NCVHS to Advise NPI Contingency Tie to Data Dissemination?
Just received a notice from a colleague attending the X12 meeting that a CMS official reported to the group that NCVHS (advisory body to HHS) is considering a contingency plan for NPI. According to this account, they don't want to encourage laxity in the deadline, but do want to ensure that end-to-end testing takes place before the final cutover to NPI-only transactions. To this end, the current thought is to tie a 6-month timeframe to the availabiltiy of NPPES data via the still-to-be-announced Data Dissemination Policy (DDP). What do we know about that?... Click to read more... [ HITSync top ]
In his State of the Union Address this week, Bush stated that "A future of hope and opportunity requires that all our citizens have affordable and available healthcare," but limited government's responsibility to "the elderly, the disabled, and poor children." The young, middle-aged, able-bodied middle class and their children are to purchase private health insurance, through a variety of complex and indirect mechanisms at both the state and federal level.
The solution? Tax cuts, of course. The President proposed tax deductions for those who can afford health insurance: "Families with health insurance will pay no... payroll taxes on $15,000 of their income. Single Americans with health insurance will pay no income or payroll taxes on $7,500 of their income."
The President also proposed "Affordable Choices" grants to encourage health coverage incentives to be offered by the states, expanded HSAs, assistance for businesses through Association Health Plans, medical error reduction through HIT, increased price transparency, and medical liability reform. See the AHA reaction.
A certain cable news channel has begun analyzing the body language demonstrated by interview participants based on video clips. This year’s SoU feed gives us a window into the upcoming legistlative session, with Vice President Cheney, and House Speaker Pelosi demonstrating real time response immediately behind the president. Never one to buck a trend, HITSync offers its own point-by-point analysis of their relative gestural enthusiasm in response to Bush’s healthcare proposals. Click here for healthcare transcript and response chart, with links to video. [ HITSync top ]
NPI and Real Time Adjudication Gatherings
WEDI conducts its Sixth NPI Industry Forum, "For the Love of NPI," on Monday, February 12 2007, in Herndon, Virginia. In conjunction, WEDI and ASC X12 will holds its a Real Time Adjudication Forum Conference on February 13 and 14. Healthcare IT Transition Group's Martin Jensen will participate in these sessions.
These fora are where policies are dissected, criticized and advocated at the national level, offering anyone in the industry the opportunity to effect change. You can register for one or both of the topics. The NPI forum will discuss:
Data Dissemination and Industry Updates
WEDI NPI January Industry Readiness Survey Overview
Health Data Stolen... Again and Again The Boston Globe reports that the health data of 130,000 Aetna members was stolen when a lockbox containing backup tapes disappeared. Deja vu: This week we learn that another lockbox containing backup tapes went missing from vendor Concentra Preferred Systems, resulting in the theft of the health information and SSNs of 28,279 Nationwide members.
Can't help wondering why this keeps happening. First laptops, now lockboxes -- both rather too portable. Convenience stores have their clerks drop their little rolls of money -- about the size of backup tapes -- down a chute that plunks it into a fortified safe that can only be opened by certain people at certain times. That's duh number one.
Duh number two : Free software can be downloaded that encrypts the data on a laptop so strongly that even the government can't get it off. What's more, the same software makes it possible to hide even the fact that encrypted data is present, so you won't be kidnapped and forced to decrypt anything. (Check out the free, open source, easy to use TrueCrypt software at www.truecrypt.org.)
Blue Cross Funds HIT-based Diabetic Care Plan
Regence BlueCross BlueShield of Oregon has seeded a project with a $45,000 grant to provide a family physician group with the EMR technology needed to implement improved diabetic care. Reports Healthcare IT News, Regency's chief medical director says that the grant is intended to play "a constructive role in repairing our healthcare system... The outcome is to reframe healthcare." Pretty ambitious for a little bitty grant. But there’s plenty of room for improvement, and we wish them all the best in furthering the cause. Chronic care management is one of the areas benefited most by electronic medical records, which provide the structures necessary to track disease over long time periods and to prevent crisis through early interventions. [ HITSync top ]
It's Really, Really Hard, But Now It's Solvable
Interoperability (how many other eight-syllable words can you rattle off real quick?) is the key to getting enough medical data within reach of providers that they can prevent medical errors, figure out treatments earlier, and, of course, get paid quicker and with less hassle. So what's holding us up? Let's look at just one tiny piece of the problem... You have data in one system in a flat file with a multiple records for each patient. Then you have another system that operates on a relational model with a slew of tables. And then you've got some others that are also relational databases, but they all normalize the data differently. Worse still, they sometimes use the same terms or codes but apply different meanings.
