Emergency Regulations proposed for Covered California Is It ? Jones Releases Emergency Rule Over Narrow Provider Networks

Are you one of the hundreds of thousands who accepted the incompetent design of 'The Affordable Care Act ?  You are not alone.

It has taken more than one year of operation for state health officials to recognize this current disaster. 

The affordable care act has delivered an empty promise, deception, and a boiler plate plan that gives  you a health insurance card...Good luck after that.

Sick patients require help and assistance. Those who are well and especially those who have an acute or chronic illness have many challenges in life, should not and cannot negotiate the web sites, and even when they do, much of it is incomprehensible.  

Haste in signing up due to arbitrary guidelines and enrollment dates add additional challenges for those still uninsured, and those who have discovered just how terrible their new plans are presents challenges for most.

Help may be on the way now that State Commissioner for Health Insurance, Dave Jones is responding to complaints from California Consumers.  Jones is the head of the California Managed Care programs.





California State Health Commissioner, Dave Jones

On Monday, the California Department of Insurance issued an emergency regulation that aims to address narrow provider networks in the state and improve residents' access to care, Capital Public Radio's "KXJZ News" reports. 

According to the state Department of Managed Health Care, several insurers, including Anthem, have violated state law by misleading consumers about the size of their provider networks  State Insurance Commissioner Dave Jones (D) said DOI has "received complaints from consumers across the state about long waiting times, about inaccurate directories of providers, about being charged out-of-network costs when there isn't an in-network provider. The list goes on and on and on" 

Details of Emergency Regulation

The emergency regulation requires insurers to:

• Adhere to new standards for appointment wait times (DOI release, 1/5);
• Offer an adequate number of physicians, clinics and hospitals to patients who live in certain areas;
• Provide an accurate list of in-network providers ("KXJZ News," Capital Public Radio, 1/5);
• Provide out-of-network care options for the same price as in-network care when the number of in-network providers is insufficient; and
• Report to DOI information about their networks and any changes.

The emergency regulation will go into effect after it has been reviewed by the Office of Administrative Law. According to a release, emergency regulations often go into effect more quickly than standard regulations (DOI release, 1/5).

According to Jones, he can bar insurers that do not comply with the regulation from selling insurance in the state next year 

Medical Education Financing....The Next Fiasco

Report Touches Off Fight Over Doc Training $$

The Affordable Care Act will have profound effects on the financing of both undergraduate and postgraduate medical education, 

Behind the scenes is the relative paucity of primary care physicians, especially in rural underserved regions. 

A high-level report recommending sweeping changes in how the government distributes $15 billion annually to subsidize the training of doctors has brought out the sharp scalpels of those who would be most immediately affected.

The reaction also raises questions about the sensitive politics involved in redistributing a large pot of money that now goes disproportionately to teaching hospitals in the northeast U.S. All of the changes recommended would have to be made by Congress.

Released Tuesday, the report for the Institute of Medicine called for more accountability for the funds, two-thirds of which are provided by Medicare. It also called for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid. 

Since the creation of the Medicare and Medicaid programs in 1965, the public has provided tens of billions of dollars to fund graduate medical education (GME), the period of residency and fellowship that is provided to physicians after they receive a medical degree. Although the scale of govern­ment support for physician training far exceeds that for any other profession, there is a striking absence of transparency and accountability in the GME financing system for producing the types of physicians that the nation needs.

The IOM formed an expert committee to conduct an independent review of the governance and financing of the GME system. The 21-member IOM committee concludes that there is an unquestionable imperative to assess and optimize the effectiveness of the public’s investment in GME. In its report, Graduate Medical Education That Meets the Nation’s Health Needs, the committee recommends significant changes to GME financ­ing and governance to address current deficiencies and better shape the phy­sician workforce for the future. The IOM report provides an initial road­map for reforming the Medicare GME payment system and building an infrastructure that can drive more strategic investment in the nation’s physician workforce.

The funding in question is for graduate medical education (GME), the post-medical school training of interns and residents required before doctors can be licensed to practice in any state.

"We recognize we are causing some disruption," said Gail Wilensky health economist and co-chairwoman of the panel that produced the report. "But we think we are doing so in a thoughtful and careful way," including phasing in the payment changes over 10 years.

