Healthcare Policy Getting Reimbursed: Its Complicated

Billing and Delivery for health services has become extremely complex. Although fee for service (volume-based care) is deemed to be on it's deathbed by proponents of payment for quality of care and outcomes, the complexity of obtaining a payment becomes more of a juggernaut. This is occuring in the face of  a system that is not ready to convert to accountable care organizations. The infrastructure for such a conversion is completely absent. The marketplace has abundant vendor offerings.  
Although the majority of health providers now are using electronic health records and are required to be certified for meaningful use, many providers are ignoring these standards.  Interoperability remains a major hindrance to  connecting all the systems of an accountable care organization

In order to address this issue and many others take this course.

You will learn about:

• The relationship between healthcare expenditures and provider compensation.
• Payment models under Medicare and the Affordable Care Act.
• The future distribution and cost of healthcare services

• Define the 3 types of provider payment schemes.
• Recite the types of national healthcare expenditures and the proportion that each contributes to the total spending.
• Compare the compensation for US and international physicians as a multiple of gross domestic product per capita.
• Describe the methods by which Medicare determines physician payments.
• List the provider components of a healthcare delivery system.

• Describe how healthcare services will be distributed in the future.
• List the types of costs associated with healthcare delivery.
• Describe bundled payments under the Affordable Care Act and how bundled payments are different from prior programs such as global surgical fees.
• Define the incentives to achieve Medicare bonus pay within a Pay-for-Value program.
• Review the concepts in the case studies.

Health Care Policy: Delivery and Payment

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.

HealthCare.gov Online User Experiences

Similar to the roll out of Covered California, the nationwide Health.gov exchange was even more flawed and unreachable for more than one month.

Short Videos of Users on the HealthCare.gov Website

The brief videos below highlight some of the challenges faced by the study participants outside California as they used the federal HealthCare.gov website to enroll in health coverage under the Affordable Care Act.

• Positive Impressions: Participants had anxiety about applying for health insurance and were surprised and relieved by the ease-of-use and clean look and feel of HealthCare.gov. Watch Video
• Quitting Points: There were several points at which participants abandoned, or would have abandoned, the online process to seek phone or in-person help. Watch Video
• Areas of Uncertainty - General Context: Participants were unsure about some ACA concepts such as "deadlines" and "tax credits," and they didn't always find adequate explanations or help. Watch Video
• Areas of Uncertainty - Site Elements: Some participants had challenges providing income and household information, logging into the system and navigating through certain parts of the site. Watch Video

The Affordable Care Act expands coverage options and provides an opportunity to streamline the enrollment process in public and private coverage. CHCF funded an assessment of HealthCare.gov to identify actionable ways to improve consumer experience with online enrollment.

The assessment uses a methodology not common in the public sector — direct observation of consumers as they move through the website. This technique captures sources of consumer satisfaction, knowledge, confusion, and frustration. The most compelling findings relate to assisting consumers with plan shopping and selection, providing adequate help throughout the process, and ensuring accuracy in consumers' responses to application questions. The report concludes with researchers' recommendations for improvement.

Compare these findings with those of  Covered  California in our earlier blog post.

The California Health Care Foundation also published a study of Health.gov for comparison of states using the national Health.gov website.

Both reports illustrate the poor design and performance characteristics of sites not ready to 'go live'.

Were this a private enterprise it would have stood little chance of success. Supervision and implementation were poor from the bottom to the top of the chain of command.


Health.gov User Experience  download

Referral Network in the Digital Age, and the Affordable Care Act

How do you build your referral network ?

How can your practice stand out.  What is your HUMP DAY ?

Most of us when beginning a medical practice would contact established physicians, and meet them personally, handing out a curriculum vita and business cards, then sit, hope and wait for referrals.

Today young physicians immediately sign up for any health insurer or health plan to join  their network  of providers. They will accept plans that have good reputations and avoid the ones with less quality. Young providers may even seek out word of mouth from fellow practitioners to select those that pay promptly and fairly.

What Triggers Word of Mouth?

How important is this tested by time methodology for building a medical practice following? Your medical services are a  product, and can be marketed in many ways the same as merchandise. This of course is anathema to some professionals.  However given the current state of transition in the marketplace of health care, such as accountable care organizations, and the affordable care act it is still foolish to depend upon a laundry list of providers and their networks.

The Power of Word of Mouth

Word of mouth drives all sorts of products and ideas to catch on. It’s 10 times more effective than traditional advertising and shapes everything from the products people buy to the services they use. But why do people talk about some things rather than others?

Generating word of mouth or getting something to go viral sometimes seems like magic. Like catching lightning in a bottle. But it’s not. There’s a science behind it. Triggers are only one of the six key principles that drives all sorts of things to catch on. Understand that science, and you can make your own services and ideas more contagious.

Those who are new to a community will often ask social contacts, church members or get a referral from the local medical society. The truth is that most patients have no idea of who the preferred and/or best qualfied physicians are in the community.

The final decision may be the result of a combination of word of mouth, direct referral from a friend, accessibility and a prompt appointment. Demographics play a large role in obtaining health care. A geriatric medical clinic would use methods different from a pediatric clinic. Subspecialist practices can market to consumers directly, or if in a monitored network...social networking with referral sources directly may be more effective in building your network.

Generating Word of Mouth

The best thing about word of mouth is it is available to everyone. It doesn't require large amounts of capital, it just requires people to talk. The challenge is how to start people talking. It just requires people to start talking, and how to make your message(s) stand out from the noise.

Today, social networking includes social media using Facebook pages, Google + pages and Linkedin ( a network of professional colleagues), and their are medical interest groups to join that narrows your interest to your target population. There is a variety of lesser known social media platforms such as Digg, Pinterest, Delicious, or Newsana. A professional blog with RSS feeds and a subscription tab also can be a resource for your practice. Backlinks, which are links between different platforms also enhances your visibility. If you are using social media the understanding of hashtags and their use magnifies and focuses your audience.

There are a large number of tutorials and courses covering these subjects. Finding an expert in social media is not difficult.

What are the limitations of Social Media?

When asked, most will estimate that social media accounts for 50% (average) of chatter. However 50% is wrong ! The actual numbere is 7%. Research by the Keller Fay Group fins that only 7% of word of mouth occurs online. This figure may not represent certain demographics, such as an age group 11 to 30, where use of social media is greater than 7%. Now even that may be changing as older adults use social media much more in the past four years as social media platforms have expanded in quality and quantity. There is also significant churn ie, those entering and departing the social media niche.

These details are in much greater detail in a book by Jonah Turner, CONTAGIOUS, WHY THINGS CATCH ON

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