What you have here is a lack of "semantic interoperability." Let's get really specific: it's a lack of an "ontology," that is, a structure by which all these different constructs can be resolved into stream of data. The problem isn't just in healthcare, of course. And there are games afoot to solve the problem. A couple of very interesting projects are the World Wide Web Consortium’s (W3C) Semantic Web Health Care and Life Sciences Interest Group (SWHCLSIG -- pronounced "Swickle Sig"?) and the Health Information Technology Ontology Project (HITOP), both launched in 2005.
Government Health IT reports that the hard part is building awareness in the healthcare community about the need for semantic interoperability. Says Marc Wine, chairman of HITOP, the field has finally begun to understand that it "should become an integral part of the mission for making electronic communication in health care accurate, efficient, reliable and secure."
So, where's the lttle widget that just takes in all your system's particulars and spits out an ontology? Well, I'm glad you asked. Stanford University has developed an "ontology editor," dubbed Protégé, that may be just what the doctor ordered.
Citing advances in bandwidth, computing power and semantic knowledge representation, Charles Mead, a senior associate at Booz Allen Hamilton, stated that "The good news is that it is now a solvable problem. The bad news is that it is really, really hard." [ HITSync top ]
No Medicare Cuts, In Fact, New Itsy Bitsy Incentives!
The government giveth, and she taketh away. And sometimes she just hands out samples. Like those pharmaceutical cheerleader reps, the federal government is getting its foot in the door with some give-aways. "Just five minutes of your time, doc, and I'll load you up with a 1.5% P4P!" Which is to say, not much of anything. But, heck, it's free! Right? Um, well, yes, if the physician participates in a "voluntary quality reporting system" he can boost his Medicare reimbursements. Of course, there's a catch: Unless you've implemented an EMR, that quality reporting is gonna tie up quite a few staff hours. Okay, it's a step in the right direction.
Also in the legislation: Physicin payments are frozen through 2007; the maximum Medicaid provider tax rate is established at 5.5%; a reduction of 2% in the annual update for outpatient services provided by hospitals and ambulatory service centers failing to report certain quality measures; and other mesures. [ HITSync top ]
Universal Healthcare: Conspiracy of the Left and Right
The demand for universal healthcare in the U.S. may be growing, says an article in the Boston Globe. Seeing the Massachusetts plan as a "structural model," federal lawmakers are dusting off some notions they had abandoned back in the early 1990s. States the Globe, "Healthcare specialists and government officials across the political spectrum say the healthcare debate has reached a turning point, with both liberals and conservatives ready to compromise."
With Massachusetts' Mitt Romney - one of the co-creators of that state's high-visibility experiment -- eyeing the 2008 presidential campaign, and with the expected strong presence of Hilary Clinton in that race, universal health is certain to be standing at the top of political platforms. The Globe quotes Ed Haislmaier, a healthcare specialist with the conservative Heritage Foundation, saying "It's a conspiracy of the left and the right." Read a related article in USA Today. [ HITSync top ]
Payers use Denial; Don't You Wish Everybody Did?
Like Microsoft's ubiquitous desktop suite, your EHR software will soon be ratting on you. But not to prevent software piracy. Instead, new software certification guidelines will require that electronic health records systems contain embedded "fraud-detection" mechanisms. In order to achieve CCHIT certification, EHR software makers will have to make your computer tell on you if you slip up. This could be a good thing, or a bad thing.
As always, the project couples “fraud” (objective term) with “improper payments” (subjective term). In effect, the same claims denial software that helps curb fraud can be and is used to flexibly regulate claim payouts for non-fraudulent claims. Payers use these systems to "throttle" payments, cutting back as far as the traffic will allow, by selectively enforcing denial-generating edits.
