All Entries Tagged With: "healthcare reform"

Meeting meaningful use criteria

On December 30, 2009, Congress announced the long-awaited proposed goals for health information technology. Congress, with support from the Office of the National Coordinator (ONC) outlined several goals for meaningful use. This is an essential concept because to qualify for monetary incentives, eligible professionals (physicians, nonphysician providers, podiatrists, etc) and hospitals must adopt certified EHR technology and demonstrate meaningful use of that technology.

Congress further requires that eligible professionals verify that EHR or EHR modules meet government certification criteria. While standardization ensures hospitals can finally communicate with each other, let’s look more closely at what this means to hospitals and healthcare providers who have some form of technology now.

If you are lucky enough to work in a setting that uses case management software and/or EHRs your institution must determine if it is going to attempt to meet the meaningful use criteria. If your software was purchased from a vendor (Allscripts, Cerner, Epic, etc.) it is a bit easier because you can depend on the vendor to make any necessary upgrade. If you aren’t sure if your vendor plans to upgrade, you could switch to a vendor that has announced their intent to comply with standards. Check with your vendor to determine when they plan to have their products certified.

The problem is more acute for providers that use ‘home-grown’ systems.

Before bringing a home-grown system up to standard it will be necessary to determine the cost and effort to do so. Will the expense be worth the extra reimbursement CMS provides to comply initially? If it appears that the reimbursement will not cover the cost, some intuitions may choose not to upgrade.

However, there is a downside to that decision. How will the facility communicate with others when the nation’s EHRs are standardized? How will the lack of compliant technology impact its market share? Stay tuned. We will explore market share options in future posts, as providers debate issues in the proposed rule.

Meaningful use proposed criteria

Congress and the ONC determined that meaningful use will be achieved in three stages. The proposed Stage 1 meaningful use criteria, which goes into effect in 2011:

“…focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.” – Health Information Technology: Initial Set of Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Technology, 45CFR Part 170

Sound confusing? I will talk more about what Stage 1 means and how it will affect case managers in my next post. I will also examine each of the other stages.

If anyone wants to see the 169-page document in its entirety, the proposed criteria was posted in the January 13, Federal Register. Lawmakers and industry leaders are preparing comments to the proposed criteria as I write.

AHA offers comments on Congress healthcare reform bills

Editor’s Note: This post was excerpted from an article featured in the HIM Connection e-newsletter.

The American Hospital Association (AHA) offered comments and suggestions on the Senate and House healthcare reform bills in a January 7 letter to Congress.

The AHA commented on:

• Hospital-acquired conditions (HAC): The AHA is critical of the Senate bill provision to add a 1% penalty to hospitals in the upper quartile of rates of HACs. “The combination of the current Senate provisions could put some hospitals at risk for three separate payment reductions for the same infections/HACs—once through the current policy, once through value-based purchasing, and once through the new 1% penalty for hospitals with the highest HAC rates. It is unfair for hospitals to be subjected to triple jeopardy if their performance falls short of their goals,” according to the AHA.
• Readmissions: The AHA strongly disagrees with both the House and Senate bills, which impose financial penalties for “excess” (as opposed to “expected”) readmissions. The AHA believes that efforts to reduce readmissions should address “only avoidable and unplanned hospital readmissions related to the original admission.”
• RACs: The AHA urges the removal of the Medicaid RAC provision currently included in the Senate bill, which extends RACs to Medicare Parts C and D, as well as the Medicaid program. The AHA says the addition is “unnecessary for maintaining or improving program integrity.”
• Payment bundling: According to the letter, the AHA supports the testing of different models of bundling payments to improve coordination of care, noting that an appropriate evaluation is essential to determine what works and what does not before broad adoption. The AHA also offers support of the House bill language that supports “a wide array of models, including bundling payment for inpatient and physician services, inpatient and post-acute services, inpatient, physician, and post-acute services, and post-acute services only.”

AHA also comments on rural provisions, long-term care hospital concerns, offers support to health information exchange creation, and the Senate’s approach to a public plan option (i.e., creating state-based, non-public, nongovernmental healthcare co-operatives and non-public, multi-state health plans), and discusses a wide variety of other topics.

