years to move to limited production of new standards and one year to move to full compliance, bringing us to 2014.”

Don't believe it?  Check out the details on the WEDI/NCHICA site devoted to the study.  And if you still don't believe it, download the MSP file and plug in your own assumptions. Heck, join in the conversation on their listserv!  The link says "membersonly" but it's supposed to be open to everybody.  If you have any difficulty subscribing, shoot me a note and I will inform the powers-that-be.

AHIC is Behind Medicare HIT Stick

In yesterday's post, I critique HHS Secretary Mike Leavitt's directive to congress to tie any restoration of the Medicare Physician fee schedule to EHR adoption. In it, I question where such a mind-bending solution originated: The idea that you can create a positive incentive for HIT out of an essentially punitive approach.

Diana Manos at Healthcare IT News points the finger:

Leavitt's call for incorporating healthcare IT adoption into a physician payment fix bill follows pressure last month from members of the HHS healthcare IT advisory panel, the American Health Information Community, to force adoption.

Craig Barrett, chairman of Intel Corporation said after 17 meetings of AHIC, doctors are no closer to adoption.

No kidding?  A score of CEOs and bureaucrats meet in Washington for a year and a half and the problem isn't solved yet?  I guess those doctors need to understand you mean business.  Why not threaten them?  That always works. [continued]

Leavitt Ties Medicare Carrot to IT Stick, Beats Docs

I tend to be a market-oriented sort of guy.  Not just the so-called "free" market, which exists largely in pundits' brains, on commodity trading floors, and on e-bay Hummel figurine auctions, but real markets, public and private, where people and organizations act and interact collectively in a world of imperfect (and often withheld) information, unknown risks, and externalized cost transfers, both accidental and manufactured.  As such, I recognize that when the actions of one party (say the gathering and organizing of information by a physician practice) creates benefits largely for another party (say a private or governmental payer), then market forces will tend to bring about a way for the party of the second part to provide an incentive to the party of the first part to do more of said activity.

Put more simply: It makes economic sense for payers to give money, resources, educational materials, etc., to get doctors to adopt electronic health records.

So I ought to be glad to get the news today that HHS Secretary Michael Leavitt has announced plans for a strong financial incentive to Medicare providers to adopt EHR, right?  Not so fast....

Healthcare Needs the Estate Tax

I don't usually like to put off all of my conservative friends at once, but here goes. There's a complex and very important economic dynamic in the relationship between the estate tax and the financial wellness of the healthcare industry. As fiscally conservative as one might want to be, this one comes down undeniably on the side of beneficial taxation. That is, if it is important to you that money stays in healthcare.

First, let's note that the so-called "inheritance tax" is nothing of the sort. The estate tax is a duty assessed on residual value at death; it does not tax heirs on what they receive. Second, it is a tax paid by very few, indeed. In the past twenty years, between 1% and 2% of estates have been subject to the tax. As pointed out in a recent Economist story, it is responsible for only roughly 1% of federal revenues.

On its face, the "Death Tax" seems a perfect political target. Just a 1% hit to the federal budget, right? No. That would be Dead Wrong. And healthcare would be the first, and possibly biggest, casualty. Read on...

Integrated Disease Management for Diabetics Not Worth It?

The following is the text of an email I just sent to the esteemed Dr. Blackford Middleton, in response to a presentation he gave to the Agency for Healthcare Research and Quality: "Evaluating the Value of Healthcare Information Technology: New Studies on Return on Investment from HIT Adoption from the CITL."  As we've come to expect from Dr. Middleton, the research was brilliant, innovative, and persuasive.  But the conclusions were devastating: According to the analysis, the most comprehensive kind of diabetic disease management programs don't save any money.  I invite you to download the presentation and read my response below.

Medicare e-Prescribing Will Include Formulary, History

Healthcare IT News reports on HHS Secretary Mike Leavitt's announcement that Medicare Part D will adopt voluntary standards for e-prescribing.  Members of the AHIC board are pushing for a mandatory adoption.

The standards do more than just encode the authorization from the physician's office to the pharmacy.  They enable a formulary listing to help the doctor choose from a list of payer-approved meds and provide a medication history to help warn the doctor of possible drug interactions.