Makers of Denial Engine systems research all of the possible means by which a claim could be denied, amounting to literally millions of edits. It would be hard to imagine that all of the edits would ever be enforced at once, otherwise the payer would incur a provider revolt. But let's say one week's claim payments exceeded some desired maximum; next week they can throttle back by engaging more of the edits. Not only can the throttle control which edits are in force, but also for which types of providers.
Now here comes the notion of an anti-Denial Engine that resides on the provider side of the transaction. This could be very useful to providers. Theoretically, as long as the same logic is in effect with the payers (not awfully likely), providers would be able to test, adjust, retest, readjust until a claim was squeeky clean enough to slide through the tightest edit matrix. The caveat, of course, is that throttle. Remembering that there are enough edits available to squeeze health claim payments off to a dribble, you can't let your software consider every edit or you'd submit far too few claims. You'll never know which ones a given payer is enforcing on a given day.
For that reason, the idea of a provider-side Denial Soap isn't likely to be up to the task. On the other hand, such a system rooted within a clearinghouse may be really powerful. Clearinghouses see the claims traffic from enough provider/payer axes that inferrences could be made, potentially changing programmatically in real time, about the settings of each payer's throttle. In theory at least, clearinghouses could clean up on Denial Soap. In the meantime, let's keep a skeptical eye on the word "fraud." [ HITSync top ]
editorial
Marty's HIT List 2007
By Martin Jensen, COO, Chief Analyst, Healthcare IT Transition Group
Not necessarily predictions, these ten items constitute my “Watch List” for Healthcare IT in 2007. Some developments are likely, some are hopeful; others may be merely expressions of dread.
Money for HIT? The shift to a Democratic congress will see an increasing emphasis on privacy issues, but may also mean a more serious economic evaluation of individual HIT initiatives, and perhaps even a re-examiniation of the overall stance of the Federal government toward HIT as an enabler of expanded coverage, reduced costs and improved quality. Might they even be willing to put a substantial amount of money toward funding the intellectual infrastructure by issuing grants for standards development and pilot projects? Rep. Nancy Johnson's (R-CT) departure from house leadership will leave a vacuum for others to fill.
HIT may be an issue around which a bipartisan coalition can form -- and prove that the congress can actually get something done for the benefit of its constituents.
Hillary Bill, Take 2. The entrance of Hillary Clinton into the presidential race will take universal healthcare off the back burner and put it into campaign platforms. Oops – and don’t forget Mr. Obama!
Me First! Other candidates, Republican and Democratic, will need to push forward their own disparate plans to bring healthcare to most or all Americans. The Massachusetts approach, which Republican Governor Mitt Romney fought until the last moment, will become the "Romney Plan" as he moves toward the front of the line of Republican contenders. The truth of the issue -- that the collective health of all Americans is both a matter of national competitiveness and national security -- may actually see light in the campaign.
HIPAA Contingency – The Sequel. The National Provider Identifier (NPI) implementation will limp toward the May 23 deadline, crutched up by the inevitable contingency. If history does indeed rhyme, look for a CMS announcement in late March or April. But it may be mooted by the rest of the industry's grasp of reality.
Unlike the October 2003 HIPAA Transactions Rule, payers aren't waiting for Medicare to move first. Some Medicaid plans have already announced that their systems aren't going to make the deadline. A good part of the holdup can be laid at the feet of the onging delays of CMS's Data Dissemination Policy. A hopeful regulatory agenda estimated that CMS will let us know who can see the NPI data under what terms in January. But an unconfirmed rumor sets the more likely date to April. Gee, do you think the healthcare industry can implement the NPI Final Rule without NPIs?
NPI! Says Who? In terms of Medicare, the nation's largest payer, the NPI question becomes one of pragmatics vs. principle. Will Medicare's own implementation challenges lead to workarounds that eclipse the original provider-simplification intent of the NPI Final Rule?
Tip 1: CMS says practitioners employed by Covered Entity provider organizations may not themselves be Covered Entities (and thus not subject to mandated enumeration).
Tip 2: CMS put a lot of the implementation details in the form of FAQs, which supplement, expand and modify the language in both the NPI Final Rule and the X12 Implementation Guides -- and these FAQs are themselves frequently added, modified and rescinded without public review or comment.
