The release Tuesday morning of HHS' long-awaited meaningful use requirements for healthcare information technology drew generally favorable, but guarded reviews from patient, physician, and hospital advocacy groups—all of whom are still sifting through the dense, 863-page document.
David Blumenthal, MD, National Coordinator for Health Information Technology co-wrote in an opinion column Tuesday in The New England Journal of Medicine that the "most important part" of this regulation is what it says hospitals and clinicians must do with EHRs to be considered meaningful users in 2011 and 2012:
In the original proposal, we identified a broad set of objectives, all of which would need to be met. This included 23 objectives for hospitals and 25 for clinicians. The DHHS received many comments that this approach was too demanding and inflexible, an all-or-nothing test that too few providers would be likely to pass," wrote Blumenthal and coauthor Marilyn Tavenner, RN, principal deputy administrator of CMS.
"In the final regulation, we have divided these elements into two groups: a set of core objectives that constitute an essential starting point for meaningful use of EHRs and a separate menu of additional important activities from which providers will choose several to implement in the first 2 years."
Despite those assurances, Steven J. Stack, MD, a board member of the American Medical Association, reaffirmed that the nation's largest physicians' association is trying to determine if the new rules provide caregivers with they flexibility they'd called for during the comment period.
"The AMA and 95 state and specialty medical societies submitted formal comments to CMS on an earlier draft of this rule and cautioned that the proposed criteria for meaningful use was too aggressive and would prevent many physicians from participating," Stack said. "The AMA is committed to EHR adoption that streamlines the clinical and business functions of a physician office and helps physicians provide high-quality care to patients. It is critical that barriers to implementation are removed so physicians can successfully adopt new technology."
Stack said that after reviewing the final rule, AMA plans free webinars in the coming weeks to educate physicians on the requirements for meaningful use and how they can incorporate them in their practices.
William F. Jessee, MD, president/CEO of the Medical Group Management Association, said he was pleased that the federal government acknowledged physicians' concerns in the comment period. "While challenges remain, the final rule provides a better approach to the 'real-world' issues faced by practices as they move toward 'meaningful use' of EHRs," Jessee said. >
"Improvements sought by MGMA" contained in the final rule included a reduction in the originally unrealistic thresholds related to e-prescribing, administrative transactions and computerized physician order entry, among others," he said.
Jessee said MGMA will continue to work closely with the federal government "to incorporate additional changes related to implementation of the incentive program to allow the greatest number of practices to achieve widespread meaningful use of EHRs."
Blumenthal and Tavenner said the meaningful use rule must be achievable and ambitious and "strike a balance between acknowledging the urgency of adopting EHRs to improve our healthcare system and recognizing the challenges that adoption will pose to healthcare providers"
"The regulation must be both ambitious and achievable. Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself," Blumenthal and Tavenner wrote.
The Federation of American Hospitals, the lobbying and trade association for for-profit hospitals, offered guarded praise for the new rules, saying they should help provide the impetus for hospitals to advance HIT for improved patient care. However FAH President/CEO Chip Kahn said "there is further work to do."
"Under today's final rule, multiple hospitals under a single Medicare provider number will not receive their full allotments," Kahn said. "Patients of a hospital should be confident that their hospital is receiving the full HITECH incentive, regardless of whether that hospital has an individual provider number or shares a provider number with other hospitals."
Kahn said it is "essential" that Congress clarifies the definition of an eligible hospital to put all hospitals on a level playing field for the distribution of incentive payments.
In addition, FAH wants HITECH incentive payments to recognize the continuum of patient care. "Congress should expand the legislation's reach to include post-acute hospitals and care," Kahn said. "Doing so is a step we must take to reap the full rewards that information technology can offer patients through improved care integration and coordination."
Christine Bechtel, vice president of the National Partnership for Women & Families, a patients rights advocacy group, applauded the Obama Administration for "making some reasonable concessions but standing firm against industry pressure to gut the regulations."