An article in Health Data Management gives additional details about the NCPDP Script 8.1 standard.eRx is one of those "why didn't we do this already" no-brainers for all involved.  It would be helpful if the despised malpractice insurance industry took note of the patient safety benefits of HIT and put a bit of carrot at the end of this technology stick. There are some indications that this is beginning to happen.

http://hittransition.com/flashpoint/ad_rhio2.htm

Centralization, Commercialization Threaten VistA

Back in 2005, when Rep. Steve Buyer (R-Ind.) pushed a reorg of the HIT operations at the Department of Veteran's Affairs, we stood up for the good work the VA had done.  Looks like centralization has done worse than impaired development, it may actually threaten the VistA EHR's open-source model.  A recent decision to farm out the lab system to Cerner is just the tip of the iceberg, according to Fred Trotter's cogent and well-sourced analysis.  Buyer's supposed to be a friend to the vet, being a Gulf War soldier himself.  Maybe he should read Trotter's account before he goes back and offers any more "improvements."

If the Software is Free, How Do the Political Cronies Make Any Money?
Maybe Buyer could talk to Dr. Kolodner over at ONCHIT and find out why and how Free Open Source Software projects work.  Before Kolodner left his long and distinguished VA career to take over David Brailer's position, he talked about a FOSS migration path from VistA.  That's a far cry from "the current VA reorganization, which has local VistA programmers reporting to and paid by a centralized office in Washington, [and] has destroyed the control and influence of local VA hospital administrators over the direction of VistA," according to Trotter.

Even if you don't care about veterans, government mismanagement or intellectual property rights, Trotter's concise account gives some insights into the various FOSS development models.  A good read, and worth forwarding to somebody in Washington.

http://hittransition.com/flashpoint/ad.htm

Fair Share of Charity Care

In the form of proposed legislation, Sen. Charles Grassley is expressing his concern about how much nonprofit hospitals spend on charitable care. The ranking Republican on the Senate Finance Committee suggests that more is due in exchange for the billions of dollars in tax breaks received by hospitals.

Finance Committee staff has developed a controversial wish list of reforms, including one that would require nonprofit hospitals to dedicate a minimum of 5% of revenues to free care. The alternative would be to forfeit their tax-exempt status.

As we have noted in our publications, hospitals are the rare bird in the huge nonprofit sector. There are about 3,100 nonprofit hospitals, out of a universe of a million and a half U.S. nonprofit organizations. Looking at it more conservatively, there are 299,000 "reporting public charities" -- organizations large enough to be required to file tax returns with the IRS. Of those, nonprofit hospitals represent only about 3% of the entities, but consume 42% of the total charitable revenues of these reporting public charities.

CMS Discloses NPIs, Encloses Eligibility

NPPES posted its second release of NPI data for download.  Not quite  30-day cycle, but it beats the hang time for Round 1 by about 29 months.

Medicare posted a note to its clearinghouse listserv calling for a moratorium on new provider connections for eligibility inquiries through the HIPAA Eligibility Transaction System (HETS), plus a full accounting of provider connections, to be submitted by November 15.  Previously, they had placed a moratorium on new clearinghouse connections.  Something about protecting privacy, like maybe people were pinging Medicare for beneficiary information who really didn't have legitimate need.  Or maybe weren't even providers.  Or maybe that's just a rumor.  There were four or five possible causes discussed on a recent call, and I don't like to share such prattle.

I will say this, though.  Assigning accountability for connections is well overdue, and a lot of providers and intermediaries (clearinghouses, billing services, PMS vendors) are not going to be happy.  We're not just talking about administrative overhead here.  You may need to get closer to Medicare just to keep a connection.  If you're a middleman (middlewoman?  Middlehuman?), you may need to go direct.  After that first moratorium is lifted, of course....

The announcement I saw only referenced the 270/271 transaction, but it would seem logical that the 276/277 claim status would be on the CMS radar screen as well.

I should know more by Friday.

http://hittransition.com/flashpoint/ad.htm

HIT ROI and Incentivizing Swampland Development

I was digging around on some RHIO research (there's a new report out from an organization that is trying to corral the RHIOs into something that might begin to look like a National Health Information Network -- or at least look more like each other). I forgot to take my ADD meds today, so I was clicking away, deeper and deeper into hyperspace when I struck upon Mark Frisse's Policy blog.  Now, Dr. Frisse is a heavy hitter in the RHIO universe.  He sits on blue ribbon panels and he speaks to hifalutin conferences and he coauthors important papers, meanwhile holding a leadership position in one of the country's more forward Regional Health Information Organizations.

So, I expected what I usually get when I see such a luminary has a blog: Two or three cursory posts that read like press releases, followed by many months of neglect.

