Thursday, October 12, 2017

Healthcare stakeholders weigh value of claims and clinical data | Health Data Management

Prior to the introduction of the electronic health record CMS (Medicare) and other health plan administrators relied upon claims data.  Now the mandate of meaningful use has made clinical data available via the electronic health record.

Physicians disparage the EHR because of it's disruption of the clinical encounter and inefficiency in data entry.  Few would deny the enormous data collection which has taken place.  

As a result two enormous data sources are available.

In healthcare, claims data is often described as a river that is a mile wide but only an inch deep, while clinical data—the analogy goes—is a mile deep and an inch wide. Yet, with the widespread adoption of electronic health record systems by providers, claims data often gets short shrift relative to EHRs.
However, understanding the distinctive benefits of claims and clinical data is critical if providers are to properly exploit their respective values.
Isaac Kohane, MD, chair of the Department of Biomedical Informatics at Harvard Medical School, knows better than anybody the value of different kinds of data and their respective limitations. As Kohane points out, EHR data is definitely more detailed than claims data. However, he believes there are circumstances when the latter is more useful than clinical data.
For instance, Kohane contends that research shows that claims data is more predictive than genomic tests for parents who have had a single autistic child looking to understand the probability of a second child having a diagnosis of autism.
While emphasizing that he leverages EHR data for a lot of analyses, Kohane points to an ongoing “sponsored research agreement” with health insurer Aetna that provides Harvard researchers with access to tens of millions of anonymous claims records from across the United States used to examine relationships among diseases, their consequences, and their heritability.
As it turns out, a detailed family history is often the most informative data for understanding inherited disease risk. However, very few EHRs provide the capability to easily enter a family history and link it to the broader genealogy. “What we’re trying to do is make medicine a much more data-driven discipline,” adds Kohane.
Still, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, characterizes the difference between the two data types—claims and clinical—as breadth versus depth. He observes that EHRs give providers really deep data about patients for specific medical events and the overall context.
“If you only have claims data you would only be able to infer, for example, that a patient is diabetic or has pneumonia because there is nothing in the claim that tells you so,” says Tripathi. “All you know is that Blue Cross paid the provider to test for those conditions. You don’t actually have the test results. But, with clinical data, you find out what happened. In the EHR, you will have the actual lab results.” At the same time, Tripathi believes claims data is generally “cleaner” than clinical data given that the former is simpler in design and that payers actively monitor medical billing in a way that EHR data is not.
“The problem with clinical data is there are lots of individuals who are documenting in their own unique ways that is not enforced on a day to day basis,” he adds. “One of the things about claims and financial data is that when it is submitted with the wrong codes it will get rejected right away because everyone one of those is sent through a central payer. That means providers will not get paid, so they care about getting the coding right.”
However, DeSalvo charges that both claims and clinical data are “super” dirty. “I’m not sure what’s worse,” she says.
The changing impact of value based care vs. fee for service reimbursement.
Nonetheless, as the industry transitions from fee-for-service to value-based payment linked to quality, performance and reducing costs, DeSalvo contends that the more access providers have to clinical data about outcomes is going to be critical to ensure interventions are actually improving healthcare and not just decreasing utilization.

“The Holy Grail has always been the clinical data for the scientific, public health communities, and those interested in analytics, because it gives you some sense about outcomes more than process and help provides a window into complexity and control factors—particularly high-cost, high-need patients with chronic diseases—as opposed to just knowing what chronic diseases they have,” says DeSalvo.
When it comes to value-based purchasing and risk contracts, John Halamka, MD, chief information officer at Boston’s Beth Israel Deaconess Medical Center, contends that a repository of both clinical and financial data is needed by providers to succeed.
“That’s the only way to compare outcomes (clinical), quality (clinical), and total medical expense (financial) across providers,” says Halamka.

According to Kheterpal, one of the advantages of claims data is that it follows patients regardless of where they receive care.

Kheterpal agrees that major claims data holders—like health systems with their clinical data—have business strategies built around restricting access to information. However, he mentions that not-for-profit claims data holders such as the Blue Cross Blue Shield Foundation and Blue Cross Blue Shield of Michigan “do not view that data as a revenue stream and a strategic differentiator” but as “an enabler of research and clinical quality improvement.”