Some of the major players in medical education don't see it that way, however.

"Today's report on graduate medical education is the wrong prescription for training tomorrow's physicians," the American Hospital Association said Tuesday. "We are especially disappointed that the report proposes phasing out the current Medicare GME funding provided to hospitals and offering it to other entities that do not treat Medicare patients."

The panel specifically proposes that funding for medical education be expanded beyond hospitals to clinics and other training sites in the community. "Most, if not all residencies must train physicians to treat a wide range of patients -- many of whom are under age 65 and not eligible for Medicare coverage," the report says.

The American Academy of Family Physicians welcomed the proposal "to shift funding away from the legacy hospital-based system to more community-based training sites; including allowing funding to go directly to those organizations that sponsor residency training," AAFP President Reid Blackwelder said in a statement. "By giving these organizations more control over how they train residents, the financial investment will better align with the health needs of a community.

But the broader-based doctor group, the American Medical Association, reacted negatively, saying: "Despite the fact that workforce experts predict a shortage of more than 45,000 primary care and 46,000 specialty physicians in the U.S. by 2020, the report provides no clear solution to increasing the overall number of graduate medical education positions to ensure there are enough physicians to meet actual workforce needs."

That's because Wilensky's panel didn't agree with studies projecting a shortage of physicians. "There was not a consensus that there is a shortage going forward," said Wilensky, noting that rapid changes in medical practice, including sharply higher use of nonphysician health professionals such as physician assistants and nurse practitioners, might be enough to provide care to aging baby boomers and those obtaining coverage under the Affordable Care Act.

And even if a shortage occurs, the medical education system needs to better manage training since it now produces more specialists than primary care providers and leaves major areas of the country with too few practitioners, said Malcolm Cox, who recently retired from running the medical education program for the Department of Veterans Affairs. "Will an unregulated expansion produce the right physicians with the right skills in the right areas of the country?" he said at a panel discussion of the report.

Wilensky, who ran Medicare when Congress overhauled the physician payment system in the early 1990s, said the chances for making such changes depend very much on lawmakers from states that currently get less funding -- which is most of them.

Given the fact that a disproportionate amount of current funding goes to institutions "in New York, New Jersey, and Massachusetts," Wilensky said she's surprised "that everyone else has tolerated this peculiar distribution of funds" for so long.

Whether change happens will depend on "whether some of the have-not states are willing to say 'wait a minute,'" she said.

The New York teaching hospitals, in particular, are well-known for their clout on Capitol Hill.

"They are fantastically great in terms of their protection of their turf," said Bill Hoagland, a longtime Senate Republican staffer and now senior vice president of the Bipartisan Policy Center. "People talk about the third rail of politics as not touching Social Security. I have found that you touch anything dealing with medical education you get bombarded."

By far the most heated criticism of the report's recommendations came from the Association of American Medical Colleges, which represents medical schools and the teaching hospitals they affiliate with.

"While the current system is far from perfect, the IOM's proposed wholesale dismantling of our nation's graduate medical education system will have significant negative impact on the future of healthcare," said AAMC President and CEO Darrell Kirsh. "By proposing as much as a 35 percent reduction in payments to teaching hospitals, the IOM's recommendations will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials."

But those supporting the IOM's recommendations say the system is in major need of change. "The current system is unsustainable," said Edward Salsberg, a former top official at the Bureau of Health Workforce at the Department of Health and Human Services. "Healthcare is moving to the community, but our system of financing graduate medical education is tied to inpatient care."

In any case the responsibility for Medicare, HHS and the taxpayer falls disproportionally on government funding, without support from private health payer insurance entities.

Progress on the Frontiers of Health and Medicine

The frontiers of medicine are not only in the development and transformation of delivering health care, but is also a physical impediment to delivering a level of quality health care.Rural health care presents unique challenges for delivery of care. There are fewer providers, facilities, and less economic support.

As described by Leila Samy, Meghan Gabriel, and   Jennifer King on HealthITBuzz , 

Leila Samy

  

                                                                Meghan Gabriel
                                                                                                               Jennifer King

              

Critical Access Hospitals (CAHs), some with a census of fewer than 10 patients, are the smallest of the small rural hospitals. In some regions, such as frontier areas, a CAH may be the only local health care provider serving an area the width of the state of Rhode Island! CAHs are small, geographically isolated and have limited resources.

