Stolen Records Deja Vroom
A laptop containing Social Security numbers for 4,599 state workers or their dependents, birth dates and, for some employees, their prescription drug history was stolen from a Medco Health Solutions worker. According to Newsday, the company delayed reporting the theft for six weeks. States have differing laws governing just what kind of speeding ticket should be written on medical records escaping down the information highway, but it's clear that digitization raises the likelihood of a quick getaway once the car is out of the garage. Just over a month ago, Oregon's Providence Health System admitted that it had lost 365,000 patient records (see our article Missing Persons: 365,000 Patient Records Stolen). [ HITSync top ]
Hospitals Ask Lawmakers to Invoice Payers for $268 Million for HIT Fifty-seven upstate New York hospitals are proposing state legislation to take $268 million from for-profit health insurers and put it into a Health Care Reinvestment Fund. The redistributed profits would be used to buy HIT for members of two hospital organizations, and would be paid in four annual installments of $67 million. Distributions to hospitals would be based on inpatient discharges.
According to the group, 2003 HMO profits in New York state topped $1 billion, while hospital losses were an estimated $383 million. According to the coalition of businesses and hospitals, providers cannot afford HIT investment because of reimbursement rates from payers which fall 18% to 25% below rates in nearby regions and other states. William Mooney, Jr., president of the Westchester County Association (WCA), conceived the HIT fund as a solution. "It makes perfect sense – from a community perspective and from a business perspective – to require for-profit health insurers to invest some of their enormous recent profits in improving the information technology ability of the hospitals" said Mooney. The idea was one of numerous imperatives noted in the white paper "The Need to Rebalance Market Forces for NY Suburban Hospitals and Physicians" (download it from the link in the right column on this page).
The Health Care Reinvestment Fund is patterned after the 1977 federal Community Reinvestment Act that forced banks make loans that targeted local community needs. A spokesperson for the 23-hospital Nassau-Suffolk Hospital Council, which joined with the 34-member Northern Metropolitan Hospital Association to push the legislation, said that a draft bill was proposed to lawmakers last week. As yet, the bill has no sponsor. Read the WCA press release. [ HITSync top ]
JCAHO Responds to Hospital Data Sales Complaints -- By Giving It Away? In an eloquent nose-thumbing to his provider critics, JCAHO's chief said in a March 6 press release: "In the current environment, the meticulous collection and meaningful portrayal of relevant quality data and information have become equally vital to hospitals, practitioners, purchasers, and the public... The Joint Commission is committed to doing whatever it can to meet these needs." Dennis S. O’Leary, M.D., president, JCAHO. (Emphasis is ours.)
We noted in a November HITSync that the JCAHO "executive committee will this week recommend to the JCAHO board that the organization cease selling hospital data analyses to third parties, following months of controversy over a data-mining agreement with Blue Cross and Blue Shield Association. While negotiating the data trading contract with BCBS, JCAHO was, only coincidentally, one would hope, demanding that hospitals begin in 2006 to provide patient-specific data to JCAHO's ORYX quality improvement database... JCAHO reported a loss from operations of $1.5 million last year.
Now this, also from the press release: "The Board of Commissioners also approved the immediate launching of a new Joint Commission public policy initiative that will address the development of a national strategy for the gathering, preparation, and dissemination of performance data.... This initiative will address the issues surrounding the creation of a national public utility for performance measurement data; the potential design of a national data system that could meet multiple stakeholder needs..."
So now they've got all that valuable data -- and they're giving it away for nothing? This in spite of being in the red. We are curious about what their 2005 Form 990 will say about income sources who might be funding this free program. [ HITSync top ]
BLESS YOU HIT Quote-of-the-Day "Oberösterreichische Gesundheits-und-Spitals-AG is the largest hospital operator in Upper Austria..."
~ From an otherwise arid SeeBeyond white paper titled "Implementing Health Information Technology for RHIO Success." (Translation: Upper Austria Regional Health and Hospital.)
Commercial HIT Software Vendors: Is Your Jig Up? "The jig is up for commercial vendors," said a Burton Group analyst last week in Computerworld. "They’re discovering that in certain cases open source software is basically pulling the rug out from under them by commoditising the market." Taking a page from the "If you can't beat'em" playbook, companies like IBM and Oracle are starting to buy into open source software (OSS). As any HIT worker can tell you, there are some vendors out there who couldn't find their jig with both hands, but we're talking about some veteran reinventors, here. The big guys are screaming "Oh-Ess-Aitch-Eye-Tee," but they aren't cussing, they're just using the unfortunate acronym that devolves from "Open Source Healthcare Information Technology." As the OSS movement takes away their ability to sell software by the byte, they're starting to sell implementation by the hour. In fact, they're out there buying up the firms that created the OSS and have tankfuls of expertise ready for bottling into consulting contracts.