To read the letter, visit www.aha.org/aha/letter/2010/100107-let-aha-conferees.pdf.

ACE demonstration project could change how CMS pays hospitals and physicians

Before CMS institutes a new national regulation, it often tests it on a smaller group. These demonstration projects identify weaknesses in the new rules and allow CMS to make necessary tweaks and changes. Demonstration projects also allow other facilities that are not involved in the project to learn from their peers. A recent example of this is the Recovery Audit Contractors (RAC) demonstration period.

One of the current demonstration projects that could have a large effect on case management and coordination of care is the Medicare Acute Care Episode (ACE) Demonstration project.

Essentially ACE changes how Medicare pays for healthcare services. Instead of paying the hospital and physicians separately, CMS bundles both payments into a lump sum. The payment system operates much like the DRG system where the one payment will cover the patient’s entire stay, rather than each individual service.

Extending the DRG concept to pay for physician services would encourage physicians to work with hospitals to control costs and improve quality, stated the June 2008 Medicare Payment Advisory Commission’s Report to Congress: Reforming the Delivery System.

I spoke with a source who was excited about the idea of bundling payments. The source said physicians are currently paid for every day they see a patient so they really don’t have any incentive to keep LOS down. But the ACE program would make it so physicians have the same motivation hospitals have to effectively use resources and provide proper care in a timely manner.

Some physicians are skeptical of the idea. Some fear that the lump sum allows the hospital to control physician rates and possibly encourage hospitals to withhold certain services to keep costs down, according to a recent article published by the AMA.

CMS is conducting the ACE demonstration project is in Medicare Administrative Contractor (MAC) Jurisdiction 4 (Texas, Oklahoma, New Mexico, and Colorado).

Anyone who is at a participating facility and would like to discuss the program, please contact me (bamirault@hcpro.com). I am also interested to hear how folks that aren’t participating think this program could affect case management.

House approves healthcare reform bill

The House passed its version of the bill, can the Senate do the same?

The U.S. House of Representatives recently passed the healthcare reform bill (HR 3962) by a narrow margin (220–215). The bill’s estimated cost is more than $1 trillion over the next 10 years.

The Senate is working on its own version of the bill. If that version passes, then a congressional conference committee will meet to compromise on the two versions. If the committee reaches a compromise, it will send that bill would to both the House and Senate for another vote. If it passes both houses, the next step is President Obama’s desk for his signature.

Preliminary drafts of the Senate bill differ from the House version with respect to funding. how many individuals will be covered, and the availability of a public option.

Source: CNN

Speak up: CMSA urges case managers to contact local legislators

You may have heard, but Congress is attempting to enact some type of healthcare reform in the near future. Although the extent of that reform is still up for debate, the conversation about how to improve the current healthcare model is not going away.

What better way to celebrate National Case Management Week than to contact your local legislator and tell him or her about how case managers can improve the healthcare system?

Healthcare reform will have a huge impact on the way you do your job, which is why The CSMA Public Policy Committee is encouraging case managers to speak up and share their experiences.

“We want case managers to share their stories with their local legislators,” said Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC Chair of the CMSA Public Policy Committee.

Gleason says she and the committee are not asking people to talk politics, but rather share what works with the current model and what needs improvement. The idea is that if case managers and other healthcare professionals share their wealth of knowledge with lawmakers, who have likely never worked in a hospital, than our government will be better equipped to create reform that works.

You can also think of it as another form of patient advocacy. Case mangers know how the system affects certain populations because they deal with difficult case everyday. This is a chance to tell the story about the time it broke your heart to tell someone, “I’m sorry but that’s just how the system works.”

The Case Management Model Act

The public policy committee has also created a Case Management Model Act which defines the case management role and explains how the case management principles can be the building blocks for successful healthcare reform. You can download a copy of the Model Act at the CSMA Web site. While you are there, check out the sample letter you can send to your representative and the list of talking points you can use to call him or her directly.