CAHs are found in every region of the country, and represent roughly 30 percent of hospitals nationwide. Often serving as the focal point for all health care services in a rural area, CAHs often own and run the local rural health clinics and skilled nursing facilities. They may also be responsible for public health and emergency medical system services. These hospitals extend services to places where they wouldn’t otherwise be available. And those are the reasons why it is important for CAHs to have access to health IT systems and capabilities.

As of 2013, 89 percent of CAHs had an EHR in place; 62 percent of CAHs with an EHR had a fully electronic health record system, and 27 percent had a health record system that was part electronic and part paper.

Most CAHs adopted (as of 2013) or planned to adopt (by the end of 2014) the health IT capabilities evaluated in this study (i.e., telehealth, teleradiology, care coordination and health information exchange with other providers and patients).

As of 2013, CAHs reported the highest rates of adoption for teleradiology (70 percent) and telehealth (59 percent) capabilities. Fewer CAHs reported other capabilities related to electronic exchange of key clinical information with other providers. Even fewer (15 percent) of CAHs reported patient engagement capabilities (i.e., offer patients ability to view, download and transmit their health information

Among the challenges to health IT adoption among CAHs, financing and workforce related challenges were most commonly reported.

CAHs that pooled resources with other hospitals were more likely to have EHR and capabilities related to health information exchange and care coordination, compared to those that did not pool resources or engage in group purchasing.

CAHs with faster Internet upload speeds were more likely to have the capability to provide patients with the option to view, download, and transmit their health information compared to those with slower upload speeds.

The Federal Government is offering funding opportunities and offers Creative Solutions to Expand  Rural Health IT Funding

Benefits of Health IT adoption among CAHs and other small, rural hospitals

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The Evolution of Health Information Exchange, 2014

It can be said that the first part of the 21st Century in medicine has been the wave of information technology.  The capitalization of this relatively new department has diverted much funding from other needs in the health care industry.

The addition of HIT required federal underwriting. The ‘incentive’ was more of a negative reward/penalty instrument to force adoption of IT.  In order to maximize reimbursement from CMS hospitals are incentivized to reduce readmissions, and report meaningful use. Meaningful use follows a progressive course, escalating over time until fully implemented. Hospitals have many more stages than clinics or individual providers. Providers and hospitals alike must ‘attest’ to this functionality and demonstrate they are reporting. Failing to do so by a specific date is penalized by a reduction in reimbursement for services.

Much importance has been assigned to this effort, including improved outcomes, decreased expenses, improved patient experiences, transparency of information, accessibiliity of information for patients and providers and the unproven promises of ‘BIG DATA’

It will take some time to determine if these processes will  reduce expense or flatten the rate of inflation of health cost.  Built into and hidden from view is the cost of obtaining the data, and analytics.  A substantial IT investment and personell are added to the equation.  

The peverse nature of government is to spend more to save more…Government is fueled to expand and self-replicate ad infinitum.

Other industries such as the automotive business have profitted from BIG DATA, and it is hoped that by translating it to health care there will be dividends in treatments, cost reduction, safety, and better outcomes.

The Evolution of Health Information Exchanges

My  experience in this area began in 2005 as I led a group of physicians to consider a regional health information exchange.  It was a slow but fertile beginning.

We all focus on what is now and what lies ahead, that challenge can be justified by a brief but important look at our past accomplishments which are considerable.

Much has been accomplished, by many, and at relatively little expense in the planning phases of  HIE.  Early planning and project management time expenses were donated at no charge by physician leaders, medical societies, and interested vendors.

Well intentioned leaders do not have to spend billions of dollars to study or plan a project of this scope.  

These thoughts were corroborated as reviewed written and verbal correspondence for the early meetings of the Inland Empire Health Information Exchange (Riverside, Callifornia)

Neither can one forget the prescience of  President George W. Bush by forming the Office of the National Coordinator of Health Information Technology, Don Berwick M.D. and their successors.

