2014: A Healthccare Year to Remember

This year is action-packed with policies, mandates and programs to keep physicians, hospitals and healthcare consumers all busy and wondering what they need to do or how they may be affected. In this article, Dr. Jitesh Chawla explores of the key programs and legislation that will start up in 2014.

Health Information Exchanges

One on-going problem has been that different healthcare institutions have different IT systems. The fact that the average patient in the US moves through various providers over the course their healthcare treatment life cycle poses a problem for continuity of care as information about their past is often not available in real-time to their current provider. Meaningful Use requires system to be able to exchange data with each other. Standards such as HL7and CCR/CCD have been created. In fact, national networks such as NHIN and programs such Direct Project enable a national information highway. However, it is also at the state level that such data transfer needs to happen and health information exchanges (link) have been setup. Dr.Chawla has the opinion that patient privacy and HIPAA compliance will be of paramount importance as patient data is sent and received through the cloud. For more information about the topic, please go to http://www.healthit.gov/providers-professionals/health-information-exchange.

Health Insurance Exchanges

You all have probably heard in the news for the last several months how the Affordable Care Act legislation has mandated that everyone sign up for health insurance or face penalties. This effort, dubbed Obamacare, will have profound effects on the population. For one, today is the first day that people are using these exchanges and must have signed up for them by end of Dec 2013. The idea is to offer plans that anybody can afford. The government wants even healthy individuals to take insurance so as this will ensure subsidies to finance the sick. Other stipulations include penalties for businesses that don't sign up their employees. The penalties varies depending on the size of the businesses. Jitesh Chawla, MD feels that without acheiving the individual mandate and a national healthcare insurance system, these efforts will be short-lived and lead to only minor curbing of the unfair advantage of patients that insurers are taking.  For more information about the topic, please go to http://www.dummies.com/how-to/content/healthcare-reform-2014-mandated-coverage-insurance.html.

Meaningful Use Stage 2

Meaningful Use is a term referring to the recording and reporting of certain data by providers and hospitals to CMS in order to get extra money in their Medicare or Medicaid payments or avoid penalties. The program is divided into 3 stages each of which run, on average 2-3 years in length. For this second stage, new requirements such as emailing directly with patients, bringing up radiology reports with the EMR and entering data into speciality registries (ie. cancer, etc.) may be challenging and new for many people. Furthermore, extra expense and re-training is needed because EMR systems will have to be upgraded to allow the extra features needed to perform these functions. Dr. Jitesh Chawla feels that MU 2 compliance will be low and the standards may be lowered or another year will be added to allow time for better compliance. More information about the topic can be found at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html.



These are just some of the changes proposed to take place in 2014 that will affect provider, hospitals and patients. There are still other programs such as PQRS, MPPR, etc.that we won't have timeto discuss in this article but are important and you should know about. The best way to be ready is to understand what is expected of you through this article and links given and work with your local RECs, consultants or experienced office managers to devise a plan for compliance. Dr.Jitesh Chawla feels that though 2014 may be a year of many firsts for healthcare in the US, providers, hospitals and consumers will still be able to financially survive and make it work.

Emergency Care under Obamacare

Dr. Jitesh Chawla speaks from personal experience as a physician who as frequently worked in emergency rooms/  

   "Packed waiting rooms and we will have to see 50 patients or more in a shift," answered one emergency room physician.  This was in response to my question of how the Affordable Care Act will affect the volume of patients that a provider in the ER will see.  Many experts speculate that the expansion of Medicare under “Obamacare” will allow more people in the country to access the healthcare system.  These same experts believe that the people who receive this access will flood emergency departments around the nation in record numbers for conditions that are not emergent, causing physicians to be overworked.  In this article we will examine claims from the experts and also specific examples in the bill that pertain to our subject matter.  Hopefully we will shed some light on the subject as we move forward.

     So why the panic over the expansion of Medicaid? Many commentators cite numbers in a recent CDC report ¹ that show that recipients of Medicaid visit emergency rooms twice as much as the uninsured.  The program is being expanded for people between 19 and 65 years of age that meet the required criteria and this will allow millions of new people the opportunity be covered.  With this, many believe that these new recipients will run to the ER anytime there is a problem that could be treated by a primary care physician. The question comes down to human nature and people can speculate but no one can accurately predict the future.

      What are the commentators saying? Well there seems to be many differing opinions, most based on political leanings.  The fact remains that the Affordable Care Act has been upheld and it is a reality.  Whether you agree with the bill or not, it will affect you and your practice.  According to a paper done in 2010 by John Goodman, CEO of the National Center for Policy Analysis, the rise in emergency room volume is inevitable.  Goodman concludes that the expansion of Medicaid under “Obamacare” will insure an additional 32-34 million people. Using past projections of emergency room visits, Goodman calculates the increase of patients. "Consequently, we project that insuring between 32 million and 34 million additional people will generate between 848,000 and 901,000 additional emergency room visits every year," Goodman stated in his article.

