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One Step Closer Healthcare Shopping: Bush Signs Executive Order The Washington Post reports that the President signed an executive order requiring federal health agencies to collect and share information on healthcare quality and prices. The order affects the Defense Department's military healthcare system, Medicare, Medicaid, the Federal Employees Health Benefits Program, and the VA health system, all of whom will have to develop systems for measuring and tracking the performace of all providers paid through their programs, and then share that information between federal agencies and with the beneficiaries -- the patients. Estimated to take several years to implement, the initiative is promoted by proponents as a way to inject more competition into the care market, to reward providers who deliver high quality care, and to flag providers needing improvement. The order also mandates the use of electronic records within the affected federal programs wherever possible. Briefing reporters, HHS Secretary Mike Leavitt said that "Roughly 85 percent of all health-care records are still paper. So a part of what we'll be talking about today is the interoperability of systems that manage health records." Performance reporting, enabled by electronic records, is expected to spur price-comparative shopping among consumers.
According to Stephen Davidson of Boston University's School of Management in an Information Week article,
"These orders won't have much effect at all." The article takes the position that Bush's executive order is "unlikely to pump much life into health IT," stating that "Though it pushes federal agencies to use standards-based IT, it won't drive many reluctant doctors to adopt such software." Read our August 8 blog on the executive order. [ HITSync top ]
Hang on, Doc, Help Is On the Way
The Davis Wright Tremain firm, arguably the authoritative voice on health law in regard to HIT, explains the new Stark anti-kickback revisions published on August 8. Goaded by Congress, CMS and the HHS Office of Inspector General of HHS laid out new regulations designed to remove perhaps the most serious roadblock to adoption of EHR by physicians and other healthcare providers, who insist that cost is an unfair burden. Under the new rules, which officially become final on October 10, 2006, health systems may donate e-prescribing and EHR technology to physicians. [ HITSync top ]
Half of Middle-Income Families Have Serious Problems Paying for Healthcare
The U.S. gets a lousy report card from a new Harris Interactive survey on behalf of The Commonwealth Fund: Half of middle-income and lower-income families report serious problems paying for care and insurance coverage. Two-fifths of respondents reported experiencing unsafe, wasteful or poorly coordinated care. Three-fourths want sweeping changes -- or a complete rebuilding -- of the U.S. healthcare system. Respondents displayed a belief that wider use of IT could help improve care quality. The report finds strong public support for patient access to healthcare information. Download the full report. (Free) [ HITSync top ]
Missouri: On the Road to RHIO
Finding a way to pay for a statewide health information network is "a potential roadblock" in Missouri, according to The Kansas City Starlast week. A governor-appointed group charged with making better use of technology in healthcare says it will release its recommendations by Labor Day, but warns that they've just scratched the surface. The Missouri governor was recently instrumental in establishing a Healthcare Technology Fund.
One option the group is considering is the hiring of an outside consultant who could assist in developing funding, as has been done in other states. Panel member Karen Edison prefers to rely on local expertise, saying that "Healthcare, like politics, is local." The group may recommend establishing a nonprofit organization.
HIT state legislative activity is on the rise. According to the report, legislatures are recognizing value in connecting healthcare initiatives and IT. 38 state legislatures introduced 121 bills focusing on HIT in 2005 and 2006. During the past two years, 36 bills were signed into state law.
Governors are driving change. Ten executive orders have been issued by U.S. governors HIT expansion of various kinds.
State policy focus is on the creation of special commissions to develop HIT policy recommendations. 53 bills in 25 states call for special panels to conduct studies, file recommendations and develop plans for healthcare improvement based on HIT; 19 bills have so far passed in 14 states during 2005 and 2006.
State healthcare improvement initiatives are increasingly targeting HIT as a reliable means to achieve results. 12 such bills have been introduced in 9 states; 5 have passed in four states.
The number of states providing funding is on the rise. 15 bills were introduced in 11 states
calling for financing strategies such as government loans and grants; 7 bills in 6 states have passed to date.
27 bills in 16 states were introduced calling for authorization or appropriation of HIT or health information exchange-related funding; 8 have passed in 7 states.
States are setting target dates for HIT adoption. 3 states have introduced bills; 2 have passed.
RHIOs a-Poppin' in Tennessee
An article in Health IT World explores the remarkably advanced RHIO landscape in Tennessee. Perhaps the state's apparent health information network successes shouldn't surprise us. Its senior senator is a physician and the governor is the founder of an HMO. At the national level, Tennessee's senatorial delegation co-sponsored the Wired for Health Care Quality Act which would add $100 million a year to the NHIN build-out coffers. And then there's the state's experience with the Tennessee Valley Authority, which bears interesting conceptual parallels with today's RHIOs.