Lack of payer, provider info sharing complicates shift to value-based care

Although collaboration between payers and providers will be critical if they are to succeed in transitioning to value-based payment models, they continue to struggle with information exchange in the current fee-for-service environment.
That’s the finding of a new survey of 40 health plans and more than 400 practice- and facility-based providers, which found significant communication gaps between the stakeholder groups.  In the survey, conducted by health IT vendor Availity, the vast majority of payers and providers (84 percent of practice-based providers, 76 percent of facility-based providers and 68 percent of payers) view administrative waste—finding the right point of contact, long wait times and frequent policy changes—as a significant cause of poor communication.
In fact, the survey results show that slightly less than half of practice-based providers report difficulty communicating with and interacting with payers, compared with almost a third of facility-based providers. Among the top issues identified by providers as leading to dissatisfaction with payers are: redundant information requests, denied claims and uncompensated care, as well as inconsistent rules among health plans.


“The payers and the providers have created administrative waste, and that’s one of the significant causes of poor communication and is adding to the cost of healthcare,” says James Leatherwood, Availity’s product manager for portals. “That comes in a variety of ways, including multiple requests for the same information, which just add cost unnecessarily.”  

Currently, when providers have questions about prior authorizations, denials or payments, they call the payers. In the survey, more than 90 percent of providers and 68 percent of health plans indicated that they consider the phone to be their primary means of communication.
“Frankly, I was very surprised that 90 percent of the providers think that the phone is the best way—or, at least, the most commonly used way—to reach out to the plans,” adds Leatherwood, given the long wait times associated with this mode of communication and other inefficiencies.
While online portals are a potential solution for better managing communications, the providers and payers surveyed view the technology differently: 60 percent of payers would prefer the use of online portals as the primary means of communication, but only about 40 percent of providers were as enthusiastic.
“The plans would much prefer the providers to use the electronic tools,” observes Leatherwood. “The providers would prefer to be able to get the answer that they need, regardless of where that comes from. They don’t see the portal as the most effective way to do it based on our research.”
Nonetheless, multi-payer portals are seen by providers as simplifying the workflow by reducing the number of sites that have to be checked for patient eligibility, benefits, claims status and other insurance-related data. In the survey, a multi-plan portal was preferred by 42 percent of facilities-based providers and 35 percent of practice-based providers.
Ultimately, Leatherwood believes that having the ability to share information in advance of treatment—rather than just after care is delivered—is where the industry needs to improve if value-based payment models are to be successful.
“When the plans and providers work together, healthcare gets better,” he concludes, resulting in “better outcomes for patients, creating a healthier America, as well as saving money and reducing the costs of care.”
Ultimately the streamlining and fusion of both sets of data will result in better statistics. The statisticians have their hands full, and depend upon provider input.


Friday, September 8, 2017

Insurance Comissioners

<h1>Vital Health Officials You’ve Never Heard Of: Insurance Commissioners In The Hot Seat</h1> <span class="byline">
By <a href="http://californiahealthline.org/news/author/julie-appleby/"><strong>Julie Appleby</strong></a> </span>
<p>With insurance premiums rising and national efforts at health reform in turmoil, a group of 50 state bureaucrats whom many voters probably can’t name have considerable power over consumers’ health plans: state insurance commissioners.</p>
<p>As insurers threaten to exit state markets and voters at town halls complain about unaffordable prices, the state commissioners are central characters in the unfolding drama that is America’s health coverage.</p>

<p>“What’s the worst job to have right now? Insurance commissioner,” said Christopher Koller, a former commissioner from Rhode Island who is president of the Milbank Memorial Fund, a foundation that works to improve health. “They’re trying to keep the market stable.”</p>
<p>Most are wrestling with how to take on this task amid ongoing political rancor over the fate of the Affordable Care Act. Several commissioners are slated to testify <a href="https://www.help.senate.gov/hearings/stabilizing-premiums-and-helping-individuals-in-the-individual-insurance-market-for-2018-state-insurance-commissioners">Wednesday</a> before the Senate health committee to talk about market stability and how to ensure patients have affordable health care.</p>
<p>The political debate highlights the role of this crew of wonk-ish administrators who sometimes preside over underfunded, understaffed offices and whose range of duties usually spans well beyond health care and its myriad complexities.</p>
<p>In all but one state, the commissioner regulates all types of insurance, and in several he or she might hold other jobs — such as lieutenant governor (Ohio), state auditor (Montana) and fire marshal (Mississippi, North Carolina, Tennessee and Georgia).</p>

