Some Democrats say it seems more likely Congress will opt for scaled-down health legislation, instead of the broad expansion of insurance coverage President Barack Obama is pushing. Rep. Emanuel Cleaver (D., MO) said he hopes Congress will "punch the reset button," and sees two core principles as vital to a bill: competition to drive insurance costs down and eliminating insurers' ability to deny coverage because of pre-existing health conditions.
HHS Secretary Kathleen Sebelius continues to press the need for healthcare reform with the release this week of a new government-sponsored report that highlights the escalating cost of healthcare and the threats to coverage for seniors.
"Senior citizens have seen their premiums and out-of-pocket drug costs rise and without reform, many seniors on Medicare could lose access to the doctor they know and trust," Sebelius said. "Health insurance reform will protect the coverage seniors depend on, improve the quality of care and help make Medicare strong."
The report identifies several problem areas for seniors, including:
Overpayments to private plans: A typical older couple in traditional Medicare will pay almost $90 next year on average to subsidize private insurance companies who are not providing their health benefits. Health insurance reform will eliminate these overpayments.
High prescription drug prices: Health insurance reform will cut the drug costs that seniors have to bear in the "doughnut hole" by 50%.
Imminent doctors' payment cut will limit access: Because of a flawed system for paying physicians, Medicare is scheduled to reduce its fees by 21% next year. According to a recent survey by the American Medical Association, if Medicare payments are cut by even half that amount, or 10%, 60% of physicians report that they will reduce the number of new Medicare patients they will treat, and 40% will reduce the number of established Medicare patients they treat. Health insurance reform will stop this cut and ensure seniors can continue to see their doctor.
Preventing Medicare from going bankrupt: The Medicare Hospital Insurance Trust Fund is projected to be exhausted in eight years, sometime during 2017. Health insurance reform will reduce overpayments to private plans and clamp down on fraud and abuse to bring down premiums for all seniors and extend the life of the Medicare trust fund by five years.
Notification to HHS on all breaches (immediate if 500 or more victims)
Notification to media outlets on breaches of 500 or more patient records
Valid encryption processes for PHI in databases consistent with National Institute of Standards and Technology (NIST)
However, there is something new and significant—a "harm threshold" provision that will help covered entities and business associates (BAs) determine whether or not to report a breach.
HHS said in the interim final rule that many commenters on the draft guidance in April suggested HHS add a "harm threshold such that an unauthorized use or disclosure of [PHI] is considered a breach only if the use or disclosure poses some harm to the individual."
HHS agreed. Now, covered entities and their BAs will perform a risk assessment to determine if there is significant risk of harm to the individual whose PHI was inappropriately dispensed into the wrong hands.
According to the interim final rule, the important questions are:
In whose hands did the PHI land?
Can the information disclosed cause "significant risk of financial, reputational, or other harm to the individual"?
Was mitigation possible? For example, can you obtain forensic proof that a stolen laptop computer's data was not accessed?
In certain cases, if the information includes only a patient's name and the fact they've had services at the hospital, that's no harm, no breach.
But what if the information includes the patient's oncology treatments? Lots of potential harm there. And that's a breach.
This is good news for covered entities, especially when you look at all those faxes with PHI that go to the wrong address in a hospital. If that fax goes to another HIPAA covered entity who immediately shreds it, no breach notification required.
"It's good news since it appropriately lets organizations off the hook when the breach, as defined by the Recovery Act, doesn't appear to put the patient or plan member at measurable risk," says Kate Borten, CISSP, CISM, president of The Marblehead Group in Marblehead, MA.
Chris Simons, RHIA, director of UM & HIM and the privacy officer at Spring Harbor Hospital in Westbrook, ME, says the harm threshold provision in the interim final rule leaves the rule "nowhere near as strict as I was expecting."
"Privacy officers should be breathing a sigh of relief that those faxes sent by mistake to one doctor instead of another, for instance, will not be required to be reported," Simons adds.
Covered entities and BAs may get off the hook on some breaches with good reason, as cited above. But at other times the harm threshold may lead them down the wrong road, misjudging or underrating the impact of the breach.
"The bad news from a privacy compliance perspective is that while the harm threshold approach requires organizations to perform and document a risk assessment in every instance," Borten says, "introducing the concept of a subjective harm threshold can be seen as a big loophole that some organizations will stretch."
Most Americans believe the nation's healthcare delivery system needs to be reformed, but there is no agreement on how it should be done. And despite months of media coverage, most people remain in the dark about Congress' healthcare reform process, a new Internet poll of 1,000 people shows.