Fresh Facts on Hospitals Kaiser Family Foundation's free online resource, Statehealthfacts.org, has just published new hospital data, shedding light on trends over the past five years. This most recent data shows a continuing general trend toward fewer hospitals nationwide, with a few states increasing slightly, and the more populous states (California, New York, Pennsylvania and others) declining in hospital numbers. Hospital beds per 1,000 Americans continued to decline -- 2.8 in 2004 down from 3.0 in 1999. These declines are virtually all in the nonprofit and government-owned sector, as for-profit bed counts have remained steady. Despite the aging population, hospital admissions have remained flat since 1999, even in Florida. Over five years, admissions are down slightly in government facilities, flat in nonprofit hospitals, and up slightly in for-profit hospitals. Across the three ownership categories, outpatient visits are up, inpatient days are down. There is, however a continuing rise in ER visits, from 365 per thousand in 1999 to 383 in 2004. [Source: The Kaiser Family Foundation, statehealthfacts.org. Data Source: Calculation based on 1999, 2000, 2001, 2002, 2003, and 2004 AHA Annual Surveys.] [ HITSync top ]
How Many Others? The Cost of OTH000 From HIT Transition Weblog: How can just missing a couple of numbers cost you over a quarter million dollars a year? When Medicare first announced that they were excluding the use of Surrogate UPINs in certain situations, we were worried about the impact on provider billing. There seemed to be a lot of exceptions to the "one doctor, one ID" ideal that lies behind any strict identifier requirement. What about residents? What about retirees? What about non-Medicare doctors? Clarifications from CMS provided some temporary reassurances -- we wouldn't face many of these hard questions until it was time to implement the surrogate-free NPI schema. Providers can still use RES000, RET000, VAD000 for the time being. The UPIN exclusion would apply only to OTH000 on Part B claims, and only in the Referring and Ordering provider contexts. This narrowing of scope resulted in a significant reduction in the overall impact of the policy. How much difference could it make if you were missing a couple of numbers? Well, one provider discovered that, despite their best efforts, it might cost them over a quarter million dollars a year. Read on... [ HITSync top ]
AHIC to Up Ante for HIT Role in Disaster Response Within a year, the federal government wants medical histories online for use by all emergency first-responders. Laudable objective, if overambitious. Better just call it a goal, for now. Post-wake-up-call buzz has HHS Secretary Mike Leavitt stumping for a slew of recommendations contained in Hurricane Katrina "after-action reports." (After-action reports or reviews are filed by local and regional agencies following a disaster, each one usually focusing on a particular local area. Google hurricane katrina after-action for numerous links.)
Ambitious goal, indeed. The ante isn't actually in the pot yet. The blue-ribbon AHIC (American Health Information Community) members have been cautioned not to suggest spending any money. Nope. Either this has all gotta happen for free, or the administration just wants to make sure that when it gets around to doing something, its funding proposal won't look pathetic next to some intellectual elite panel recommendation.
According to Healthcare IT News, AHIC has been asked to come up with recommendations on "breakthrough" projects designed to speed adoption of HIT, but HIT czar Dr. David Brailer "reminded AHIC that its charter does not include making recommendations on fiscal policies surrounding IT adoption. The group is charged with making recommendations, not implementing healthcare IT projects... He also encouraged AHIC’s workgoups to 'separate the difference between fact finding and making recommendations.'" [ HITSync top ]
Only 7 Real RHIOs? Q: What's a real functioning RHIO? A: One that's serving up records and, well, meets Forrester Research's definition. Forrester says they only found seven "up and running" RHIOs out there. These are exchanges that are serving a fairly large number of organizations or users. Named in the report are HealthBridge, Indiana Health Information Exchange (IHIE), Michiana Health Information Network (MHIN), Northwest RHIO, Philadelphia Health Information Exchange, SAFE Health Info, and Taconic Health Information Network and Community. According to Forrester, RHIO development will roll out much slower than advocates expect. The report points out pitfalls in moving from conception to reality, including large upfront costs and "transformational inertia." Forrester identifies three architectural models: Federated Database, Clinical Messaging, and Event Notification; and three governance models: Consortium, Corporation and Public Service. You'll have to drop $775 on the 15-page report for the definitions (though perhaps it will be worth it just to find out why they didn't count the Utah Health Information Network, which fledgling organizations rightly look to as a model for how to do RHIO right). Or you could check out the trove of free information at eHealth Initiative (who, by the way, can point you to upwards of 66 RHIOs). [ HITSync top ]
How much did you earn from Medicare last year? Or should I say, how much did you think you had earned?
