Medicaid Expansion Debate

Dr. Jitesh Chawla felt from the outset that the Medicaid Expansion effort part of the Affordable Care Act was going to be an uphill battle.

The 26 states have refused the are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion.Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

Dr. Chawla found out the North Carolina practices who take Medicaid didn’t really even much of an opinion of the expansion in the first place. In Mississippi, Republican leaders note that a large share of people in the state are on Medicaid already, and that, with an expansion, about a third of the state would have been insured through the program. Even supporters of the health law say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base.
“Any additional cost in Medicaid is going to be too much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.
The law was written to require all Americans to have health coverage. For lower and middle-income earners, there are subsidies on the new health exchanges to help them afford insurance. An expanded Medicaid program was intended to cover the poorest. In all, about 30 million uninsured Americans were to have become eligible for financial help.
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Post comments and join Dr. Jitesh Chawla for the discussion on this important topic.

What medical providers need to know about switch to ICD-10

Jitesh Chawla, MD. would be the first one to say this is a major "trial period" for fellow medical colleagues due to the ever increasing requirements from the governement.

Most providers of small practices don’t have the time or resource to fully understand how ICD-10 will impact them. In this article, I will explore this very important topic and provide suggestions for providers of how to prepare for ICD-10 compliance.

The intention behind ICD-10 is to provide a tool that would provide a more detailed, accurate code to match the actual diagnosis. As disease diagnosis has become more specific, ICD-9 codes appear to be obsolete and often don't describe the condition accurately.

The law states for all organizations covered under the 5010 electronic transactions version instead of the older 4010/4010A versions. If you are not familiar with this terminology, please check with your billing manger or practice management software vendor.

ICD-10 is divided into 2 areas: clinical modification (CM) and inpatient procedure coding system (PCS). Inpatient procedure codes are not affected. Outpatient codes are still represented under the current system. ICD-10 is more specific on anatomical location, specificity of diagnosis, etc. To put this into perspective, take for example, if a patient was had a furuncle (boil) on the face and went to the dermatologist. The same patient then returned a few weeks later and had a carbuncle. In ICD-9, the same code would be used which is 680.0. In ICD-10 (specificity of the condition) would be recorded. The furuncle would be L02.92 and carbuncle would be L02.93. Furthermore, ICD-10 would enable you to record which encounter (initial versus subsequent).

The basic structure of the ICD-10 code is:

Characters 1-3: the category, 4-6: cause of problem, body part affected, severity of illness, 7: Place for extension of the code

Some EMR systems have a connection with live database and so a switch to ICD-10 will not affect the users when picking a diagnosis for their note. However, with EMRs that don’t have this link to the live database, the issue is how to migrate the codes into the system. A strategy would be to use transition tables which provide the ICD-10 equivalent to the ICD-9 code since there is no way to convert the codes. ICD 10 Code Translator . Just plug in the ICD-9 code and it will convert it to the equivalent ICD-10 code. This provides enough relevant background for most people about ICD-10 and the issues surrounding it. Please be sure to examine the table below that compares ICD-9 and ICD-10 codes. For providers, health care staff

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.

Accountable Care Organizations: Are they right for me?

As providers we are always bombarded with new regulations, government mandates and creative insurer plans or programs designed to help us increase our revenue. But with limited time and other resources, doctors and mid-levels need to quickly and clearly understand if some new program is right for them. With that in mind, here is a summary of ACOs ( Accountable Care Organizations) based on what we know about them from the latest CMS regulations and a pros/cons analysis to help you decide if it is something you want to participate in.

Definition:  An accountable care organization is a group of providers and suppliers of services that coordinate to provide high quality care (as defined by CMS) to a group of Medicare beneficiaries who are not in a Medicare Advantage Plan.

•Providers from individual practices, group practices or a network of ACO professionals can participate regardless of speciality

•The financial benefit is that providers can get the savings from care provision in an ACO program as extra revenue

•The risk is that providers may share in the loss of money from care provision in an ACO program

The requirements to participate are:

•File application with CMS

•Form a legal entity that is linked through bank accounts with CMS,

•Have at least 5,000 Medicare beneficiaries over 3 years in panel,

•From governing body with at least 75% of individuals participating in ACO.

•Have a Board certified physician as medical director, CMS liason on ACO leadership

 committee

•Have quality improvement program and abiility to identify high-risk individuals in place

Approval is a for a 3-year period at stretch. 

What quality measures are tracked?:

•Patient-care giver experience

•Care coordination

•Patient safety

•Preventative health

•At risk population/frail or elderly

These measures are tracked by comparing to benchmark data sent by CMS and scores 1-5 are assigned to each. If the performance is better than the benchmark then savings occurs, if not then loss.

Pros- ACOs:

Can result in extra revenue through cost savings

Help organizations establish valuable care processes (ie. quality improve program, tracking certain data, better of electronic medical record functions)

Results in better coordination of care for the patient

Advantages of ACO schematic


(Reference: susiecookhc.wordpress.com)

Cons-ACOs:

Time-consuming to set up an ACO and run it

Could be costly from setting up the ACO, loss from performance below benchmarks

Too many unknowns -not sure what new rules CMS will require in years to come 

The ideal ACO participants: Practices that have several providers and staff, have a QI program, use the EMR to track outcomes and have a large Medicare population.  

Quotes about ACOs from different experts in the field: 

“But if ACOs models are to work, they’ll eventually have to embrace smaller practices, which make up the vast majority of U.S. medical groups overall. And if those groups are either EMR-less or just getting started, it’s going to be pretty tough to share value-based payments, coordinate across episodes of care and track quality jointly” -Kathryn Rourke (EMR and EHR)  

“But here’s the problem with ACOs: They are a tool in a big tool box of care and cost management tools but, like all of the other tools over the years like HMOs and IPAs, they won’t be used as they were intended because everybody—providers and insurers—can make more money in the existing so far limitless fee-for-service system.” – ROBERT LASZEWSKI (The Healthcare Blog)

Conclusion:

Accountable care organizations represent, yet, another paridigm to deliver high-quy ality care. The summary about ACOs presented here is very cursory with specific details that are available on the CMS website . I hope the information presented here will give you, as provider, a feel for wether the ACO program is something that you qualify for and want to participate in. My opinion is that ACOs are not a good return of investment for small practices with 1-3 providers or any practice without the extra resources and time to devote for this.

What do you think? Are ACOs something you want to or would be a part of? We would love to hear your thoughts?

By: Jitesh Chawla, MD.