Healthcare Economy: June 2010 Archives

The Golden Nugget in Meaningful Use

"Meaningful Use" does not need an introduction any more. The sentiment about reporting on CMS defined Meaningful Use (MU) measures to become eligible for ARRA EHR incentives are varied across organizations. Many consider it a necessary evil leading to additional IT investments to support Meaningful Use reporting. According to a recent PwC report on MU, 80% of the provider CIOs are concerned about meeting MU reporting criteria in time for 2011 incentive payment. Lack of clarity around some of the measures adds to their woes.

In this race against time to comply with MU reporting requirements and become eligible for EHR incentives, the approach towards MU compliance tends to become short-sighted and narrowly focused. Most providers expect their EHR vendors to support MU reporting requirements and little preparatory efforts have been initiated at the organization level. For early movers, most of the activities for MU compliance have been around IT requirements to support MU. One of the biggest causes of anxiety, for larger hospitals which have multiple Healthcare Information Systems in their IT environment, is how to get all the data together from multiple systems to report on MU.

While short term tactical approach to MU may serve well to meet 2011 deadline, the biggest benefits will be reaped by those who have long term strategic approach to it. The three staged criteria for MU focused on data capture and share (Stage 1), advanced decision support (Stage 2) and improved outcomes (Stage 3) are catalysts for healthcare IT driven transformation in provider organizations. The golden nugget of 'seeding continuous high performance culture' within provider organizations is inherent in MU roadmap. It will require Healthcare Enterprise Performance Management approach towards MU and expansive planning to mine this golden nugget.

So, how is Healthcare Enterprise Performance Management approach towards MU compliance different? In broad strokes, some of the key ingredients are:
• Increased focus on end user adoption and training on healthcare IT systems
• Business process optimization and redesign to facilitate data collection/data quality management for MU
• Organization change management to promote high performance culture and clear accountability for various performance measures
• MU reporting system that not only focuses on reporting on CMS MU measures but also monitors other operational and clinical KPIs that directly or indirectly influence MU compliance
• Ability to monitor and enhance benefits realized from MU compliance

I will discuss some of these in more detail in my future blogs

Posted by Seema Pandey at 10:25 AM | Permalink | Comments (0) | TrackBacks (0)

ICD 10 - reimbursement opportunities

The new version of MS-DRG's reflecting the specificity of the ICD-10 codes is not going to be released until at least a year after the ICD-10 compliance date - this is going to allow CMS to build claim history in ICD-10. CMS has mapped ICD-10 codes to the existing DRG v 26.0, in such a way that, for exactly same medical services, the assigned DRG will be the same, regardless of whether ICD-9 or ICD-10 codes are used to arrive at the DRG. As far as AP-DRG and other commercial DRG's are concerned, I don't even know if there's a plan in place to revise them based on ICD-10.

That's a sigh of relief for most organizations that are viewing ICD-10 as another regulatory burden. Immediate significant changes to reimbursement schemes are not needed - it helps both providers and payers push out the most complex of the ICD-10 related changes by at least a couple years.

Let me take a step back and reiterate one of the most significant advantages of moving to ICD-10. ICD-10 is going to help the healthcare industry, by ensuring that claim reimbursement reflects the resource usage more accurately. And does this need to wait till the new DRG's are published? - I'd say no and here's why:

The combination of current DRG's and ICD-10 codes can provide the same level of detail that the new DRG's will potentially provide. For example, even if a v26 DRG doesn't differentiate Open or Laparoscopy approach, payers can make that determination using the associated ICD-10 code and negotiate different rates for open and laparoscopic procedures. ICD-10 codes can start playing a more important role in reimbursement contracts, even in straightforward MS-DRG "relative weight" based reimbursement schemes.

I realize that it's not going to be that easy to implement and that's why most organizations probably won't - but then innovative organizations will differentiate themselves from the rest of the pack by starting to take advantage of ICD-10 right away, rather than wait for years for CMS to come up with new version of the MS-DRG's.

Posted by Vijay Kumar B at 7:09 AM | Permalink | Comments (0) | TrackBacks (0)

"ICD10 and Meaningful usages... the twains shall meet, for sure"

Deviating a bit from my previous discussion regarding provider's movement, up the EMR adoption chain, today I wanted to take a slight tangential divergence today to talk about the other big guy in the arena. Yes, I am talking about the adoption of ICD10. But is it really a tangential diversion? Isn't that the million dollar question?

Let's begin with the ultimate goal of all the reforms that are being passed left, right and center... Reduce the cost of care while increasing the quality of care. And both, the meaningful usage performance matrices and the added granularity of ICD10 attempt to do the same. Let's see how.

We all know well by now that the attempt to electronicize (if there is such a word. If not, I should copyright it) the medical records is focused at reducing errors, sharing information, eliminating redundant procedures etc., all leading to reduction in cost and improvement in quality. So there is not much discussion there. Let's now see if I10 also meets these criterions.

One of the significant administrative cost factor associated with payer industry is the manual processing of claims. It is estimated that every extra percentage of pended claims (ones that cannot be auto-adjudicated) cost an average payer anywhere from 3 to 5 million dollars a year. That may be chump change for some of the big names but is nothing to scoff at. Every single effort that reduces the manual processing, counts. Today, most of the Laminoplasty claims (for comprehensive Myelopathy) are manually reviewed. With the advent of I10 that provide the exact location of Stenosis and identify compression syndrome, these claims can be greatly auto-adjudicated, thereby saving administrative cost.

Let's now talk about improved quality of care. The elimination of 'V' codes from I10 and codification of factors that influence health such as obesity, will surely provide for better wellness management programs. Similarly, the added granularity, such as the distinction between people with persistence asthma versus people without persistence, will allow better stratification of patients for disease management programs. These changes can only improve the quality of care.

