June 2015

25th Jun
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Interoperability and the 21st Century Cures Act

By Miranda Crowell

 

In the health tech world, “interoperability” is a fancy word begging for a hashtag and for acceptance within the medical community. With a continuously growing push for the use of electronic health records (EHRs), the issue of interoperability gained the attention of Energy and Commerce Committee Chairman Fred Upton (R-MI) and Rep. Diana Degette (D-CO). The 21st Century Cures Act (Cures Act) is sprawling, with topics ranging from drug development to clinical trials. And when it comes to interoperability, the Energy and Commerce Committee hopes that the Cures Act, if passed by Congress, might ease the process of sharing research and clinical data by making systems more interoperable.

But what does interoperability mean and why is it important? Depending on who you ask, interoperability has various definitions. In short, it is the ability for one system to connect with another system. The Office of the National Coordinator for Health IT (ONC) defines the term as “the ability of systems to exchange and use electronic health information from other systems without special effort on the part of the user.” The definitional stance taken by ONC and HIMSS, or the Health Information and Management Systems Society, includes various levels of interoperability and stresses the notion that interoperability includes data-sharing between and among various EHR vendors and other health technologies. Moreover, interpretation of data by the receiving system is important, at least to some degree. Consider this banking analogy as an example of an interoperable system: any ATM can facilitate a withdrawal from any bank at any time, and thus, the ATM is interoperable among banking systems.

There is a glaring need for interoperability standards in the healthcare field. For example, a local, independent doctor may have little to no electronic method to share a patient’s health information if that patient visits a hospital. This scenario highlights a common problem where a lack of access to information, or the slow speed of access to information (should such access exist), could lead to a poor patient outcome. To that same point, the Department of Health and Human Services (HHS) states that a lack of immediate access to relevant health information is the cause for 20% of preventable medical errors. These examples and statistics only scratch the surface on the need for interoperable health systems.

Zoning in on interoperability, the expansive Cures bill directs HHS and ONC to set standards for what makes a particular health technology interoperable. In order to be considered interoperable, the technology in question must (i) allow for the secure transfer of the entirety of the patient’s data, (ii) allow access to the entirety of the patient’s data without special effort, and (iii) not be configured to block information. A more detailed description can be found here at page 236, and the specifics surrounding these standards are forthcoming by HHS and ONC. Earlier drafts to the Cures bill did not include any specific language on the topic of interoperability, but the Energy and Commerce Committee responded to pleas from groups such as Premier Inc, a healthcare improvement alliance group.

As sweeping as the Cures bill may seem, there are some issues when it comes to the interoperability sections of the bill. For example, the College for Healthcare Information Management Executives, a professional organization for senior-level healthcare IT professionals, was displeased when the new version of the bill did not include any language on patient identifiers, stating that a standardized approach for collecting and sharing data can only occur when a patient can be positively identified. Moreover, EHR vendors will not be penalized for a lack of interoperability until January 1, 2018. As Fibroblast CEO Scott Vold voiced, “Washington is moving at a glacial pace to increase interoperability; the two and one-half year gap between the present and the implementation of penalties for EHR vendors is too long because the technology could change and the market could shift.” (You can hear Scott’s thoughts on the Cures bill and other topics on here.) The bill received a unanimous 51-0 committee vote on May of 2015. And as the bill makes it way to Congress, all health-tech parties should keep one eye on Cures and the other on the ever-changing world of healthcare technology.

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15th Jun
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The Shift (Part 3) – How Payors Are Influencing Value-Based Payments

By Miranda Crowell

 

After some basic explanation about fee-for-value payment models in The Shift Part 1, followed by a pro/con discussion of fee-for-value payment models in The Shift Part 2, the final piece in this series focuses on various non-provider perspectives surrounding shifting payment models. This post touches upon how insurance companies are embracing The Shift to drive unprecedented change in our healthcare system.

As Optum puts it, the main drivers of market transformation are the need for 1.) consumer-centric healthcare delivery, 2.) value-driven care, and 3.) healthcare infrastructure modernization.  Admittedly, a consumer-centric healthcare system could mean shifting the delivery of care from a long-standing employer-epicenter to a more individualistic approach. Additionally, the way that people view healthcare may change over time. Value-based contracting will push physicians to achieve both quality and efficiency targets before sharing in any cost-savings acquired by fee-for-value contracting. As Payal Shah puts it, this new system will result in a better patient experience, lower healthcare costs, and overall higher quality care. With society’s ever-increasing interest in social media, brand perception could play a role in the patient’s decision to chose a particular provider over another. After all, sharing an opinion about a physician is only 140 characters away.

But it isn’t just patients that are going to see changes. From an employer perspective, UnitedHealthcare told employers in 2012 that they “expect the aggregated return-on-investment of our value-based contracting programs to exceed 2:1 in terms of savings vs. incentives paid because only a portion of the savings will be shared with providers.” The concept is that employers will see a hard-working, healthier workforce with a value-based delivery system, thereby incentivizing employers to be open-minded to changes.

Insurance companies have been anticipating the slow switch from service to value-based contracting. As Shah noted, “insurance companies are working in collaboration with health care providers … regarding payment for incentives, and payors are making sure that savings are realized.” UnitedHealthcare Group is on board with value-based contracting and anticipates a 20% increase in value-based payments in 2015, raising payments from UnitedHealthcare to somewhere “north of $43 billion,” according to Forbes. Blue Cross and Blue Shield (BCBS) companies reported a portfolio of 350 locally-developed, value-based programs in July 2014 and have since increased that number to 570 companies by March of 2015. From 2013 to 2014, BCBS had a 9% increase in claims affiliated with value-based programs and reports $71 billion (yes folks, that another “b”) in programs that provide incentives for quality-based care based on a 2014 annual survey.