<p>Most commissioners have the authority to reject premiums or modify rates they deem excessive. They also have the power of their bully pulpit. California Commissioner Dave Jones, for example, lacks the statutory muscle to override insurers’ rate increases, but he often uses his position to publicly call out insurers’ premium hikes.</p>
<p>In an unusual arrangement, he shares regulatory authority over health insurers with Shelley Rouillard at the Department of Managed Health Care. She regulates a much larger share of the health care market but doesn’t grab the spotlight as much. She too has <a href="http://www.latimes.com/business/la-fi-aetna-rate-hike-20150716-story.html">publicly scolded</a> major insurers, such as Aetna, for unreasonable rate hikes. Her agency is reviewing next year’s premium increases for the Covered California exchange.</p>
<p>Unlike Jones, a Democrat who is <a href="http://www.sacbee.com/news/politics-government/capitol-alert/article113581408.html">preparing to run for state attorney general</a>, insurance commissioners lean nonpartisan. “Historically, insurance commissioners have seen themselves as civil servants more than politicians … and have kind of stayed out of political battles,” said Tim Jost, emeritus professor at the Washington and Lee University School of Law, who also serves as a consumer advocate with the National Association of Insurance Commissioners (NAIC).</p>
<p>But, he added, “at least for the moment, it’s more politicized than it has been in the past.”</p>
<p>Eleven commissioners are elected and the remainder are appointed and — as such — face new political pressures in a highly partisan health care debate.</p>
<p>The individual insurance market, where about <a href="http://www.markfarrah.com/healthcare-business-strategy/A-Brief-Look-at-the-Turbulent-Individual-Health-Insurance-Market.aspx">17 million people</a> purchase their own plans because they don’t get it through their jobs, is the focus for much of this drama.</p>
<p>GOP repeal-and-replace talking points have hammered a message that the individual market — including the government exchanges — are imploding. But Democrats counter that though they face difficulties, this is not the case. The insurance commissioners are caught in the middle and have the power to make either narrative come true.</p>
<p>Many had to scramble this summer — negotiating, offering incentives or just downright pleading — to get insurers to stay in their markets.</p>
<p>At one point, there were more than 40 counties nationwide with zero insurers for next year. As of Aug. 24, when insurer CareSource agreed to provide coverage in Ohio’s Paulding County, no more of these so-called “bare counties” remained.</p>
<p>When Julie Mix McPeak, commissioner of Tennessee’s Department of Commerce and Insurance, persuaded Blue Shield to return to areas of the state that it had pulled out of last year, she recalled: “Some critics said I was going out of my way to prop up Obamacare. Others said I wasn’t doing enough because I’m from a red state and that must mean we want Obamacare to fail. But I just want access to coverage.”</p>
<p>Critics worry that in some states the position is a <a href="https://www.washingtonpost.com/investigations/drinks-junkets-and-jobs-how-the-insurance-industry-courts-state-commissioners/2016/10/02/1069e7a0-6add-11e6-99bf-f0cf3a6449a6_story.html?utm_term=.21073464b328">revolving door</a> with industry, moving them to do less than they could.</p>
<p>“It a double-edged sword,” said Sabrina Corlette, research professor at Georgetown University’s Health Policy Institute. “Knowledge of industry … is very important in the job. [But] … if someone is coming from and going back to industry, it does raise some red flags about where their interests really lie.”</p>
<p>Sometimes a past résumé draws increased public scrutiny of a regulator’s actions on issues under the department’s purview.</p>
<p>Connecticut Insurance Commissioner Katharine Wade, who was a Cigna executive before being named commissioner, was fined $500 in June after the state’s Freedom of Information Commission ruled that she improperly withheld documents related to a proposed merger between Aetna and Humana. She is appealing the ruling, her office said, seeking clarity on what they see as a conflict between insurance laws, which require confidentiality for some information, and the freedom of information statutes. The proposed merger was called off in February after a federal court blocked the deal, but not before a state review of Connecticut-based Aetna’s plan drew criticism because of Wade’s past employment.</p>
<p>McPeak and other commissioners also say that cost issues need to be tackled, but there’s no bandwidth to take on these thorny issues because they have to deal with the more immediate problems.</p>
<p>“We can’t get to affordability if I don’t have a policy for people to buy,” said McPeak. For next year, “I’m telling consumers there will be problems and they will see rate increases. But at least they have an option.”</p>
<p>These efforts are made more complicated by President Donald Trump’s repeated threats to eliminate subsidies used to lower deductibles for some ACA policyholders, which would raise premiums. Payments are currently being made on a month-to-month basis. It will likely be a topic during the upcoming Senate hearing.</p>
<p>“We would all like to know what the rules are. When there is uncertainty, it’s difficult to make short- or long-term decisions, said Al Redmer, who was appointed Maryland’s insurance commissioner in 2015 by Republican Gov. Larry Hogan.</p>
<p>And the subsidies aren’t the only point of contention, with the partisan divide also reflected among some commissioners.</p>
<p>Trump and Congress are causing uncertainty that is “sabotaging the progress we’ve made,” Washington state Insurance Commissioner Mike Kreidler <a href="www.insurance.wa.gov/news/eleven-health-insurers-file-2018-individual-market-37-counties-leaving-two-no-coverage">wrote</a> in June. His state strongly embraced the ACA.</p>
<p>Kreidler, a Democrat who formerly was a member of Congress, was first elected commissioner in 2000.</p>
<p>In contrast, Oklahoma Insurance Commissioner John Doak, whose state opposed the ACA from the start, has made it no secret that he supports repeal of the law, calling it “this disastrous experiment.” Doak, a Republican who was elected to the position in 2010 after working for various insurance companies, <a href="https://www.ok.gov/triton/modules/newsroom/newsroom_article.php?id=157&article_id=33277">blamed ACA regulations</a> for “so many insurers dropping out of exchanges or resorting to double digit premium increases.”</p>
<p>Commissioners’ regulatory powers vary by state, depending on the rules state legislators have put in place for them to enforce.</p>
<p>“Some states have comprehensive protections for consumers … while others have limited protection,” said Claire McAndrew, director of campaign strategy at Families USA.</p>
<p>But if they are so motivated, consumers can always find means to take an activist role.</p>
<p>Past commissioners, for instance, talk of using the regulatory process itself — pushing the boundaries in drafting the rules or using a “slow walk” toward their implementation — to work around these boundaries.</p>
<p>Even so, they face other limits. For instance, staffing levels for their departments are down nearly 6 percent since 2008, according to the most recent NAIC <a href="http://www.naic.org/prod_serv/STA-BB-16-01.pdf">statistics</a>.</p>
<p>That’s a big disadvantage when contrasted with the “strength of insurance industry lobby,” said J. Robert Hunter, a former Texas commissioner and now director of insurance at the Consumer Federation of America.</p>
<p>And some fail to counter industry influence in legislatures and even inside their own offices, he added.</p>
<p>He recalls that when he took up his post in Texas, he met with lawmakers in the Statehouse, some of whom were “unabashed” in their support of the insurance industry, warning “we’ll hurt your budget” if he went too hard on industry.</p>
<p>He didn’t play ball.</p>
<p>“If insurers are always happy, something is wrong,” said Hunter. “Insurance commissioners’ jobs are to hold them to account.”</p>
<p>Correction: This story was updated on Sept. 6 to correct the spelling of Connecticut Insurance Commissioner Katharine Wade. It also adds a description from her office of the dispute she is appealing. The interactive map was updated Sept. 6 to reflect the appointment of a new insurance commissioner in Pennsylvania.</p>
<p>This story was produced by <a href="http://khn.org/">Kaiser Health News</a>, an editorially independent program of the <a href="http://kff.org/">Kaiser Family Foundation</a>.</p>