"The American people have yet to be convinced to step beyond their partisan views, or change their perspectives on key healthcare issues," according to the results from the poll, Divided We Remain, conducted by Denver-based consultants Penn, Schoen and Berland Associates. "It's not that reform lacks support—75% of Democrats and 55% of Independents—think that the time for change is now. But there is little consensus about how reform should be accomplished. These polling results reflect the partisan divide over healthcare that has been playing out in Congress."
The poll found that:
56% of Americans agree that the healthcare system needs to be reformed, but few are willing to make the hard choices to pay for it. When asked what they're most worried about when it comes to healthcare, respondents focused on rising costs, including insurance premium and prescription drug price hikes and the prospect of not being able to afford health insurance. In spite of those concerns, however, sizeable majorities said they are not willing to pay more in taxes (64%) or in premiums (74%) to cover the uninsured.
Beyond the general agreement on a need for reform, Americans don't agree on what should be done. A partisan divide between Democrats and Republicans exists on nearly every question about healthcare reform—including general strategies, specific proposals, revenue sources, and the proper mix of responsibility between government, business, and individuals. Democrats generally favor a government-based approach that promotes universal coverage through the provision of a "public option." Republicans generally believe that individuals, rather than businesses or the government, should be financial responsible for making sure that all Americans have access to government, and think that reducing healthcare costs is a bigger priority than is increasing access to care. At the moment, opinion among both Democrats and Republicans is split on whether or not to mandate health coverage—with opinion trending against mandates. Independents split most often. Where they do pick a clear side, it is often more Democratic, but not hugely so.
In spite of months of media coverage and the increasing volume of public discussion on healthcare reform, the American public has a limited understanding of what's happening in Congress. Very few (only 37%) are able to correctly define the term "public option," even when given only three options to choose from. (That's nearly the equivalent probability that one would expect if everyone were just guessing.) And when asked to categorize supporters and opponents, Americans tend to expect a landscape similar to 1993—when pharmaceutical and health insurance companies and lobbyists united in opposition to proposed reforms—rather than grasp the reality of 2009's process, which has garnered some support from such parties.
The poll found that independents are the key swing vote, and 73% of them believe that the government should be most financially responsible for making sure that Americans have access to affordable, quality care. Furthermore, four out of five independents support the creation of a new federal health insurance plan that individuals could purchase if they can't afford private plans offered to them—the essence of the so-called "public option." But with Congress deadlocked over these issues—and 75% of independents stated that any eventual healthcare legislation should be bipartisan—there is clearly much hard work ahead if health reform is to happen this year, despite the fact that Americans still trust President Obama most to do the right thing on the issue.
The poll of 1,000 Americans was conducted over the Internet on Aug. 12-13.
Healthcare leaders have long felt that they are on the front lines: Fighting disease, budget cuts, insurance, and reimbursement procedures. Now these organizations are feeling the added pain of a global economic meltdown that is threatening their very existence. Generally required to keep more cash on hand than other businesses, healthcare organizations are suffering from an inability to access capital and remain solvent. The economic downturn has forced hospitals and health system executives to make difficult decisions in recent months.
In order for healthcare organizations to emerge with their reputations and operations intact, they will need to be inspired in the way they lead their organizations now, and in the months ahead.
Last fall, Warren Buffett said the nation had been hit by an "economic Pearl Harbor." In these circumstances, employees and colleagues are looking for genuine leadership; leaders that can reach beyond the routine of managing, and focus on the morale, productivity, loyalty, and survival of their organizations. The military has lived with these responsibilities for a long time. In the army, there are key leadership rules in a battle, and they are relevant for directors wondering how to lead their shell-shocked and cynical troops.
The healthcare leaders that are successfully battling through the downturn—and surviving—are those using the same principles that have been tried and tested during times of both war and peace.
Everyone is afraid in a battle, the leader included. It is natural to feel this way in a high-pressure environment, but the leader must not reveal his or her fear to their teams. They must conceal their fears to avoid amplifying hysteria. Forget all the talk about showing your weaknesses and vulnerability. No matter how bad you feel, don't show it!
Do not let your troops lie down in a firefight or they may not be able to get up. Instead, you need to maintain momentum and purpose by forging ahead rather than risking inertia through a "wait and see" attitude. Keep their energy and enthusiasm focused on the future and preparing for better times. Unfortunately, it appears that too many organizations have already allowed paralysis to happen. We see paralysis in leaders in every industry and healthcare is no exception. If we are to come out of this war, we will need innovation, ideas and direction
Forget all this talk of "human capital." If you treat your people as dispensable units, then they will behave like them—costing you more and achieving less in the process. It is a military leader's responsibility to bring his troops back alive. Similarly, healthcare leaders have an obligation to their teams to help prepare and protect them. In turn that leader will inspire confidence, loyalty, and hard work.