     What does this mean for emergency room physicians? It means that in an average 12 hour shift, physicians may see 30-35 patients at a busy hospital and many consider this a busy night.  Some fear that with the projected rising number of patients, doctors will be spread too thin and the quality of care will decrease as physician fatigue increases.  As it is with many issues in the United States, a problem presents itself and businesses and society responds.  Many states have opened Osteopathic medical schools, with a desire to train new physicians to practice in rural or underserved areas.  The thought process is that if more physicians are trained with an emphasis on these areas, they will meet the demand that the increased numbers cause.  Many allopathic medical schools are now offering rural health programs.  The University of Alabama offers a rural physicians program in which a qualified student can train to practice in an area where healthcare is not usually abundant.  This can be in rural farming communities or lower income neighborhoods.  The hope is that by training the physicians to serve in these areas, more patients will seek help at these clinics than flock to the emergency room.

    It may be inevitable that emergency rooms will have an increased number of patients under the expansion of Medicaid.  All signs seem to be pointing in this direction.  However, maybe the attempts at filling the physician shortage in certain areas will funnel the patient load away from ER's around the country.  We will continue to examine how the Affordable Care Act will affect certain aspects of our healthcare system.

 Stay tuned from more health information from Jitesh Chawla, MD.
Reference:

1. http://www.cdc.gov/nchs/data/hus/hus10.pdf

Viewpoints about Doctors' Salaries

Really, how many porsches do you need?" has been a popular motto among proponents of Obamacare in response to objections by physicians at the possible pay cut brought on by the bill. This is a fair statement as most anyone would agree that if you are wanting to become rich, a medical profession is not the best option. However, physicians do have a reason to gripe in this case. After 4 years of med school and the loans that one can accrue over this period and the gigantic liability that a practicing physician faces, one would expect to be compensated at least enough to be able to pay off these fees once their residency is completed.

There have been many politically slanted opinions about the effect that Obamacare will have on doctors' salaries. Many in the medical profession are left wondering, "Will I be able to pay off my student loans?...Will I be seeing twice as many patients for half the amount of money and provide a lesser quality of care?" No one an really say for certain what will happen until the bill is fully implemented.

Many people fear that pay cuts will dissuade potential physicians from attending medical school and cause a great shortage of doctors in our nation. I think the best way for us to navigate this topic is to look at what the bill will do in theory to your salaries, without a political slant. First of all, it is important to understand what the goal of Obamacare is. It's goal is to lower costs of the American Healthcare system without lowering the quality of care. It resembles a European style of healthcare, and in this type of system, physicians make less money on average. In an issue of the journal, Health Affairs, the amount that French primary care physician makes was compared to what an American one makes.

PCP's in the United States on average netted around $186,000 while a comparable French doctor made $95,000. How will Obamacare affect the American pay? Well it is widely stated that the bill will cause physicians to be reimbursed at a lower than market rate for Medicaid. In other words, lower than what they are being paid now. This could spell doom for specialists such as general surgeons, who see many Medicaid patients for surgery.

With the lower pay an inevitability many believe that physicians will have to see a larger volume of patients to make the same amount of money that they do now. Many comment that this will cause a large decrease in care as doctors will rush to see as many patients as they can in a shift. We will continue to look at this issue in the coming weeks with more specific examples of how the ACA will affect you.

Role of EMRs in Accountable Care Organizations

As the final rule on ACOs ( Accountable Care Organization) has come out, it is apparent that that the value that EMRs (electronic medical records) bring is unprecedented.  Under the Medicare Shared Savings Program, ACO participants (which may include medical practices, hospitals and payers) are graded and paid based on 4 domains of care quality: 1) patient experience;  2) care coordination and safety;  3) preventative health; 4) at-risk populations.  The program consists of a 3 year performance period in which the performance of the ACO mapped against thresholds set by CMS. To reap financial benefits from this program, providers must report on 23 of 33 quality measures spanning these 4 domains during the second year and 33 out of 33 in the third. Some of the measures, like # 20, which asks for the percentage of providers that have received Meaningful Use money are easy to satisfy if you have a Certified EMR.

ACO participants are incented to work together and efficiently because if they don’t meet the CMS thresholds they must pay money back. Data is key when trying to coordinate care and the exchange of clinical data must be done properly to meet the quality measures set by CMS.

Now it must be apparent to medical providers that if they want to join an ACO it is very important that they are comfortable using an EMR. The good news is that there are certain features of the software that allow providers to capture the necessary data for ACO quality measures easily. For example, in the Preventative Health domain there are measures such as Adult weight screening and follow-up and Tobacco Use Assessment. Both of these are Meaningful Use criteria and any certified EMR has screens and buttons to record this information. 

In another example, the domain of at-risk population contains a diabetes composite measure in which the number of diabetics who BP is less than 140/90 must be recorded. To do this, it may necessary to setup a report in which there are fields to search for a patient’s diabetic status and their blood pressure level concurrently. For instance, in Patagonia Health’s EMR, there is a section called “My Reports” where users can fully customize search criteria for certain disease conditions, procedures and demographic characteristics.