"Providers who take federal aid will now, appropriately, be required to use IT in ways that improve outcomes for patients and support the caregivers who now struggle to coordinate care in our fragmented system," Bechtel said. "An end is finally in sight for the days when doctors have to sift through incomplete and incomprehensible hand-written medical records—when patients must tote test results from doctor to doctor—and when family caregivers spend endless time trying to coordinate medications and treatments for those who can't do so for themselves."
As HIT gathers momentum, Bechtel said regulations should be strengthened "so providers who violate privacy laws are ineligible for federal IT dollars, and so providers are required to give all patients timely access to their health information as well as to the kind of education resources that help improve their outcomes."
Troubling yet predictable findings emerge from the 2010 Review of Physician Recruiting Incentives, the annual survey from physician recruiters Merritt Hawkins/AMN Healthcare, which reflects the market realities of the past year for healthcare in a down economy.
The survey also provides clues for the near term. It's based on 2,812 permanent physician and certified registered nurse anesthetist searches in 48 states which the Irving, TX-based recruiters conducted from April 1, 2009, through March 31, 2010.
First, recruiting was down in 2009-10 for the first time in the 17-year history of the survey, even though there is nothing to suggest that demand has abated.
"This is quite possibly our most accurate survey ever because the decisions that were made from the client base were 'had to,' and not 'want to' decisions," says Merritt Hawkins Senior Vice President Travis Singleton. "We have a bottleneck. The needs didn't go away. In fact, they compounded. But our clients said there was an almost complete stop, wait, and hold. In that respect, the survey is the truest representation of what these different clients had to do to survive."
Among the contributing factors, Singleton says, were the overall poor economy, a corresponding lack of capital, the uncertainty of healthcare reform, falling medical utilization and reimbursements, and an unwillingness of many physician-candidates to relocate in a challenging economic climate.
Second, hospitals, health systems, and medical groups in more-populated areas were doing the bulk of the hiring. In 2008-09, hospitals, physician groups, and other healthcare entities in communities with less than 25,000 people conducted 39% of the Merritt Hawkins searches, and communities with 100,000 or more people conducted 26% of the searches. That's a flip-flop from 2008-09, when smaller communities conducted 39% of the searches, and larger communities conducted 26% of the searches.
"You can tie that to financial woes," Singleton says. "The smaller groups and hospitals were on the front line. When you saw capital dry up, when you saw the pressures of having to put guarantees out to recruit physicians becoming tougher, the ones that flat out couldn't do it were the communities with 25,000 or less. I'm not saying it was easier for the larger systems, but the larger metro and health system-oriented clients had the wherewithal and resources to recruit."
Third, even though recruiting is down, the overall demand for primary care physicians remains strong. Family practice, internists, and hospitalists were among the top five most sought-after specialties.
Family practice and internal medicine are going to continue to rise "as the geriatric patient base demands it, with our chronic and high-risk patients that we are dumping on the system," Singleton says. "Hospitalists have been our Steady Eddie and that will remain the same because it's become an accepted practice of both quality and expense savings."
Interestingly—and tellingly—psychiatrists and emergency physicians were among the top five medical specialties sought in 2009-10.
"The economy is down and you can tie emotional and mental health with economic times," Singleton says. "Certainly, when it is combined with people's jobs, it has been the most undiagnosed and unclear of all modalities out there."
Singleton says the rising demand for psychiatrists also may reflect the growing understanding in the healthcare community that mental health is underserved and the push for mental healthcare parity. "There has been such a need for psychiatry for so long. These patients have been shuffled through the primary care system, and to be quite frank, that isn't the best way to diagnose and treat these patients," he says. "As that has been getting more publicity over the last two or three years, you are seeing the need go up."
Unfortunately, psychiatrists represent the oldest demographic among healthcare specialists, and not enough younger physicians are coming into the field. "Those who want to come into the field only want to do outpatient, and the need right now is inpatient," Singleton says.
Fourth, despite the demand, primary care compensation remains the lowest among medical specialties. Family physicians' compensation averaged $175,000. Orthopedic surgeons were tops, averaging $519,000.