Physicians were dragged into the mix as naysayers, not wanting more complex procedures to interfere with patient management responsibilities. We are now well along the way and there will be no turning back.

Even more than the abilit fo providers to exchange medical information is the added dividend for analytics, and support for accountable care organizations.

Health Reform to 2014 and Beyond or Back to the Future

The More You Understand About the 2014 Changes,  The Better.

If you had not noticed.

I am retired from clinical practice, and  admit I miss seeing patients.  My career goals have changed as some of you have noticed.

During the last decade I became interested in health information technology and set out to communicate with fellow professionals.  Readers of Health Train Express and it's predecessor will see an evolution, beginning with electronic medical records, health information exchange, health reform, mobile health applications, remote monitoring, and telehealth. They all serve to integrate our health communications for providers and patients.

During the last 12 months I was diverted by the Affordable Care Act and  the promises of Accountable Care Act. The potential for these new paradigms are great, however the day to day activities of providers and hospitals will  increase their load, and without additonal reimbursements. Providers have been expected to make huge capital outlays for health IT, design,implement and use these new systems.  They are directed at reductions in reimbursements to allow the large growth in patient access.  i doubt whether there will ber an actual decrease in the gross outlays for health care.  However during the past two years there have been reports of a decrease in the rate of growth.

There are some key actions to implement changes:  These webinars are designed to address specific areas that will require action.

Understanding Payment Reform - Beyond Fee For Service 

In the past decade there were some pre-paid and capitated models. The new paradigm is to approach payments connected to outcomes.  How they will be measured is open to great debate, and the subject should be addressed actively and with transparency before changes are made to avoid a catastophe such as the Health.gov benefit exchanges.  Some of these issues may be addressed by a 'global fee to hospitals and providers and/or medical groups as part and parcel of integrated medical systems.

Understanding The 2014 EHR Incentive Program 

The webinar addresses objective information for non-acute providers,practice and clinics on how to prepare for 2014 changes to the CMS EHR Incentiviei Programs.

An ICD-10 GEMS Crosswalk Overview

GEMS is a term which most providers are not familiar. CMS on it's web site offers these white papers. 

• 2013 General Equivalence Mappings - Diagnosis Codes and Guide [ZIP, 583KB]
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     The compressed zip files contain 3 white papers.

     The Dxgem file addresses specifics of conversion from ICD9 to ICD10.

MDs Everywhere's Vice-President of Development, Doug Salas explains the impact of 14,000 ICD codes expanding to 70,000 will have on documenting

Understanding HIPAA Requirements and Safety Measures 

HIPAA has been around since the mid 1990'. Providers have always known the standards of ehtical private confidentiality.  HIPAA was designed for others, institutions who deal with large amounts of patient health and financial data.  Penalties and fines are impressively high and the law has been enforced agains several large hospitals and other custodians of health records.

Recording and Archived:  (In case  you cannot attend the webinar at it's schedule time) At the time of registration you will receive a link and a date, which can be downloaded to an Outlook  .ics file.

All of the webinars will be archived for later viewing

Health Software Vendors

Software and hardware age quickly in health care. Software and hardware evolve, change and become obsolete quickly in the course of five years. Much changed during this 1/2 decade as providers and hospitals geared up for the HIT revolution.

Just ten years ago (2004) EMRs were very few and only 10-25% of providers or hospitals had any type of electronic health record.   The concept of health information exchanges and interoperability were still seminal ideas. Mobile health applications were few.

Following the HITECH Act the progress has been staggering. On the one hand it stimulated the adoption of EHRs, on the other hand in a rush to capture the incentive and avoid penalties, users were coerced to obtain inadequate electronic systems which were not tested for ethnology or true user functionality.  Many were and still are a barrier to efficiency and do not instill confidence in physicians by patients when providers faces are embeded in their display, which minimized face-to-face contact.  Transference as most providers realize is a key component of patient reassurance and compliance.  Score two big negatives for the current generation of EMRs.

Many providers have invested in EMRs, some already had EMRs which were compliaint enough to be CCHIT certified for interoperability (necessary to use HIX (health information exchanges) to exchange data with diverse EMRs.  Some were able to be upgraded to satisfy Meaningful Use, Stage I.