Here are five strategies you would do well to implement in tough times.
Empower ALL of your people to deliver results
Surprisingly, healthcare organizations can be more authoritarian than the military, with leaders refusing to loosen their grip on others' roles. Empowering your team to adopt a can-do spirit will give you a great advantage over whatever battle you might be fighting. By doing so, you foster an environment of agility and dynamism that can lead to passion, innovation, and wellness.
Strategize, revise, repeat
In the army, they say that no plan survives its first encounter with the enemy, and that's true for healthcare as well. The plan might look fantastic while it's being developed at an off-site retreat, but the reality of putting it into practice at the front line is often quite different. So, revisions and further communications become increasingly important in times of crisis.
Identify the enemy
Knowing the business of healthcare and understanding how to improve healthcare in the current environment are two different things. It would be foolish to go into battle without enemy intelligence. Yet many health leaders ignore market influencers and research. By role-playing possible scenarios that may affect your organization's plan, you can stress test initiatives and anticipate outcomes before problems arise. Can a plan withstand attacks, such as increased regulation, reduced reimbursements, increased healthcare demands, an aging population, and even legal actions? How? Thinking about possible scenarios before they happen is pivotal to retaliating with a quick effective counteraction.
Measure success, not targets
If a soldier adhered to a target of "taking the base camp" after it was deserted, they would miss the point that the enemy has already gone elsewhere. Targets exist to give black-and-white answers to whether an organization is doing well. In the current climate, it is particularly important to review your targets and confirm that they accurately reflect your goals.
Keep your eyes on the horizon
These recommendations are not alien to leaders. But at such precarious times as these, correctly applying the techniques can be the difference between success and failure. In battle, the fast beat the slow, and the organized will always defeat the unprepared. Healthcare leaders today who realize the importance of setting aside time to address the issues above will find themselves well prepared to fight larger issues, and will emerge from the downturn well-positioned for a healthy recovery.
Damian McKinney is a former Royal Marines Commando and is CEO of McKinney Rogers, a global consultancy firm. He may be reached at dm@mckinneyrogers.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
I told you last week that my opinion was that hospital leaders were the only folks showing leadership on healthcare reform. Sometimes one exaggerates to make a point. As several readers pointed out, many of the quality initiatives that have forced hospital leaders to focus on quality were implemented either by Medicare or other payers or have been legislated in some instances. Fair point. However, many of these forced quality initiatives have either been piecemeal, as in Medicare's multiple demonstration projects, or of dubious financial feasibility.
Nevertheless, some forward-thinking hospital leaders are reading the tea leaves and working in advance to demonstrate value for the payer in anticipation of further restrictions on payment based on quality measures. That's a marked change for an industry that has often rightly been accused of dragging its collective feet on quality for years.
Of course, nothing much is achieved in business of any kind without some outside force pushing for it. Do you think Detroit automakers would have ever made the quality strides they have in recent years without the market telling them their cars were crappy compared to the competition? Better late than never, I guess. What about any other consumer product or retail experience? No, players in those lines of business know they must improve and cut costs in order to survive—otherwise people won't buy their product or service. That's hardly ever been the case in healthcare. But maybe we're getting there, based on conversations I've had with two hospital leaders lately on their performance improvement projects, based on so-called Lean manufacturing principles, which were first developed, oddly enough, in the auto industry.
As one system implemented Lean over the past several years, it experienced a 25 % reduction in total cost of care, hasn't had a medication error in the last 15 months, achieved a patient satisfaction ranking of 100%, and slashed documentation time in half, enabling nurses to increase the time they spend with patients by 70%.
"The tools put the decision-making in the hands of those who do the work with the patient," says Tim Olson, chief financial officer at ThedaCare in Appleton, WI, who credits his organization's work with Simpler Healthcare, a Lean-addled consulting firm, for the strides the system has made. "As CFO, I shouldn't be telling people what capital decisions to make," he adds.
What a strange statement.
"Isn't that why you worked so hard to get that "C" in your title?" I said.
"In the old world, if you had VP or C in your name, you got to make that decision, but that's not necessarily the best way to do it," he responded.
Therein lies the beauty in Lean. Frontline workers are the ones who do process redesign. They know best where the waste is, after all. Leaders just empower them to do it.