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"Under the current structure, primary care salaries are about what they can be," Singleton says. "They are going to go up a little more, but there is just no room. Without massive reform, you aren't going to see a huge difference."
"The more telling stat in this survey is the lows. We always focus on the average, but when you look at the lows, family practice compensation jumped up $20,000 (from $120,000 in 2008-09 to $140,000 in 2009-10) in one year. That is massive considering the total compensation. That tells us it is so competitive out there. There are no more oases. There are no destination cities. Everyone is somewhat on a level playing field, and that is scarier than the average going up."
Fifth, the numbers of physicians abandoning private practice for hospital employment has swelled from a trickle to a stream to a tsunami. "We are seeing it on a scale like never before," Singleton says, adding that the desire for employment is now coming from both physicians and hospitals.
"In the past it's been one side pushing an agenda—the hospital wanting market share," he says. "This time it's the hospitals realizing that to control costs and outcomes as best they can—but also in an effort to control their lifeblood, the physician—you have to have flexibility. And in today's market, there is no flexibility without employment."
As compensation becomes more competitive, Singleton says more hospitals will be even more incentivized to take up the employment model or something similar, especially as accountable care organizations come to the fore.
Synergy of care and bundling are examples of those things pushing down this funnel of employment. "Those larger organizations that have experience in that field are one step ahead," he says. "Some of these other smaller clients that know this is the outcome have never done it before. They are not equipped to employ physicians. If anything, the numbers of employed physicians will shoot up next year because that segment is now forced to join the game."
On the physician side, Singleton says it's a wonder that any private practices are left, especially in light of the ongoing uncertainty over healthcare reform and Medicare reimbursements.
"Think about the year that they just went through," Singleton says. "Imagine coming to work. The rules of the game could change on you at any moment. There is such a lack of stability and a lack of guarantees in their world right now. Anything that can give them both of those areas they are going to do. Employment does just that."
Another deadline has passed in the long-drawn efforts of the nation's academic medical centers and teaching hospitals to recover more than $2 billion in social security taxes that the hospitals and their medical residents paid under protest to the federal government for more than a decade.
Teaching hospitals filing for a Federal Insurance Contributions Act (FICA) are required by The Internal Revenue Service requires refund to have submitted by July 9 a power of attorney Form 28-48, assigning representation for the refund process. The IRS will send back a notification letter that sets in motion a 120-day organizational period for hospitals to document their FICA rebate claims.
Teaching hospitals are trying to regain FICA taxes that they and residents paid from 1995 until April 1, 2005. For years, the IRS had treated medical residents as employees, requiring them and their teaching hospitals to pay FICA taxes on their earnings, even though no specific regulation was on the books addressing the special status of residents. The teaching hospitals claim that medical residents are students in a learning environment, and are therefore exempt from paying FICA taxes.
In April, 2005, after years of lawsuits and complaints, the IRS imposed specific FICA requirement for medical residents, but said that teaching hospitals and residents that had paid the FICA taxes under formal protest in a "pre-regulation" period between 1995 and the first quarter of 2005 would be eligible for a rebate, plus interest.
By some estimates, teaching hospitals and medical residents could each be due rebates of between $3,000 and $3,500 per resident, per year, for the 10-year period. Several estimates peg the total value of the rebates as more than $2 billion.
The legality of the April 1, 2005 FICA requirement for residents is being challenged in a separate suit that will be heard by the U.S. Supreme Court this fall.
Robin Greenhouse, a partner and tax specialist with the law firm of McDermott Will & Emery LLP, which has litigated on behalf of several teaching hospitals, said the FICA refund process will require extensive documentation, and that any teaching hospital that has not begun the process should do so now.
For example, teaching hospitals must show the IRS a consent form signed by every medical resident dating back to 1995, which Greenhouse said could prove to be particularly time consuming.