But Tennessee's health exchange projects are taking diverse approaches. Two are writing their own code, while another has adopted code from a Seattle RHIO. Another has already made it to live production -- MidSouth eHealth Alliance (MSeHA) is backboning live feeds from 12 hospitals. Innovation Valley Health Information Network (IvHIN) appears to be the most aggressive of all, planning to make tracks by "turning on the whole kit-and-kaboodle of electronic data all at one time," according to Johnny Walker, CEO of IvHIN's code partner, Patient Safety Institute, and they expect to throw the switch in just a little over a year.
The Health IT World article states that "Another difference is in privacy policies. IvHIN adopted a unique opt-in approach," asking patients to voluntarily share health information. The article didn't mention which of the state's RHIO projects IvHIN's privacy policy differed from, but other sources have noted that TennCare, the state's Blue Cross Blue Shield-managed Medicaid, elected to place its patient medical data onto an information exchange, thus creating Shared Health Inc., a RHIO that would serve all of its business partners. This would indeed represent a different kind of privacy policy, as one those partners is the commercial BCBS plan, which now has access to the state's Medicaid records. On August 6, Tennessee's Shared Health model was recently presented to a meeting of the National Governors Association (NGA) Health and Human Services Committee as the only solution with a "sustainable business model" ready for roll-out across the U.S. [ HITSync top ]
Florida's Bush Sorta Backs RHIOs
Florida governor Jeb Bush got pretty excited about the prospect of saving healthcare dollars by implementing RHIOs, so RHIOs became one of his pet projects. In the first year, Florida gave its fledgling Tampa Bay RHIO project $450,000 for a six-month pilot project, but slashed support for the second year to $360,000, far short of its $2.2 million budget for expansion. Where should the dollars come from? "We're going to reach out to private-sector employers," says Russell Thomas, who presented Tampa Bay's progress report to the governor. "They need to step up and volunteer both dollars and time to help us." The Tampa Bay project, which is phasing-in with early programs aimed at chronic care patients, plans to raise $350,000 in cash from the community and cover the remainder with in-kind contributions of volunteer hours and supplies. [ HITSync top ]
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Advocates Call For More Privacy Safeguards in EHR Laws
"We are not going to be able to get healthcare costs under control and improve quality without dramatic implementation of health [technology] over the next 10 years... That doesn't mean give the healthcare industry a blank check — we've got to have standards — but I'm afraid we're going to have to take some risks." Sobering but practical words from Robert Laszewski, a health policy consultant quoted by The Los Angeles Times last week. The article looks at ways in which the House-approved HIT bill has become a lightning rod for criticism from privacy advocates, consumer groups and civil
libertarians.
Dr. Deborah Peel of the Patient Privacy Rights Foundation said that the main concern is "that if this information leaks out to employers, it can destroy people's reputations and livelihoods." Some physicians are also concerned that without adequate privacy regulations, a data repository could be mined for nefarious purposes such as a "witch hunt" to discredit a physician with outspoken views on performance reporting.
A version of the bill was approved unanimously by the Senate in 2005, but the House version ignited passionate debate over a number of issues, including privacy. Republicans were able to squeak the bill through the House last month past strong Democratic opposition. A primary contention has been a provision that would require a rebalancing of privacy jurisdictions, moving the point of leverage from the states to the federal government. Federal privacy standards -- current and future -- have been expected to be more relaxed than state law, but the bill's proponents insist that a uniform national rule is needed for health record exchanges to ascend the NHIN ladder.
Privacy advocates may win some of the concessions they seek. Citing concerns over mid-term elections, a Government Health IT article notes that, of the 50 HIT bills before Congress this session, only one has much chance of becoming law, and both the Senate and House versions have been amended in deference to various pressures, with further battles expected as a law is finally hammered out.
The LA Times article notes the importance of getting these bills enacted, citing HIT-related cost efficiencies identified by a Rand Corporation study last Fall, which estimated $81 billion+ in annual savings. As use of the system spreads, medical practice efficiencies would arise, potentially saving another $346 billion annually. Perspective: If an average of $333 per month were made available to each uninsured American for insurance premiums, the cost of achieving 100% coverage would be a mere $184 billion annually -- or less than half the annual savings potential of widespread HIT. That leaves the other $230 billion+ annually toblowluxuriously on HIT capital investment. And the estimated $20 billion cost of handing every physician that doesn't yet have one a working EMR would be a drop in the bucket. While politicians bicker and various segments of the healthcare industry look to somebody else to foot the bill, 46 million of us go without health insurance, and every year between 44,000 and 98,000 die due to medical errors -- one human life every five or ten minutes -- and that's just in the hospitals. Tick...