Brett Esrock, president and chief operating officer at Covenant Health System in Lubbock, TX, is also a believer. He's only been at Covenant for two years, but he's spreading the gospel of Lean there because of his 20 years at St. Louis's SSM Healthcare, which has espoused Lean techniques for nearly that long.
"I drank the Kool-Aid," he says.
Esrock throws his employees into so-called three-day "rapid improvement events,"—time away from work spent on redesigning processes for efficiency. "Day one, they look at you like you're crazy. They want to run away; they're not management, after all. By day two, they are discovering the problems, and by day three, they now understand they're in charge of their own future and can make substantive impacts on patient costs, hospital costs, and improve their work lives."
That's what Esrock calls the "triple win."
"If we do this right, one, we'll deliver better patient care. Two, they'll be happier staff members. Three, you use less resources and you save money at the end of the day. There's not a single event that we've done without some cost savings or revenue enhancement."
The use of family health histories has had important roles over the years in the practice of medicine—promoting positive patient lifestyle changes, increasing individual empowerment, or influencing clinical interventions.
However, a National Institutes of Health (NIH) State-of-the-Science consensus panel this week found that it is "unclear how this information can be effectively gathered" and used in primary care settings for assisting with common chronic conditions, such as diabetes or asthma.
"When you look closely at family history, you find that there's a lot we don't know about it," said the conference chairperson, Alfred Berg, MD, MPH, who is a professor at the University of Washington Department of Family Medicine in Seattle. "The term is common use, but it really doesn't have a common definition. Clinicians and patients understand it in different way."
hile family history questionnaires often are not standardized, they still may cover a wide variety of factors. "The questions may be imbedded in complex risk assessment tools, along with other demographic and health factors," Berg said at a telebriefing. "We don't know much about its accuracy. We don't know much about the potential usefulness—about disease prediction and...being used as a basis for intervention."
For two days this week, the 16-member panel looked at studies and heard from experts about topics including key elements of family histories in a primary care setting for the purposes of risk assessment for common diseases, if family histories will improve health outcomes for the patient and/or families, and if family histories could result in adverse outcomes for patients or their families.
The evidence review focused on ability of family history to accurately identify and predict outcomes for certain kinds of common chronic diseases. "For the most part, we found the evidence supportive but of insufficient quality to be able to tell how accurate and how useful it would be to actually change clinical outcomes," Berg said.
Berg emphasized that the panel's findings are not directed at consumers. "Consumers have an interest in family history—they're often asked about it when they see clinicians. If they are asked about the information, it's certainly is in their interest to make sure the information is accurate and complete," Berg said. "But the evidence review is not constructed in a way to make recommendations to change consumer behavior about family history."
Berg added that "a lot of interesting possibilities" exist about how a family history can be integrated into health system records and how that "might make it possible for individuals to do a much better job about managing some of the lifestyle issues that might be implicated by genetic susceptibility." However, he said, "those issues were simply not addressed by the review."
The panel noted that additional research will be needed to understand how the routine collection of family history will lead to improved health outcomes. To help address these gaps, the panel outlined several research recommendations in three categories: The family health information to be collected, the optimal way to collect and use it, and the outcomes of this tool for diagnosis and engagement with individuals and family members.
Berg emphasizes that family histories still should be a part of primary practice, "but the evidence review itself doesn't really change the approach that we're going to be taking."
The panel's statement is an independent report and is not a policy statement of the NIH or the federal government. The conference was sponsored by NIH's Office of Medical Applications of Research and the National Human Genome Research Institute.
With serious implications for the government's ability to detect fraud, waste, and abuse in the Medicaid system, an Office of Inspector General report found a lack of timeliness, accuracy, and comprehensiveness of the federal database used for that purpose.
Key problems were found with the Medicaid Statistical Information System's (MSIS) tolerance for errors in the data submitted, which allowed certain claims filed by states seeking reimbursement "to clear quality review with an unknown number of errors," the report said. Error tolerance levels were frequently adjusted upward to allow 100% of errors to slip through so the claim could pass through quality review.
The MSIS is maintained by the Centers for Medicare and Medicaid Services for 57 million beneficiaries, at a cost of $308 billion in 2006, $174 billion of which was paid by the federal government.
The database has been seen as a key element to be used by the Health Care Fraud Prevention and Enforcement Action Team, (HEAT), created by the U.S. Department of Justice in May as an interagency effort to combat health care fraud.
Among other problems identified in the MSIS system:
It did not capture 55% of service provider identifiers that would assist in fraud, waste, and abuse detection. "For example, MSIS did not capture the referring provider's identification number," to indicate who ordered the medical procedure, product, or service. "Without the referring provider identification number, fraud analysts cannot use MSIS data to assess whether a qualified physician submitted the order as required to receive certain medical benefits."