Imagine my suprise when I discovered his posts were personal, thoughtful, insightful and -- get this!  -- recent.  And long.  (He almost makes me look concise.)  But readable.  Unfortunately, he doesn't include a permalink on his blog entries, so you need to go to his October archive and scroll down to find "Building Nirvana Without Draining the Swamp."

His point -- one of them -- is that it's basically futile to talk about return on investment for healthcare IT, or to determine who should pay for it, until we fix the healthcare system itself.  Since Michael and I are doing a webinar on ROI for healthcare IT in a few weeks, I thought I had better read it. (Continued)

HIT The Campaign Trail

The EMR Medical Software Information and Resources blog summarizes each of the candidates' positions on healthcare information technology.  But one burning question remains: Will they inhale?

Gates' Way to Healthcare

In what must be one of the all time editorial coinky-dinky's in recent memory, an editorial from Bill Gates appears in today's Wall Street Journal -- just one day after Microsoft released its Health Vault Personal Health Record portal! 

But we must admit it's timely.  As Bill points out, "a groundbreaking 1999 report on health-care quality" pointed out that our healthcare system kills nearly a hundred thousand Americans a year, and a 2001 followup "urged swifter adoption of information technology."  And George Bush Jr. even mentioned HIT in his 2006 State of the Union.  Stop the presses!

I'm from Bellevue and I'm Here to Help You
Not to worry, Microsoft is on the case.  "We envision a comprehensive, Internet-based system that enables health-care providers to automatically deliver personal health data to each patient in a form they can understand and use."  That's a relief!  We thought you were building an information silo and hoping patients would somehow deliver information to their providers.  Knowing that your expectation is that all providers will start pushing data back through your narrow, proprieary pipeline is a real relief.  For a minute, there, we thought you were clueless.

Not to Harsh Your Buzz, Dude, But....
Meanwhile, in the non-healthcare press, there's this little line in the Economist about how the industrialized world has managed to make it for nearly 20 years without a major recession, a phenomenon referred to somewhat oxymoronically as "The Great Moderation."  The finding, from a report by Stephen Ceccetti, et al, appears somewhat mundane.  "More than half the improvement in the stability of economic growth in the countries they studied is accounted for by diminished inventory cycles."

You mean it wasn't Windows for Workgroups?

Building the Round Table
That took me back to a book I bought a couple years ago, "Challenge and Consequence....forcing change to eCommerce."  It's a geeky and somewhat breathless account of the evolution of Electronic Data Interchange through the establishment of X12 and other standards development organizations.

Each generation has its challenges and responsibilities.  Some of us born during the period from 1915 to 1950 were challenged to invent electronic commerce....  People worked at this in a spirit of service to company, industry, country, world and each other.  Their work significantly contributed to the outsanding improvment in economies that was experienced during the 1990s, and will continue to be effective for many years to come....

Ralph Notto's book was published in 2005, but most of the content seems to have been written much earlier.  He names names and lists specs.  He tells stories and gives history lessons.  Sometimes he refers to himself in the third person.  As a one-time X12-er, and a strong believer in the win-win proposition of collaborative engagement, I loved every page of it.  But I thought it might be a little over the top in terms of his claims about the economic impact of EDI. 

Until I read that passage in the Economist this morning.

All of Us Is Smarter Than Any of Us
See, solving the problems that HIT can solve is not about developing products, or portals, or PHRs.  It's about everyone coming to the table and agreeing to do things the same way.  That means everybody gives up a bit of control, and they trim their wish lists and moderate their customer promises.  They disclose innovations rather than keeping trade secrets.  They dream about data flowing freely rather than getting bottled up in repositories or being forced through proprietary switches.

We don't need another Bill solution.  We need a Melinda solution.

Feds say "Ewww!" to Senior Sex

I'm just minding my own business, scrolling through Medicare's FAQs when I come upon this one: Are Erectile Dysfunction (ED) drugs covered under Part D?

Now, I know just mentioning this on my blog (plus using the dreaded S-word in the subject) will add to our negatives on the spam nazi sites.  But still....

The answer to the question, of course, is "No."  Or, more specifically, "Not anymore."  For Contract Year 2006, they were covered, but your friendly representatives explicitly withdrew funding via the QI, TMA, and Abstinence Programs Extension and Hurricane Katrina Unemployment Relief Act of 2005. (I swear I did not make that legislative title up).