"It requires identifying last-known addresses, sending out consent forms, responding to inquiries, tabulating the information you get, that will all go to the IRS," Greenhouse says. "There is a lot of work the academic medical centers are doing either in-house or with outside consultants. These are residents who may no longer be affiliated with these academic medical centers. So identifying their last known addresses takes work." Greenhouse says teaching hospitals need to at least make a "reasonable effort" to contact former residents, using first-class mail, and giving residents 45 days to respond.
"That is an area where hospitals need to be careful. The IRS will look at the reasonableness of their efforts," Greenhouse says. "They don't have to be perfect but they have to have acted reasonably."
Teaching hospitals must also understand that moonlighting by medical residents is not exempt from FICA taxes that Greenhouse says needs to be "scrubbed out" of refund claims. "So, academic medical centers need to review their records and identify potential amounts for moonlighting. The IRS will be looking for that," she says. When the claim is approved, teaching hospitals will get a lump-sum check from the IRS that will include an aggregate amount for the medical students.
"The medical center is going to have to send out individual checks to the former residents and they are going to have to include the appropriate amount of interest," Greenhouse says, adding that the interest rate the IRS pays individuals on claims refunds is higher than the rate it pays corporations.
The teaching hospitals also must submit to the IRS a Form 1099, indicating that taxable interest was paid on the reimbursement, and a Form W-2c, which will be sent to the Social Security Administration to reflect that FICA taxes were not deducted on the medical residents' pay.
North Shore–LIJ Health System said today that starting Sept. 1 it will require newly hired nurses to either hold a Bachelor of Nursing Science degree or earn one within five years.
Michael Dowling, president/CEO of the Great Neck, NY–based 15–hospital health system, said the new requirement—the first of its kind for any hospital in New York State—is based on research that links higher levels of nursing education to improved quality outcomes, lower mortality, and fewer adverse events.
“As patient care becomes more complex and high–tech, there is growing evidence that developing a more highly educated nursing workforce improves patient safety and leads to higher–quality, more cost–effective patient care,” Dowling said, in a media release.
Nurses who do not have a BSN must enroll in a bachelor’s degree program within two years of their hire date and earn their degree within five years. North Shore–LIJ offers tuition assistance to employees for BSN degrees, and flexible onsite nursing degree programs with several Long Island universities and colleges.
Nurses already on staff who have not earned their BSNs are exempt from the new requirement, but they are encouraged to continue their education and take advantage of the health system’s tuition reimbursement program, says Maureen White, RN, senior vice president/CNO of the North Shore–LIJ.
“Nurses require a broad–based education that prepares them to meet increasingly complex patient health needs in constantly evolving practice environments,” White says. “Nurses must be prepared to work with individuals, families and communities of diverse backgrounds in a range of settings as part of interdisciplinary teams. The bottom line is that our nurses have a deep and direct impact on every single patient who enters our doors, more so than any other medical professional.”
White says about 60% of North Shore–LIJ’s more than 10,000 nurses already have a bachelors, masters or doctoral degree, and 465 nurses are now working on obtaining their bachelor’s degree.
“So it’s clear that many already recognize the importance of advancing their clinical knowledge skills and enhancing patient care in their own environment,” White adds.
In 2009, a bill was introduced in the New York State Legislature to require registered professional nurses to attain a BSN degree within 10 years of their initial licensure. If passed, New York would be the first state in the country to have a BSN as standardized entry into the nursing profession. Attempts by nurses and other advocates to pass similar legislation in the state date back to 1976.
Community Health Systems, Inc. has acquired Marion Regional Healthcare System in Marion, SC, the Franklin, TN–based private hospital chain announced this week. Financial terms of the acquisition were not disclosed.
The system includes Marion Regional Hospital, a 124–bed, full–service, acute–care hospital, Mullins Nursing Center, a 92–bed skilled nursing facility, and other ancillary services. Marion Regional Hospital becomes the sixth CHS–affiliated, acute–care hospital in South Carolina. It is located 20 miles east of Carolinas Health System, an affiliated, 420–bed, tertiary hospital in Florence, SC.
“We are pleased to expand our presence in South Carolina and look forward to opportunities for Marion Regional Hospital and our other affiliated hospitals in South Carolina to work collaboratively as they advance healthcare for their respective communities,” says Wayne T. Smith, chairman/president/CEO of CHS.