In a 2002 report, the OIG used referring provider ID numbers to estimate that Medicare paid $61 million for improperly documented services in 1999.
It did not capture almost half of the procedure product and service description data elements. Such elements specify "the tooth number, quadrant or surface subject for dental procedures."
"Without these details, fraud analysts would have difficulty using MSIS data to detect fraudulent Medicaid claims for duplicate or medically unnecessary dental procedures," the report said. Incorrect information about the tooth surface subject to dental procedures contributed to an estimated $12 million in improper Medicaid payments in 2003.
It did not capture 42% of billing information elements, such as dispensing fee payment information. "Without details regarding fees paid, fraud analysts cannot use MSIS data to assess whether the total amounts claimed and reimbursed contain inappropriate fees," the report said.
"For example, in a 2008 report, OIG analyzed data obtained directly from states to determine that Medicaid dispensing fee reimbursement rates were about $2 higher than the average Medicare Part D dispensing fee."
It did not capture 36% of the beneficiary eligibility data elements required to detect fraud, abuse, or waste. "Three of the four missing data elements were for the beneficiary's name (first, middle, and last name). Absence of beneficiary names may hinder analysts' ability to reliably match Medicaid claims data to other sources."
The MSIS is the only nationwide Medicaid eligibility and claims information source. It was approved in 1984 as a voluntary state reporting option for electronic Medicaid fee-for-service claims. In 1997, the Balanced Budget Act mandated MSIS-program participating in 50 states and the District of Columbia starting in 1999.
As of last month, 34 states were sending their MSIS files electronically. The system is also used for healthcare research and evaluation, program utilization and expenditure forecasts, congressional inquiry responses, and other health-related database searches.
Other findings included the fact that the MSIS data were on average 1.5 years old when they were publicly released. This was due to states missing the deadline for filing claims and for the lengthy time eligibility forms and claims spent in the quality review process.
Also, despite the fact that the Department of Justice and the OIG in 2007 identified 182 data elements that help with fraud, abuse, and waste capture, not all of those elements are in fact collected by the MSIS system.
"We determined that Medicaid Statistical Information System (MSIS) data were not timely, accurate, or comprehensive for fraud, waste, and abuse detection," the OIG said.
"CMS did not fully disclose or document information about the accuracy of MSIS data," the report added.
The 27-page document was prepared by Stuart Wright, OIG deputy inspector general for evaluation and inspections, and was addressed to Cindy Mann, director of the Center for Medicaid and State Operations.
To answer questions about how to give and get reimbursed for care during a disaster, federal health officials have issued an extensive and updated list of answers to 132 questions on topics ranging from H1N1 influenza to mental health counseling.
"The timing is very appropriate because not only is hurricane season here, but we're preparing for questions coming in on H1N1," says an official for the Centers for Medicare and Medicaid Services, who said the agency's policy does not let him be quoted by name.
The official adds that the agency assembled the questions in one place so that providers would not have to search for the answers in a large manual. "These are real questions from real providers."
The answers respond only to what is appropriate without a federal declaration of emergency, called an 1135 waiver.
For example, it explains that CMS will reimburse providers for administration of vaccines for both seasonal and Novel H1N1 vaccines, but if the federal government provides the individual vaccine doses at no charge, the providers may not be reimbursed for the vaccine's cost.
Another questioner asked, "Will it be possible for providers enrolled in mass immunizers to roster bill Medicare for H1N1 administration as they do for seasonal flu?" a process by which an entity that administers vaccines to large groups of people can submit one claim for treating 500 patients.
Answer: "Yes."
"Will reimbursement for H1N1 vaccine administration be the same as for seasonal influenza?" Answer: "Yes, the payment amount for the H1N1 vaccine's administration will be the same as the payment for administration of seasonal flu vaccine. Multiple payments for administration will be available if the H1N1 vaccine requires multiple doses."
Other topics deal with payment adjustments in an emergency or disaster, waiver of Medicare requirements, physician care, ambulance, lab and other diagnostic services, drugs and vaccines under Part B, durable medical equipment, end stage renal disease facilities, home healthcare and hospice services, EMTALA, critical access hospitals, inpatient rehabilitation facilities, and mental healthcare.
Medtronic Inc., CEO Bill Hawkins defended his company's longstanding practice of collaborating with physicians, although he acknowledged these paid relationships could pose a conflict of interest. Hawkins said working with doctors to improve devices and commercialize inventions is crucial to advancing medical technology. Yet these relationships have triggered inquiries by Congress and the Department of Justice.