RAC, Medicare's new cost recovery initiative, is rolling out in Florida, New York and California, with other states almost certain to follow. RAC stands for "Recovery Audit Contractor" and it refers to a firm that is hired to recover money from providers for claims that have long been settled. How? They'll use historical data and more sophisticated editing techniques to find "duplicate" charges, coding errors and procedures of questionable necessity. That should sound familiar to anyone that's been keeping up with my warnings about Denial Engine technology. If there was any doubt that these tools would take hold, Medicare has eliminated it by carving out a lucrative market for them in the federal budget.
"I'm from the Government, and I'm Here to RAC You." There are three tiers of audit under the program. The first involves Part A DRG reviews that require medical record requests; the second applies to Part A and B recoveries based on claims information alone, and the third involves Part B record requests. While all three audits could conceivably be triggered by a Denial Engine analysis, the second tier explains how the automation works:
The second level involves overpayments determined by the recovery audit contractor’s proprietary data mining systems. These are overpayments that clearly do not meet the requirements of Medicare policies. These overpayments do not require a medical record request because it is very clear that an overpayment has occurred. These overpayments may be for a Part A or Part B service.
It Could Be Worse -- It Could Be...Raining Medicare audits are nothing new of course. What's new is that the feds have gotten serious about it, the tools are sharper than ever, and the incentives are completely one-sided. Officially, RACs are tasked with detecting "overpayments and underpayments" -- but they are rewarded only for finding overpayments. Does the term "contingency fee" ring a bell?
And don't think that "provider relations" will be a mitigating factor. Your friendly neighborhood Medicare carrier, DMERC or FI is ineligible to become a RAC, though they will continue to play a role in handing over your data and deducting the recovery amounts from your revenue stream. As for the RACs? These junkyard canines are free agents.
On Your Mark, Get Set -- You Lose Unlike other Medicare demonstration projects, this one doesn't grant providers a learning curve. Providers in New York, Florida and California may be taking the hit now, but they're taking it for claims they billed over a year ago -- and up to three years ago. That means if you're not in one of those states, your lead time for getting ready expired sometime before the levees broke in the Ninth Ward.
Permission to RAC, Sir? And while we're waiting for that wave to hit, don't forget that the whole industry follows Medicare's lead. We know that Denial Engines are already being used by some payers, and that they're expanding their reach into clearinghouses and TPAs. But once the results from the RAC demos start being published, the market's perception of the tools could quickly turn from premium add-on to core functionality. Notice of Medicare's success could very well be interpreted by States and private plans as permission to follow suit.
Where Are We Going and What am I Doing in this Handbasket? If providers invested as much in IT as they spend lobbying in Washington, they'd already be prepared. But some will no doubt resort to the traditional legislative hand-wringing and the customary passive-aggressive public posturing in an attempt to minimize the impact of the RAC initiative. At a national level, that may be an appropriate response. After all, there's always more money for health care, right?
But for an individual provider, I'd recommend finding a vendor who can pull on the revenue rope from the other end.
______________________________ Martin Jensen is COO and Chief Analyst at Healthcare IT Transition Group, and serves as co-chair of the WEDI Business Issues and Health ID Card Subworkgroups. His standards development experience includes work with X12 on the 5010 versions of the Claims standard, and in leading multi-organization collaborative efforts. He recently served as team leader for the WEDI/HL7/X12/AFEHCT National Health Care Claims Attachment Survey and is engaged in the 835 Coalition, a national effort to improve the adoption rate of the 835 Remittance Advice transaction.
According to the group, 2003 HMO profits in New York state topped $1 billion, while hospital losses were an estimated $383 million. According to the coalition of businesses and hospitals, providers cannot afford HIT investment because of reimbursement rates from payers which fall 18% to 25% below rates in nearby regions and other states. William Mooney, Jr., president of the Westchester County Association (WCA), conceived the HIT fund as a solution. "It makes perfect sense – from a community perspective and from a business perspective – to require for-profit health insurers to invest some of their enormous recent profits in improving the information technology ability of the hospitals" said Mooney. The idea was one of numerous imperatives noted in the white paper "The Need to Rebalance Market Forces for NY Suburban Hospitals and Physicians" (download it from the link in the right column on 