Maybe the privacy mavens should start demanding just that kind of a compromise -- HIT legislation and a federal privacy law in exchange for universal coverage. You can almost hear the bill's chief proponents starting to huff. [ HITSync top ]
Where is RHIO Money Coming From?
Well, in Maine a goodly dollop is coming from the Maine Health Access Foundation (MeHAF). Health Affairs reports that by 2010, HealthInfoNet in Manchester, Maine expects to be “a cutting-edge, statewide network giving authorized health care professionals and treatment centers immediate, secure access to a patient’s health records,” according to a press release from the Maine Health Information Center, which houses the HealthInfoNet project. MeHAF gave the project a $1 million challenge grant over twenty months, and the organization is raising matching funds (MeHAF, YouHAF?) MeHAF was formed in 2000 with proceeds from the sale of Blue Cross and Blue Shield of Maine to Anthem Insurance Companies. Nonprofit HealthInfoNet has raised over $400,000 in matching funds for the challenge grant, including a $50,000 gift from KeyBank. Other fundraising has included $1.5 million over two years from private foundations, state and federal government agencies, hospital systems, a health plan, and a financial services organization. [ HITSync top ]
Blue Health Data Reaps Payoff of Standards
The St. Paul Pioneer Press covers Blue Cross Blue Shield of Minnesota's participation with 19 other Blues plans in an initiative to leverage the intelligence in patient data to lower costs and increase the effectiveness of care. The new system, dubbed "Blue Health Intelligence" goes into testing this year, with a rollout next year. According to the article, patient identification will be concealed, but suggests provider information may be included: "Although patient names and other personal identifiers are stripped out, specific doctors with their treatment patterns typically are identified when insurers mine their databases for information." (Note to the folks in Chicago: You'll want all the NPI granularity you can get in that data.)
The Pioneer Press article points out that the data can be used for research purposes as well as patient care and cost control. "What sets Blue Cross's effort apart is its size — it's twice the size of the Medicare database." From a healthcare IT perspective, what makes the data valuable is that standards have enabled the normalization of data on tens of millions of people... (Click to continue reading...) [ HITSync top ]
CMS has some bad news for all the provider organizations who decided the easy way to enumerate their NPIs was to break into subparts according to their existing Medicare numbers. ("Five Medicare numbers? We'll just get five NPIs. What could be easier for CMS than a one-to-one match?")
That approach, it seemed, should keep the provider's giant Medicare claim volume safe while creating problems only for those pesky commercial plans that wished for one NPI per tax id number.
Medicare has some news for such accommodating provider organizations. You're also going to have to send the appropriate Provider Taxonomy code [see MM5243] -- at least on institutional claims.
Let me try to explain what that means in English.
Multiple Provider Identity Disorder
Most medium-to-large hospital campuses consist of more than one type of unit: It may have an inpatient acute care facility, an outpatient surgery wing, a renal dialysis service, a psych unit, a rehab unit, etc. Often, these areas of service function under a common Tax ID number (TIN), receive mail at the same address, may do business under the same name and even occupy the same building. Traditionally, Medicare has enrolled these units as if they were different entities and assigned each its own Medicare ID ("OSCAR" number).
Other payers, notably some Blue Cross/Blue Shield plans and Medicaid plans, likewise used their own power of the purse to dictate custom provider numbers. They might start in rough alignment along Medicare's subdivisions, then improvise new variations according to their particular regulatory or contracting needs.
Meanwhile, most commercial plans use simpler (but less precise) identifier schemes, such as TIN, or TIN combined with elements of other provider information. When they need breakdowns, they sort out the details using the data internal to the claim (type of service, procedure code, member id, etc.).
Getting a Handle On Taxonomy
That's where taxonomy steps in. The provider taxonomy code list offers a way to indicate category and specialization (for an individual provider) or facility/unit type (for organization providers). Provider Taxonomy can be added as a required element of the 837 claim at the discretion of the receiving health plan. Until now, most payers, including Medicare and the majority of Medicaid plans, did not require them.