Finally, the exchange of health information between providers and entities requires ability for the system to send and receive data securely and in a format that the receiving end would be able to decipher. Exchange of clinical data is a Meaningful Use criterion and is done through CCR (care of continuity record) which generates a summary of the usually about the patient’s medication, laboratory, immunizations, provider names, vital signs, alerts. Providers simply need to press the CCR button and it generates a file. This file can then be sent in encrypted format through email currently (and through Health Information Exchanges later) to the other provider’s EMR.

EMRs have become a powerful tool that has empowered medical providers to collect the necessary data in order to provide medical care with a sense of accountability and level of quality in the form of an ACO. The Meaningful Use Program has further enabled different EMRs to have the standard features important for this data collection.

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Bringing Wellness into the Doctor's Office

Wellness initiatives are generally administered by company physicians, wellness companies or disease management organizations.  However, one offshoot of the Accountable Care Act is the requirement of Medicare providers to devise a Personalized Prevention Plan for Part B Beneficiaries.  This is apparently in line with the law’s intent to foster greater preventative services for the population.  Prevention is a major theme in wellness.

The visit is coined as Annual Wellness Visit (AWV). Among the benefits include the fact that the provider will administer a HRA health risk assessment  which can uncover various risk factors that if addressed early enough can prevent disease.  

Sample HRA (link -www.prochange.com)

A second major benefit is that he or she will devise a 5 year schedule outlining which screenings and immunizations a patient needs. It can replace the Welcome to Medicare Visit as a requirement for Part B patients but you are not eligible for this until after 12 months of becoming a Part B beneficiary or within 12 months of IPPE (Initial Preventative Physical Exam). It appears that CMS has this because they want the first year to be a trial (Dr. Chawla's opinion). The only drawback is that the AWV doesn’t cover any physical exams.

This represents another step in empowering the provider to become the primary furnisher of preventative services and not someone who treats sicknesses.

The physician is in the optimum place to administer powerful tools such as the HRA, which when used with follow-up counseling, has been shown in studies to help providers pinpoint risk factors that are not found during routine visits.  Furthermore, prevention planning has been shown for years to help health departments and agencies such as the CDC improve outcomes for population. Government regulations or the lure of higher reimbursement from payers is often what it takes to start such transformation. In the next several years as health reform completely rolls out we will watching to see how “sick care” changes to “well care”

YouTube videos by Dr. Chawla site links -OpeEMR Scheduling and OpenEMR SOAP Note

Stakeholder implications of the Supreme Court decision on the Accountable Care Act

The upholding of President Barack Obama's healthcare reform bill has translated into important implications for various stakeholders. In this brief article, we will examine what these are and some strategies to deal with the impending changes.

Key Implications

Patients:

·        Must enroll by 2014 for health insurance coverage or face penalties on income tax by 2015 (doesn’t apply to individuals who aren’t required to pay taxes)

·        Ability to get insurance at affordable rates by having options offered by insurance exchanges

·        Children up to age 26 will be able to stay on parent’s plan. This can serve as a trial period giving youngsters time to find their own insurance.

Insurers:

·        Prohibit community rating for setting premiums

·        Can’t discriminate children based on pre-existing conditions

Employers:

·        Must subscribe to health insurance exchanges

·        Small business less than 100 employees can face penalties for not providing insurance to employees

·        Small businesses receive subsidies to help all employees get medical coverage

States:

·      Decide whether to participate in providing Medicaid expansion to their citizens which may imply that after 2014 must impose heavy taxation to keep it sustainable

·        Those that do decide to participate in the expansion must have a way of tracking individuals who do and do not enroll

·        States will still receive current Medicaid funding from feds even if opt not to participate in expansion program

·        Must set up health insurance exchanges by 2014




(reference- www.newsday.com - NY HIE article)

Strategies to prepare

Patients- Start inquiring and understanding about various plans offered, discuss with your employer benefit changes they may make, enroll children in plans

Insurers – re-structure plans and offerings; understand the impact that health insurance exchanges may have on their business model/financial strategy

Employers- make sure all employees are being enrolled, understand which plans to accept in benefit offerings, and comply with requirements for receiving subsidies (small businesses only)

States- work fast on setting up health insurance exchanges, re-examine risk/benefits in offering Medicaid expansion coverage, and develop adequate IT systems/process for tracking who in the population is in enrolled in Medicaid.

The full after-effects of the Accountable Care Act (ACA) law will only become
apparent in the next several years as various stakeholders take actions to
either comply or react to the coverage, access and quality of care initiatives
set in motion by Obama care. If you ask, Dr. Chawla this a trial period in which the country
will see whether we can fix our healthcare system.

In future articles, we will look more by in-depth by identifying which strategic options and tactics need to employed by organizations to remain compliant with ACA mandates.