However many of these pre-existing systems are now insufficient to be further upgraded due to the increasing complexity of reporting metrics to CMS and Health Insurers.  Now faced with ACOs (Accountable Care Organizations the EMR and HIX face the challenge of further requirements.

For some the time as come to upgrade their EMR even though it may be only five to ten years old.

There have been many reports about physician dissatisfaction with first, or second generation systems. Offerings are divided between small practice, medium size practices, and large enterprise integrated health systems.

Perhaps a measure of change can be found in a report from MarketWatch of the Wall Street Journal.  I find the WSJ to be a reliable source of change in markets as they measure financial changes early on.

EPIC has been the leading software vendor for large enterprise systems.  This year however KLAS has ranked athenahealth as the top vendor replacing EPIC as rated by thousands of health care providers across the U.S., athenahealth is now rated #1 in the following categories:

-- 2013 Best in KLAS Overall Software Vendor

-- 2013 Best in KLAS Overall Physician Practice Vendor

-- 2013 Best in KLAS Practice Management Service, athenaCollector(R), for the 1-10 and 11-75 physician segments

-- 2013 Best in KLAS Patient Portal, athenaCommunicator(R)

The old guard of HIT leaders is finally being displaced by more nimble, innovative models designed for health care's future - not for its past," said Jonathan Bush, chairman and CEO, athenahealth

Radiology One of the Highest Paying Medical Specialties

Contributions to this post are from:
Mike Bassett, 

One of the   principal determinants some medical specialties is salary. However, that is not the only factor in specialty selection by trainees.  Some of the other factors are:

Relatively good hours and call schedule
Flexibility of work locations
Group Practice insulated from  financial issues
Hospital based employment, an option
Support as consultant for most specialties
Technological advancements in CT, MRI, PET and other new imaging techniques

Fierce Medical Imaging reports that although Radiology reimbursement has flattened out and perhaps decreased there are an abuncance of job seekers in Radiology.

1. Study: Two job seekers for every new radiology position

An analysis of the American College of Radiology job board suggests that for every job posted there are two radiologists seeking jobs, according to a study published online in the Journal of the American College of Radiology.

According to Anand M. Prabhakar, M.D. of the department of radiology at Harvard Medical School and Massachusetts General Hospital, while the general impression of the radiology job market has been "grim," there has been little research done tracking employment statistics. 

The researchers found that the during the study period, the mean number of new job seekers was 168 per month--twice as many as the 84 job postings found on average per month. 

No appreciable difference in the number of new job postings between 2011 and 2012 was found, while the number of newly registered job seekers ranged from 80 in May 2012, to a high of 418 in October 2010. October through November of 2010 represented one of the peak periods of job competitiveness (represented by the number of newly registered job seekers), along with August through November of 2011 and October and November 2012.

Consequently, the researchers concluded that there is a seasonal variation in interest in the ACR jobs board coinciding with the July 1 start date of fellowship training programs.

The study is a relatively short term study and in a period of rapid change with the Affordable Care Act and the imminent development of Accountable Care Organizations.

Radiology suffers from the same pessimism stimulated by reductions in earnings. 

In the face of what appears to be a shrinking job market, practicing radiologists have an obligation to those just starting their careers "to help them get through this difficult time," write David Levin, M.D., and Vijay Rao, M.D. in an article published in the April issue of the Journal of the American College of Radiology.

A report last year by physician recruiting firm Merritt Hawkins illustrates how job prospects have declined for prospective radiologists over last several years. According to the report, demand for radiologists--Merritt Hawkins' most requested specialty in 2003--ranked just 18^th last year.

The reasons for the fall in demand, according to Levin and Rao? Slowdowns in utilization and reimbursements; longer radiologist hours to maintain compensation levels (consequently decreasing the need to hire new radiologists); current radiologists deferring retirement; and the advent of picture archiving and communications systems and other digital enhancements that have increased efficiency.

Read more: How sacrifice today will save the radiology industry tomorrow - FierceMedicalImaging http://www.fiercemedicalimaging.com/story/how-sacrifice-today-will-save-radiology-industry-tomorrow/2013-04-12#ixzz2rcaXLkft
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