Sen. Ted Kennedy says he won't support a healthcare reform bill unless it includes provisions to help Americans pay for long-term care. Kennedy backs a plan that would create a new long-term care fund that would be funded through a $30 per-month deduction from working adults' paychecks.
CMS continued its efforts this week to educate healthcare providers on the permanent Recovery Audit Contractor program with an Open Door Forum call for Medicare Part B providers on April 14. A similar call for Part A providers was held on April 8.
Providers may wish to listen to the Open Door Forum calls, including the helpful Q&A portion of the program—even those who feel as though they are experts on the RAC program may find they learn new information. For instance, consider the following points discussed during the April 14 call:
On medical record request limits: If your medical record request limit is per National Provider Identifier, listen up. The record request limit is based on your group NPIs, not the number of NPIs assigned to your individual physicians. "This could be an issue," explains Nancy Beckley, MS, MBA, CHC, of Certified Healthcare Compliance at Bloomingdale Consulting Group, Inc., in Brandon, FL. "An 18-member physician practice group that has a group NPI could expect requests of 50 medical records every 45 days, whereas if this same medical group issues a different group NPI to each of its three practice locations (each of which have six doctors), the physician practice group could have up to 30 medical records requested for each of the three groups—for a total of 90 medical records every 45 days."
On line-item billing: For a claim containing multiple CPT codes for the same date of service, each code (i.e., procedure) constitutes an item that RACs can review. Beckley believes this may come as a surprise to many providers considering a visit (which could encompass several CPT codes) as a claim for a date of service.
On contingency fees: RACs receive the same contingency fee regardless of whether they identify overpayments or underpayments.
On submitting electronic claims: The RACs currently aren't set up to receive electronic data interchange—nor will they be for some time. For now, submit paper claims (via fax) or send images of electronic medical records via CD or DVD.
If you prefer to find out more about the RAC program during a live outreach session, you may find CMS is hosting an educational session in your neck of the woods. CMS is partnering with state hospital associations, state medical societies, and CMS regional offices to roll out these meetings. Check out CMS' recently updated RAC education and outreach schedule for information on available sessions. The schedule also contains information regarding which types of healthcare provider (e.g., hospitals, physicians, skilled nursing facilities, etc.) should attend the various sessions, as well as who will provide the presentations during the sessions. CMS will continue to update the RAC schedule as new sessions become available. (View the most recent version on the CMS Web site.)
If you are in a blue state, you will start seeing outreach sessions in your area beginning in August. If you are a yellow or green state, you should see sessions in your area soon. If you are a yellow or green state and believe CMS has no outreach sessions applicable to your organization in your area, e-mail CMS.
CMS acknowledged during the April 14 RAC Open Door Forum call's Q&A portion that hospital associations and medical societies hosting the provider outreach sessions may have limited participation to "members only," leaving nonhospital or nonphysician providers (e.g., physical therapy clinics or DME providers) without an opportunity to attend a session, says Beckley. If you find this to be the case, in addition to e-mailing CMS with your concerns, you should also consider contacting your national trade organization. Express your concerns to organizations such as the American Physical Therapy Association, the National Association of Rehab Providers and Agencies, or the National Association for Homecare and Hospice, Beckley suggests.
CMS also plans to provide an outreach presentation on its Web site for providers unable to attend the live sessions.
Consumers thinking twice about all but the most critical or emergent care are at the crux of one of the most significant transformations in healthcare today. The rise in consumer driven health plans, economic difficulties, and more have led many patients to carefully consider which healthcare treatments they really need, and which they can delay or avoid altogether.
Once the territory of the un- or underinsured, active decision making based on cost when it comes to healthcare is trending up for everyone. Recently, this trend hit home personally, when I went to a podiatrist to see about having a persistent and annoying wart removed. Seven treatments of liquid nitrogen later, the wart was still there, and my doctor said it was time for the big guns: laser treatment.
To this point, between my office copay and the 20% copay on "surgical treatments," each liquid nitrogen blast was about $60 out of my pocket. Knowing the laser procedure would be more expensive, my physician suggested I call the outside vendor he uses for laser wart removal to determine what my total cost might be. He said, "It's better than calling your insurer—usually they're a little thrown by the term 'laser.'" I was then handed the vendor's bi-fold brochure and told to make an appointment with the receptionist before I left.
Here's where the difference between yesterday and today for healthcare marketers hits like a sledgehammer. Until recently, I would have simply scheduled the laser appointment. I had good insurance coverage, so my exposure was at worst 20% of the procedure cost. I'd already been through seven treatments at $60, and would want to see the treatment through to the end. (No way the wart would win this battle.) Like many others, I would have moved forward with the treatment and paid the bill.
But not today, and maybe not ever again. First off, I've spent $420 to date on this stubborn little hitch hiker. Do I really want to spend another $200, or more? For most people, that's not trivial coin. I've lived with the wart for 10 years, what's a few more? At the very least, I will call the vendor and my insurance company before moving forward.
No more blind healthcare purchases for me, at least not when I have a choice in the matter.
My attitude is not unique. According to a recent Kaiser Family Foundation HealthTracking Poll, 53% of respondents said their households had cut back on healthcare in the previous year due to cost concerns. Retailer CVS recently announced the closing of 90 MinuteClinics for the season, to "align with consumer demand." Many hospitals and health systems are reporting dramatic drops in utilization. Summing it up recently was David Wessner, CEO of Park Nicollet Health Services in Minneapolis, who was quoted in a Minneapolis Star Tribune story on the financial ills of hospitals. Wessner said: "We're seeing that demand is far more elastic than it was in other years."