This comes hard on (oops!  There I go again!) the heels of a survey that reported that a lot of seniors actually enjoy s--, um, you know.  And I'm thinking you wouldn't have to look too har--, er, far to find evidence that being, um, well, active was good for them -- improving their mental health, providing exercise, and perhaps, in certain instances, helping them pay their way through the Part D donut h--

Oh geez.  Forget about it. 

Just like Grandpa may have to....

Acute and Obtuse: Angles on Health IT Funding

Part 2 in a series on health IT funding.
See the other installments in the Grants and Funding category.

You’re a software vendor and willing to throw some effort behind getting your customer’s HIT/telemedicine/clinical technology project funded, but you’ve got exactly zero experience in grant research and grantwriting. Or you’re a hospital IT director frustrated over tight resources – barely enough to keep the lights on – and you’ve got no visibility into the institution’s fundraising operation. Maybe you’re the CIO with the same feelings.

There’s money out there for health IT. The entire U.S. nonprofit sector – an annual $1.4 trillion chunk of the economy – collects only about $70 billion from government, and over $460 billion from private sources...

Kaiser Family Foundation Tracks Healthcare Campaigning

Republicans and Independents rank healthcare right behind Iraq as the most significant issue in the 2008 presidential election; Democrats rank the two equally.  You can track the issue between now and next November on a site the Henry J. Kaiser Family Foundation has set up: health08.org

WEDI, NCHICA to Map HIT Regulatory Timeline

Those of us who work in healthcare IT have this mental cascade of imperatives: regulations, new versions of standards, Medicare mandates and more.  It stretches back in time and on forward into seeming infinity, a dizzying ladder of challenges with strings of letters and numbers indicating the rungs: IPPS, HIPAA, TCS, 4010A1, NPI, ICD-10, 5010, AHIC, ad infinitum.

The trouble is, we are supposed to be familiar with all of them; what's more, we frequently get assigned to implementing multiple initiatives at the same time.  Worse, we are often called upon to implement one intiative (say, the National Provider Identifier Final Rule) when the feds have left out a necessary pre-requisite (like NPI Data Dissemination).  When it happens, we say, "What were they thinking?"  But a more important response is to try to prevent it from happening again, as when a number of standards development volunteers contacted congressional staff to let them know they can't implement the ICD-10 coding system until they've adopted a version of the claim standard (X12 v. 5010, for instance) that supports it.

A new collaboration between the North Carolina Healthcare Information and Communications Alliance, Inc. (NCHICA) and the Workgroup for Electronic Data Interchange (WEDI) will serve to connect the dots for regulators, standards developers and industry implementers alike.  It's not a simple calendar, but instead a map that includes dependencies, timelines and comment periods.  Way cool, and way overdue.

Read more about it online at Carolina Newswire and FCW.

Dam the RHIOs?

In a provocative editorial, Fierce Healthcare's Anne Zieger puts forward the arguments for Why RHIOs shouldn't exist.  She cites legal issues, cost issues and the challenge of getting competitors to share data.  She also references a Fierce Healthcare story on our recently-released 2007 survey of RHIO Finance, asking, "how long can this model last if most efforts are paid for by grants?"

She posits one potential RHIO alternative: "[Some] form of medical data banking--by a trusted intermediary rather than providers--seems to solve many problems that straight-ahead data exchanges can."  She also suggests that Patient Health Records, "[once] they become more robust," might be an answer to the data sharing challenge.

She admits to being a bit contrarian.  "All I'm trying to say here is that before we fixate on RHIOs as the answer to patient data sharing, we should probably make sure we treat RHIOs and HIEs with all due skepticism."

Fair enough, but I think she may be missing a point or two, as are many in the RHIO space.

Link to All CMS NPI FAQs

Many moons ago, I wanted to share a query string that would bring up all CMS FAQs that include the term "NPI."  That was preferable to linking to specific items, because new items were being constantly being added.  I did the search query on the CMS site, which created a URL that was a mile long.  I systematically eliminated components of the string until I came up with something that produced the desired results, but was only a furlong or two in length.

I've given this out before, but I didn't have a direct, isolated link on my blog, so here it is.  You can click on the big ugly string, but that often gets broken in pieces when you copy/paste/send via email, so if that's an issue, you can link people to this blog post by copy/pasting the second string.  (I don't use tinyurl because I'm not sure what they are selling to do what they do for free.  I am selling mostly free information with a few fee-based webinars and mostly-free presentations and white papers thrown in).