“We also look forward to working with the hospital’s medical staff and employees as we build upon their commitment to provide quality health services for the residents of Marion County,” he adds.
CHS is the largest publicly–traded hospital company in the United States and operates acute–care hospitals in non–urban and mid–size markets throughout the country. Through its subsidiaries, the CHS owns, leases, or operates 123 hospitals in 29 states with approximately 18,000 licensed beds.
WellCare Health Plans, Inc. said a federal court will allow the Tampa-based health insurer to pursue claims against former Chairman/President/CEO Todd Farha and other top executives.
In addition, WellCare said the U.S. District Court in Middle Florida this week dismissed all claims against current and former directors.
"This is a logical next step in the company's transformation that began in October 2007," said Alec Cunningham, WellCare's CEO. "This is another in a series of company efforts over the past two-and-one-half years to remediate past practices and forge a new future for members, associates, and stockholders."
In 2007, WellCare stockholders filed federal and state lawsuits against Farha, former CFO Paul Behrens, former General Counsel Thad Bereday, and other current and former WellCare directors. WellCare appointed an independent special litigation committee that concluded that the company should pursue claims against Farha, Behrens, and Bereday for breach of duty and breach of contract.
The SLC said it found no evidence supporting claims against the WellCare directors who were named in the actions. The SLC asked the federal court to make WellCare the plaintiff in the actions so it could pursue claims against the three former executives. In addition, WellCare entered a settlement with the original plaintiffs and their counsel.
"These are key legal developments for the company," said Timothy S. Susanin, WellCare's senior vice president, general counsel and secretary. "WellCare can now pursue its claims and hold these former executives accountable for their conduct."
WellCare has been the subject of widespread speculation and litigation for the past four years, after federal investigators raided the insurer's Tampa headquarters, carted off boxes of documents, and grilled executives.
In June, a federal judge unsealed a whistleblower complaint that accused WellCare of egregious conduct, including dumping hundreds of sick newborns and terminally ill patients from the membership rolls to bolster profits.
Florida Attorney General Bill McCollum told Health News Florida this month that former executives at WellCare are the subject of state and federal criminal investigations.
WellCare provides managed care services for Medicaid and Medicare for approximately 2.2 million people nationwide.
For the month of July, healthcare organizations will receive grants from Health and Human Services totaling $390 million to strengthen their medical surge capability.
HHS' Office of the Assistant Secretary for Preparedness and Response will issue the 2010 funds through the Hospital Preparedness Program. The grants are intended to bolster the ability of hospitals and healthcare facilities to respond to the public health emergencies such as natural disasters, disease outbreaks, or acts of terrorism.
All states, territories, New York City, Chicago, Los Angeles County and Washington, DC, will receive grants to develop the following:
—Interoperable communication systems
—Systems to track available hospital beds
—Advance registration of volunteer health professionals
—Processes for hospital evacuations or sheltering
—Processes for fatality management
—Healthcare partnerships at the community level
—Hospital participation in statewide and regional exercise programs
Various grants received:
—California, $32 million
—Los Angeles County, $12.3 million
—New York State, $13.6 million
—New York City, $10.2 million
—Texas, $28.2 million
—Florida, $22 million
Steven E. Weinberger, MD, has been promoted to executive vice president and CEO of the American College of Physicians, effective July 19. The selection was made after a national search and based on recommendations from a search committee appointed by the ACP Board of Regents.
Weinberger will administer ACP's activities in medical education and publishing, membership services, business development, and public policy. He succeeds John Tooker, MD, who announced his intention to step down last October. Tooker will serve as ACP?s associate executive vice president for one year to help the leadership transition.
A career administrator and board-certified internist and pulmonologist, Weinberger served as ACP's deputy executive vice president since 2009 and as senior vice president for medical education and publishing since 2004.
Before joining ACP, Weinberger was faculty associate dean for medical education and a professor of medicine at Harvard Medical School.