Monday, August 7, 2017

3 Doctors Over 60 Tell Us How Healthcare Has Changed

"It's not like it used to be"




How has medicine changed in the last 30 or 40 years?  

circa 1950

circa 2000



circa 2015

 Just in the last decade medicine has changed a lot. For instance, by the end of the year approximately 90% of office-based physicians nationwide will be using electronic health records (EHRs).

The doctors: Over 100 years of collective experience

  • Barbara Bergin, MD, is an orthopedic surgeon at Texas Orthopedics and has been a doctor for 31 years. I highly recommend you check out Bergin’s blog, where she offers tips on keeping your joints healthy using conversational language, humor, and personal anecdotes.
  • Damien Howell, PT, DPT, OCS, is a physical therapist at Damien Howell Physical Therapy, and has been practicing for more than 40 years. Howell also blogs. “I started that webpage in 2003 before blogs existed,” he says with a laugh.
  • John Errol Asher, MD, is a board-certified infectious disease physician and internist, who began practicing more than 40 years ago before retiring this year.

As a senior retired ophthalmologist I have witnessed most of these changes. In 1962 when I was a junior medical school student Medicare came into existence.

The reference article focuses on the electronic health care record, which is too narrow a focus on changes over the last 49 years.

Perhaps the most annoying aspects of change have been the growth and interference with doctor and patient choices for treatments requiring authorizations for payment of claims. This interference is perhaps the one greatest change in health care.  This is the result of increasing costs, yet health care costs continue to increase.

Recently increasing regulations and CMS rules have been found to increase costs offsetting any possible reductions in health care cost.

In an effort to decrease overhead, many physicians have created group medical practice business structure,   in an effort to build an organization with greater negotiating power,  and to reduce overhead.  The former may be valid, the latter is in doubt.

3 Doctors Over 60 Tell Us How Healthcare Has Changed