Tip 3: Medicare is said to be renaming its provider numbering systems (including OSCAR and UPIN) as "certification numbers." Why is that important? Well, if the NPI Final Rule eliminates the use of proprietary provider numbers, then defining your numbering scheme as something other than a provider number may free up its use for "other purposes" within the context of a standard transaction. Will providers put up with this regulatory sleight-of-hand? Since most of them still don't have a clue that the NPI Final Rule was supposed to (eventually) make their lives easier -- in some cases they have even lobbied actively against rational implementation -- don't expect to see doctors marching on Washington to demand that CMS comply with its own rules.
Many HIT Returns. Standards will continue to quietly reduce friction and create opportunities in the marketplace. You might see some actual national ROI numbers, but the real evidence will be the increasing merger-and-acquisition in the HIT vendor community, as investors see the immense revenue potential (a potential that somehow continues to elude many in healthcare executive suites). Likewise, vendor offerings will go downmarket, with more sophisticated tools being offered to smaller providers, now that they don't need an IT staff to keep them running.
Many will take the application service provider architecture (or whatever we call it these days), approach. After all, nobody wants to be sending techs onsite to maintain that server by the coffee pot in the chart room. Take a double-click and call AOL in the morning.
Real Time Adjudication Will Become the Next Big (Administrative) Thing. Sure, the clinical folks will be slugging it out over EHR/PHR and CCHIT non-interoperability specifications. And the NHIN crowd will be trying to connect the “Network of Silos” established by all the state and regional RHIOs. But what is there for those of us that have been working under shadow of the HIPAA mandates for administrative transactions? No fear – Real Time Adjudication (RTA) is being driven by market forces to the top of the priority list. RTA will address the dysfunctionalities imposed by the CDHC, HDHP and HSA initiative (Consumer Directed Health Care, High Deductible Health Plan and Health Savings Account, respectively).
Providers want RTA so they can capture the correct patient responsibility amount while the patient is still in the office; Payers want the Providers to have that information because they know that if providers have to wait, a lot of those dollars will go uncollected – and will lead to higher contract rates in succeeding years. Vendors, banks, credit card issuers – heck, they just want a piece of the action. That explains why the WEDI/X12 session on RTA has turned out such an impressive list of participants – including HITTG.
Provider Clue Delivered; Charge Deducted. Last year, my tongue was firmly in my cheek when I predicted that providers would “Buy a Clue” regarding HIT. This year, in part due to the expansion of the Denial Engine phenomenon and the willingness of both private payers and the federal government to pull more money out of providers’ pockets, The Clue will be delivered and its price deducted from each month’s remittance. Luckily, most providers have nowhere to go but up, since they still lag in adopting the cost-reducing and revenue-enhancing HIPAA transactions, much less implementing the more sophisticated tools that are being made available.
Employers Quit, Win. I’ve argued that doing away with America’s employer-sponsored health care system is critical to overturning the huge, costly system that leaves over 40 million of us without healthcare coverage. Turns out, some folks seem to agree with me, including some employers, private health plans, states (as employers, at least) and George W. Bush?
Er, the NY Times quoted Paul Fronstin, director of health research at the Employee Benefit Research Institute, a nonpartisan organization: “The president’s [State of the Union] proposal would mean the end of employer-based benefits as we know them. It gives employers a way out of providing the benefits because their employees could get the same tax break on their own.” Okay, so I didn’t say the table cloth could be pulled out without spilling a few wine glasses, did I?
HIT Skills Drive Bidding War. It’s already started happening. In the past few months, colleagues with enviable positions in large corporations are showing up in my inbox with “change of address” emails. What’s luring them away from cushy (if demanding) corporate careers that offer them plenty of perks and prestige? Well, I’m guessing money has something to do with it. The old “We can’t give you a $10,000 raise but we can buy your time from a consulting company at three times your salary” principle of corporate intelligence is surely at work here, as is the “Our pay grade policy can’t let us give you more than your manager” valuation stratagem.
How about the “Look for ‘Company Loyalty’ just after ‘Company Layoffs’ in your Employee Handbook” index? All this, and stock options too. I wish them all luck.
How did we do last year? Check out our 2006 HIT List and see.
______________________________ 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.
Marty recently served as team leader for the WEDI/HL7/X12/AFEHCT National Health Care Claims Attachment Survey and is currently involved in state Medicaid remediation and working with HIT software and services companies on implementation of the National Provider Identifier.