Lastly, healthcare infrastructure modernization products and services will be a player on the field that should not be ignored. One quick tour around Matter in Chicago, Illinois, will demonstrate that healthcare tech innovation is already influencing healthcare delivery. For example, Fibroblast Inc., a patient referral management platform, recently landed a deal with Presence Health, Illinois’s second largest health system with over 1 million patients.This takes us full circle back to the concept of patient-centered healthcare; with an increased access to choices in providers, patients will inevitably increase use of information such as branding perceptions, word-of-mouth, and social media when choosing a provider similar to choosing a meal via GrubHub. In summary, the effects of market transformation are far-reaching. Needless to say, the next few years should prove to be one wild ride for all involved with the healthcare market.

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03th Jun
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Clinically Integrated But Not Necessarily Aligned: Who’s to blame for patient leakage in Clinically Integrated Networks?

Patients are falling through cracks in our healthcare system, leading to poor patient outcomes and hundreds of millions of dollars in lost revenue opportunities per healthcare system. This problem is intensified by declining fee for service reimbursements and the financial risks of value-base payment models.

Why does out-of-network patient leakage occur, who is to blame, and what can be done about it?

On June 24 at 12 PM CDT, Fibroblast, in collaboration with Matter and EDLoop, is hosting a one hour webinar discussion of how and why out-of-network patient leakage occurs in a Clinically Integrated Network from the perspectives of an independent private practicing physician, an employed physician, and former ACO executive.

Click on the flier below or this link to register.

Fibroblast Webinar

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02th Jun
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The Shift (Part 2) – Shifting Medicare Payment Models: The Good, The Bad, and The Ugly

 

By Miranda Crowell

In Part 1 of The Shift, we gave our readers an informational crash course on the shift of Medicare payments from fee-for-service to fee-for-value. In Part 2 of The Shift, we hope to provide our readers with arguments for and against this type of payment system, realizing that such a discussion is for information purposes only. This change in the healthcare market is going to happen, but that doesn’t mean that all the kinks are ironed smooth just yet. Nonetheless, the future looks bright (and getting brighter as time passes!)

The Good

Now that the hype from the resplendent payment-reform unveiling has died down, it is time to see the plan in action. The working parts of Medicare payment reform look promising, and reform is proving a positive shift for the many players in the healthcare field. For starters, the old-school Sustainable Growth Rate formula of Medicare payments was scrapped in April, and everyone on both sides of the aisle could high-five in agreement that a broken formula was finally given the boot. Furthermore, the ACA gives involved agencies a broad range of authority to promulgate rules to help the whole reform process run smoothly; perhaps some good ole’ fashioned notice-and-comment rulemaking is just the trick for all those worried that certain facets of shifting payments is not broad enough. For example, the Center for Medicare and Medicaid Innovation is authorized to work with states to test all-payer payment reforms. Maryland has seen some success in setting payment rates at the same level for both public and private payers and operating in a system constraining both volume and price. Others passionately argue that a combination of patient-care navigators, IT tools, and cultural change have led to success in bundled care. Amedisys, a company out of Baton Rouge, Louisiana, saw a 21% decline in 90-day readmission rates in one of their regions testing bundled payments – an undeniably impressive feat.

The Sort-of Bad and The Kind-of Ugly

Recall that the goals of shifting Medicare payments from fee-for-service to fee-for-value are to rid the healthcare market of payment systems that promote a piecemeal approach to patient care, to improve patient outcomes, and to decrease the costs of healthcare on both a patient and market level. Arguably, Accountable Care Organizations (ACOs) may be off to a slow start; but they are steadily gaining steam. As the Center for American Progress reports, ACOs are maturing. Most of the saving incurred by ACOs were seen in the Pioneer Model, or the select few healthcare providers that bought into ACO lifestyle early on. As the Center for American Progress reports, “Of the 23 ACOs that participated in the second year of the Pioneer program, only 11 earned shared savings while 6 [ACOs] generated more than $25 million in gross losses.” Second year savings by ACOs represented only 0.008% of net Medicare spending in 2013. Additionally, a (somewhat limited) report posited that there was little difference in the quality of care received by a bundled payment group compared to a non-bundled payment group. (You can access the report here.) But as good science tells us, a larger sample size and timeline are needed in order to get an accurate account of ACO and bundled payment successes; anything else should be considered merely preliminary.

While not universally felt, some healthcare providers may be displaying appreciation and apprehension at the same time. There is appreciation because the idea of promoting better health outcomes is certainly a charming goal, and the marketing of these promises is pretty impressive. As recently as the end of May, the Million Hearts Cardiovascular Disease Reduction Model was announced to compliment shifting payment models, and generally, people seem on board. It’s hard not to be dazzled by the idea of it all. There may be some apprehension because providers’ goals can be treatment- and answer-driven, while those of administrators may be more numbers- and efficiency-driven. Overall, it is expected that both providers and administrators will be speaking the same language soon enough. And this type of initial hesitation is to be expected where any major system-shocking changes are introduced into the industry – these things just take some time.

Final Thoughts

So far, the successes and failures of Medicare payment reform show that, like any other large change, market reform takes time. Lessons from succeeding Pioneer Model providers can be shared to similarly situated providers, and some early pilot programs seem promising. Small sample sizes and relatively short time frames make testing the outcomes of payment reform difficult. (You can read more about drawing conclusions of payment reform via Modern Healthcare.) In general, there is hopeful anticipation when it comes to ACOs and the new payment models, and there are tools like Fibroblast to help along the way. In our final piece of this series, you can find out how such shifting Medicare payments will impact parties working with the healthcare market, but not necessarily within it.

 

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