Big Ugly String to CMS NPI FAQs
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?&p_page=1&p_search_text=NPI&p_new_search=1&p_search_type=answers.search_nl&p_sort_by=&p_gridsort=4%3A2

Short Friendly String to this Blogpost
http://blog.hittransition.com/2007/08/link-to-all-cms.html

NPI Dissemination Roulette Closed, Winner is Pending

Today's announcement of the newest dissemination target date puts an end to your submissions to our Dissemination Roulette contest.  Of course, we won't be able to announce a winner until (or if) the NPI Registry actually goes online.  Remember, just like in real life, you don't win awards for getting close to the estimate, you win for getting close to the truth.

That allows us to complete the de-identified (initiated last Friday) list of the entries received before today's announcement.

Lucy Tees It Up Again; NPPES Dissemination Now Sept 4...?

Today's inbox greets us with this missive from CMS:

Dissemination of Data from the National Plan and Provider Enumeration System (NPPES) to Begin September 4, 2007

In case you were still wondering whether the previously-announced August 7 release date for the downloadable data had somehow avoided the scrutiny that held up the online NPI Registry site, the answer is no.  They say

Data will be available in two forms:

A query-only database, known as the NPI Registry.
A downloadable file. 

Since these both appear under the heading, "Dissemination of Data...to Begin September 4," one might assume that both would be available September 4.  I would discreetly point out that the simultaneity of these two releases is not necessarily explicitly indicated by the text. (And a closer reading confirms this: "The NPI Registry will become operational on September 4 and the downloadable file will be ready approximately one week later.")

Two More Weeks to Hide Your Privates
For the privacy-minded, the other deadline mentioned may be more significant: "health care providers need to submit their edits no later than Monday, August 20, 2007" to ensure they will be reflected in the public release.

Good Grief!  Again with the Football?
Another delay, another date for the calendar.  Anybody got a pencil?  Scrolling down the page, we found this reassurance: "Don't our eyes look sincere?  The sincerity of the eyes is an important indicator, Charlie Brown."

First Round Entries in NPI Contest

We've collected a number of responses to our NPI Disseminator Roulette contest.  We asked for an estimated date for the NPI Registry to go online, and, more importantly, the reasoning behind the estimate.  As you might guess, the answers were, well, unpredictable.  Here's a selection.  As promised, the identities of our contestents have been disguised....

State CIOs Invite Bigger Role in RHIO

The organization that represents the CIOs of state governments says its members should take a more active role in their states' Regional Health Information Organizations. This would definitely rate a "Duh Of The Month" here at the HIT Transition Weblog, except that I'd like to take a step backward and say that I'm not entirely sure that it's such a good idea until state governments show more willingness to pay for RHIO development.

According to a Government Health IT article, the National Association of State CIOs (NASCIO) is calling for its members to have a bigger say in how RHIOs develop. “Integrating these regional efforts will become a critical aspect of state CIO responsibility,” states a NASCIO brief. State government CIOs could serve as advisors to represent state health programs' technical interests.

Fine idea... but governments are already more involved in RHIO management than the dollars they offer would seem to justify.

CMS Disseminates NPI Transcript

Any port in a storm, the sailors say.

CMS has posted the transcript of it's June 14 Data Dissemination Roundtable. We'll still wait until the August 1 for Real Soon Now to arrive.

At least until August 1, that is.

Minnesota Schools the Nation in HIT

Once again, the state of Minnesota is showing us all how it is supposed to work.  They're not satisfied with the federal mandate for a single standard -- they want a single interpretation of the standard.  In fact, they insist upon it:

MINNESOTA LEGISLATION
Section 4:  Uniform Electronic Transaction Standards (62J.536)
The Administrative Uniformity Committee (AUC), under the direction of the Department of Health, will adopt uniform transaction standards for claims transactions, eligibility transactions and remittance transactions.  Eligibility transaction standards will be adopted by January 15, 2008 and implemented among plans and providers no later than one year later; eligibility transaction standards will be adopted by July 15, 2008 and implemented among plans and providers no later than one year later; and remittance transaction standards will be adopted by December 1, 2008 and implemented among plans and providers no later than one year later.  The AUC must create a single, uniform companion guide for each of the transaction categories.  For purposes of this requirement, “provider” includes nursing homes, boarding care homes, and home care providers.

All transactions must be electronic by the implementation dates for each type of transaction.  Web-based and direct data entry methods may be used to meet this requirement.