Here's a sample from the current code list:
Hospital Units
Medicare Defined Swing Bed Unit - 275N00000X
Psychiatric Unit - 273R00000X
Rehabilitation Unit - 273Y00000X
Rehabilitation, Substance Use Disorder Unit - 276400000X
Hospitals
Christian Science Sanitorium - 287300000X
Chronic Disease Hospital - 281P00000X
Children - 281PC2000X
General Acute Care Hospital - 282N00000X
Children - 282NC2000X
Critical Access - 282NC0060X
Rural - 282NR1301X
Women - 282NW0100X
Long Term Care Hospital - 282E00000X
So Medicare seems to have decided that taxonomy is the fix for the problem of one-to-many NPI-to-OSCAR number challenges. But however that fix was architected, the decision was made to require taxonomy even when it wasn't necessary for crosswalking -- i.e. the one-to-one NPI-to-OSCAR situation.
In a Perfect World, All Dogs Would Be Named Rover
Why is this new requirement so taxing? Initially, it doesn't appear so difficult in the institutional claim, where it applies only to the Billing/Pay-To Provider and the Attending Physician.
Except that what value you plug in can depend on which department originates the claim, which hat the physician happens to be wearing, and, what's most vexing, which payer is receiving the claim. Medicare may want you to code certain claims as Medicare Defined Swing Bed Unit (275N00000X), while Payer B's system will burp if you don't refer to your entire operation as General Acute Care Hospital (282N00000X). That requires the application of payer-specific logic to your outgoing taxonomies.
Pretzel Logic
How specific must that payer-specific logic be? Well, according to Medicare, the swing bed logic works like this: Look in the third position of the OSCAR code for a U, W, Y, or Z. For type of bill X8X, use one of the following to show type of facility in which the swing bed is located: 275N00000X short term hospital (U); 282E00000X long term care hospital (W); 283X00000X rehabilitation facility (Y); or 282NC0060X critical access hospital (Z).
And how about this logic? For Hospital Based Satellite Renal Dialysis Facilities (OSCAR number digits 3 through 6 are 3500-3699), Type of Bill 72X and taxonomy code of 261QE0700X and a zip code different than any renal dialysis facility issued an OSCAR number that is located on that hospital’s campus.
Oh, that's a relief. I was afraid there would be math.
A Web of Hoops
If you're a provider, you are probably willing to jump through such flaming hoops for Medicare, but what happens when payers large and small start insisting you apply the idiosyncratic provider taxonomy "logic" that will make their systems work? (Yes, I really do know of a certain payer that required ER submitters to code all their physicians as "Family Practice.")
We know of at least one large (very large) billing software vendor that is said to support only one taxonomy code per system. There's a big conceptual chasm between that ultra-minimalist capability and the payer-specific incendiary-hoop-jumping logistical provider taxonomization engine anticipated by the Medicare requirements. Wait till the other payers start posting their taxonomizing schema! (Since Medicare has shown its hand, expect the other plans to follow.)
When they do, print them out along with MM5243, then stack them into a single folder, carry it to your software vendor (and clearinghouse), and say, "Got any idea how ya gonna make this work?"
Let No Good Enumeration Go Unpunished
Pretty straightforward so far. Right?
What some do NOT understand is why the providers that caved in, er, acceded to the implied threat in Medicare's "expectations" document -- and enumerated their NPI subparts along Medicare's existing OSCAR demarcations -- will still have to modify their systems to send taxonomy as if they had not.
What Would Work
What would work -- better, at least -- is if all payers took a "last resort" approach to taxonomy: Ignore the taxonomy that was sent (if any!) unless it was actually needed to identify that particular provider in that particular context. But this would require complex logic on the payer side: If NPI does not yield unique OSCAR number, then check NPI+Taxonomy.
I guess the logic of forcing providers to do the work really is simpler. As long as you're not the provider.
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Prior HIT Transition Blog Posts on Taxonomy:
The Answer Is: "For that you would need a taxidermist."
NPI Contestant: How do I know what taxonomy code to use?
...And what of Taxonomy? That situational bane of everyone's existence might come over the hill at the last minute to save the day. Or it might really foul things up, if payers assume they can “assign” them to providers, in violation of code usage specifications. NPI Implementation On Jeopardy? Answers from the WEDI NPI Hearing in Chicago http://blog.hittransition.com/2006/04/npi_implementat.html
"I seriously doubt that most provider systems will be ready to send it via the complex ways necessary to match payers' undiscovered needs and unexpressed expectations." Valentine from Uncle Sam: NPI Is HIPAA Deja Vu http://blog.hittransition.com/2006/02/valentine_from_.html
______________________________ 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.