He also served as executive vice chair of the department of medicine at Beth Israel Deaconess Medical Center in Boston and executive director of the Carl J. Shapiro Institution for Education and Research, an organization affiliated with both Harvard Medical School and Beth Israel Deaconess Medical Center.
ACP is the largest medical specialty organization and the second-largest physician group in the United States. Its members include 129,000 internists, related subspecialists, and medical students.
Connecticut Tuesday announced that it has reached a settlement with Health Net and its affiliates over the failure last year to secure the private medical records of 1.5 million policyholders and for the insurers' delay in reporting the breach.
Connecticut Attorney General Richard Blumenthal said the settlement imposes a $250,000 fine on the company for HIPAA and HITECH violations, and requires the insurers to adopt rigorous security and notification measures.
The settlement involves Health Net of the Northeast, Inc., Health Net of Connecticut Inc., and parent companies UnitedHealth Group Inc. and Oxford Health Plans.
Blumenthal said the insurers cooperated with the settlement, accepted responsibility for breach, and agreed to a remedial action plan.
The May 14, 2009 loss or theft of a portable computer disk drive at the company's Shelton, CT office impacted about 446,000 Connecticut policy and 1 million other policy holders across the nation. The breached data included personal health records, bank account numbers, and social security numbers. Health Net waited until Nov. 30 to provide notice of the breach.
The information included 27.7 million scanned pages of more than 120 different types of documents, including insurance claim forms, membership forms, appeals, grievances, correspondence, and medical records.
Health Net had maintained that the disk drive had been misplaced, but Blumenthal said a consultant hired by Health Net concluded that it had been stolen.
"This settlement is sadly historic — involving an unparalleled healthcare privacy breach and an unprecedented state enforcement of HIPAA," Blumenthal said in a statement. "These missing medical records included some of the most personal, intimate patient information — exposing individuals to grave embarrassment and emotional distress, as well as financial harm and identity theft," he said.
Health Net issued the following statement: "Protecting the privacy of our members is extremely important to us. As the Connecticut Attorney General stated, Health Net has worked closely and cooperatively with his office and state regulators to enhance our security systems and controls through additional associate training and education, as well as state-of-the-art security programs. All of these improvements will result in Health Net being in the forefront of securing member health information. As stated in the agreement with the Attorney General, to date Health Net has no evidence that there has been any misuse of the data."
Health Net has offered to pay for two years of credit monitoring services for any impacted members who elect the service.
University of Florida officials in Gainesville have notified 2,047 people that their Social Security or Medicaid identification numbers were included on address labels affixed to letters inviting them to participate in a research study.
The letters were sent through the US Postal Service on May 24, and the information also was shared with a telephone survey company. The problem was discovered June 6. Using Social Security numbers and other individual identifying numbers for non-essential purposes is against university policy, UF said in a media release.
The company, Burlington, VT-based Macro International Inc., said it will purge and destroy the information and sign legal documents indicating the task has been completed. The Gainesville-based printer that produced the mailing labels, Renaissance Printing, said it has already done so, UF said.
"We were dismayed to learn of this breach and deeply regret any concern this may cause these individuals," said Susan Blair, UF's chief privacy officer. "We have taken steps to address this problem and are continuing to evaluate our processes and procedures."
The letters were generated as part of a research study conducted through the UF College of Medicine's Department of Epidemiology and Health Policy Research. They were sent to parents or guardians of adolescent girls listed in a statewide database to seek their participation in a telephone survey about human papillomavirus, or HPV, vaccination. The study included a control group of unvaccinated girls ages 9 to 17 and those ages 11 to 17 who had received the vaccine.
The numbers — which were included on the address label so the telephone survey company could identify participants by their number only — were supposed to have been generated randomly. Instead, 647 were Social Security numbers and the remainder were Medicaid numbers, in both cases preceded by an alphabetical character with the hyphens omitted.
UF officials told the Florida Agency for Health Care Administration and the federal Office of Civil Rights. Information about the breach and has posted a notice on the university's home page and the privacy office's website.