How does this change things for healthcare marketers? In a nutshell, your customers are becoming a much more challenging sale. No longer will healthcare consumers blindly follow the advice of their physicians to receive further treatment, not when they're own money is at stake, and not when there's a choice in the matter. So not only will it be harder to compel consumers to choose your organization, it will be harder to convert them to additional care even if you do.
What could my physician and his health system have done differently to ensure I took the next step, and went Star Wars on that wart? Here are just a few ideas:
Provide phone or email access to a patient advocate to help me determine the actual cost of the procedure. As it was, I was left to bridge the financial questions myself. I was on my own to contact the vendor and my insurance company to determine the actual cost of the procedure. I have a stake in becoming wart-free, but the health system has a financial stake as well. Why not make it as easy as possible for me to take that step?
Make information about pricing examples and options available via literature or on your web site. Now that I'm spending more of my own money (i.e. "consumerism"), I will be more apt to shop around. Maybe there are better options out there. Maybe cheaper as well. If you can't provide a real, live human advocate to help me figure this out, at least provide me literature that gives some pricing examples. Even better, provide me a link to a page on your web site that provides all the information I need, phone numbers, sample pricing, etc.
Leverage your brand equity when passing consumers off to strategic partners or other vendors. The brochure I was given was from the vendor, with the vendor's brand. But I don't know them, which means I don't trust them. That introduces a whole new player into the mix for me, which makes it harder for me to just take the next step, sight unseen. Remember, as competition heats up, brands matter even more.
Provide educational materials, promotional brochures, etc. that have your brand, even if the service is provided by an outside vendor. It's one less mental hurdle patients have to leap over to take the next step.
Multiply my story across the thousands of services, treatments and procedures you provide, and you can begin to see the impact consumerism will have on healthcare organizations. Healthcare marketers who are still using the old-school equivalent of liquid nitrogen applications as their strategies may want to consider charging up the laser, and consider new and different ways of addressing changing market demands.
A healthcare organization's logo represents the all-important first impression, since that is often the first interaction a patient has with a brand. The logo is often a brand's most visible and memorable element, at least at first. After interacting with any business, healthcare or otherwise, all the attributes of that organization are then assigned to the logo, which may or may not reinforce what that visual mark says.
Advertising agencies that used Flash to build deep, immersive sites with intricate animation have in some cases been embracing a low-fi, low-cost approach by tapping out-of-the-box Web software and free tools and platforms. The trend signifies a shift in strategy from the wowing of consumers with an experience driven by tech wizardry to the weaving of brands into the fabric of the Web and an emphasis on content. This means putting a premium on sharing, flexibility and speed.
The new 15-member Federal Coordinating Council for Comparative Effectiveness Research, authorized under the American Recovery and Reinvestment Act (ARRA) to assist federal agencies in coordinating and comparing the effectiveness of health services research, heard suggestions from the public April 14 in Washington on where to focus its efforts.
The goal of comparative effectiveness research (CER) is to provide information on the relative strengths and weakness of various medical interventions. Individuals participating in the listening session—representing provider, patient, research, medical education and other healthcare organizations—urged the panel to consider a variety of options.
John Martin, director of Premier Research Services, a research group owned by nearly 200 not-for-profit hospitals and healthcare organizations, urged the council to make sure that CER be aimed at "true research"—not administrative activities—and that the research be patient-focused.
Rather than just rely on findings from clinical trials, attention should be focused on whether a treatment "provides the greatest benefit to the patient in a real-world healthcare environment," Martin said. To that end, he suggested that results for CER "should be used as a guide for the best available treatment based on quality, safety, and efficiency—but not as a substitute for provider judgment."
"The care provider and the patient should have the opportunity to fully weigh each measure in selecting the best pathway for care," Martin added.
Collaboration also will be important. "Our experience has shown that involvement of stakeholders such as hospitals and healthcare systems early in the process—if it's considered in the development of research priorities—more likely will lead to the transition from research practice to use in acute healthcare facilities."
Harold Miller, president and CEO of the Network for Regional Healthcare Improvement (NRHI), a nationwide coalition of regional collaboratives, said it is difficult to "do good comparative effectiveness research if you don't have good data on the use of treatments and outcomes that result."
"Moreover, what matters is the effectiveness of treatments in the real world—not in the laboratory," Miller said. The "fastest and most cost effective way to get real world data" is to build on the "extensive quality measurement and data collection" that are already being developed around the country—such as through the health collaboratives, he said.
Jeff Allen, executive director of Friends of Cancer Research, noted that CER historically has used data and evidence obtained through literature reviews of individual trials. These reviews generally cannot "create new knowledge" and "provide little insight into the effectiveness of healthcare interventions outside of clinical trials," he said.
Instead, he called for new ways of thinking—such as linking public and private healthcare databases (such as insurance claims)—which would have the potential to "generate an unprecedented amount of information for a variety of research activities."
Myrl Weinberg, president of the National Health Council, which represents the interests of individuals with chronic diseases and disabilities, noted that efforts should be made to "disentangle the findings of good comparative effectiveness research" from insurance coverage and reimbursement decisions.
"We need to break the immediacy of that relationship in order to avoid denial of appropriate care," Weinberg said. Weinberg noted that patients' greatest concern was that CER will be used "inappropriately to deny access or to funnel them into a one-size-fits-all mode of care."
Elena Rios, MD, president and CEO of the National Hispanic Medical Association, which represents Hispanic physicians, said that CER could add to the body of knowledge to assist in reducing healthcare disparities. It also could help promoting effective ways of communicating with Hispanic patients and their families.
Earlier this year, the Recovery Act appropriated $300 million for the Agency for Healthcare Research and Quality, $400 million for the National Institutes of Health, and $400 million for allocation at the discretion of the Secretary of Health and Human Services to support CER. The council will make its recommendations in June.
Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached atjsimmons@healthleadersmedia.com.