Beyond the obvious congruence of objectives, there are similarities in implementation efforts also. When one is adopting EMRs in any case for the purpose of meaningful usage, wouldn't it make sense to add the I10 logic in there at a small incremental cost rather than to leave the effort to a later day and incur another huge IT bill?

In addition, both meaningful usage and I10 implementations impact not only the technology portfolio of the organization but also change the business process landscape significantly. Why incur the cost of two separate assessment exercises when one can do it at the same time at a much smaller incremental cost.

So, wouldn't it be a good idea to merge the two initiatives that are currently being governed by two separate entities and are working against dissimilar timelines? Me thinks, it would not be a bad idea at all.

Posted by Rajiv Sabharwal at 6:58 AM | Permalink | Comments (0) | TrackBacks (0)

Payout neutrality using the new MS-DRGv26 is a debate...simulate your payments now

The released version of ICD-10 based MS-DRGs by CMS is technically only a "draft" and the final version expected by 3rd quarter of 2014 is still due for the federal rulemaking process. CMS initiated the project with an intention to produce a grouper that can replicate the existing DRG logic using ICD-10 codes and assign patients the same MS-DRG they would have been assigned to, if they were coded in ICD-9-CM. This means that Medicare is aiming towards financial neutrality for their trading partners.

Frankly speaking, if such a thing is possible, then ICD-10-CM/PCS codes and the ICD-9-CM codes are no different. Then why is US healthcare moving for ICD-10? Obviously, not just to upgrade from its precursor ICD-9 or to position itself better in the international health space. I guess, the correct answer is to use ICD-10 as a catalyst for mitigating the long standing concerns- 1.) compromised quality of care and 2.) escalating healthcare cost. ICD-10's clinical granularity promises better care but, its inherent ability to identify the wider disparity in severity (and presumably resources) than the ICD-9 predecessor is "the power" to make payouts/reimbursements more tailored and precise.

In this context, the CMS initiative to keep the MS-DRGs intact irrespective of being induced by ICD-9 or ICD-10 is highly debatable (from ICD-10's financial incentive perspective). Why? Let me site two examples-

a. The ICD-9 code 39.31 (SUTURE OF ARTERY) today maps to MDC 5, MS DRG 252-254. Post ICD-9 to 10 conversion this source code having 195 target codes (as per GEM) will be in the same MDC 5, but surprisingly in a different DRG, i.e. 237-238.

b. Post 2013, ICD-10 codes OB717DZ or OB718DZ will derive DRG 165. But obliging to the CMS MS-DRG conversion principle if any one intends to map those ICD-10 codes back to ICD-9, OB717DZ and OB718DZ ICD-10 codes will get mapped to ICD-9 code 96.06, Other Intubation Respiratory Tract, which will be then altogether a different DRG (DRG 203).

With many such empirical data, it's evident that maintaining payout neutrality in ICD-10 world is going to be real challenge & arduous task. In a nutshell there is an inherent need to split the MS-DRGs acknowledging the clinical depth of the new ICD codes. Moreover, once CMS has collected a year or two of ICD-10-based data the landscape of DRGs is sure to change considerably.

It is never a business wise decision to wait till 2015. Right away one has to initiate some intelligent payout simulation and make some payment changes and that's obvious - such as when the ICD-10 codes clearly distinguish minor and major procedures and it doesn't make sense to lump them together now that they know exactly which procedure was performed by the provider(because of the increased specificity in ICD-10-PCS).

Posted by Dr Suman De at 6:17 PM | Permalink | Comments (1) | TrackBacks (0)

Meaningful Use - Are you stuck : Take the first step

After the promulgation of ARRA 2009 there has been a huge debate, discussion, mapping of what actually Meaningful Use of EHR is ? Is it just implementing EHR technology , capturing information /using the data,showing better health outcomes etc.

There is widespread belief and intermittent evidence that the use of Electronic Health Record technology and other health information technology (Health IT) can facilitate improved quality, safety, innovation and efficiency. There is also widespread evidence of the failure of health IT to generate anticipated results, with recent reports showing 50-80% of EHR projects fail to deliver the anticipated results, this happens for the fact hospital organization do not assess their core competencies, critical success factors and key valuable themes which can make them adopt the technology judiciously with more meaningful outcomes.

Today in the wake of the rising above the recession and HHS regulations forcing the ARRA - Meaningful Use mandates most providers : practicing clinicians and hospitals are in an impasse as to how to begin the journey towards ARRA - Meaningful Use Mandates - how to choose, implement the appropriate EHR technology, Meaningful Use compliance level, manage outcomes, apply for incentives with the tight timelines and all this is linked to Meaningful Use EHR technology

The two important and key issues that all providers are facing in moving forward with Meaningful Use of EHR technology implementation are:
a) How do I do it, where to begin with and move forward
b) If I do it do I really get the ROI and value realization

At this stage many providers have deployed certain level of technology with reference to ADT, LIS, RIS and to manage many other workflows few providers may be at an advanced level, some at middle level and many at a nascent levelkeeping this fact in mind every provider organization would want to optimize its past investment and effort in deploying the technology.

At this juncture it important for any eligible provider/provider organization to first perform a core Assessment to move onto the MU direction which is applicable for the value realization and critical EHR readiness . The providers should analyze their core and allied competencies across 5 themes:
• User Attitudes and Beliefs (Internal User environment: Physicians, nurses, executives)
• Technical (Infrastructure, application utilization)
• Current Technology (length and the breadth of the technology use and implementation)
• Facilitating Conditions (patient mix, metrics culture, user support,
• Care Team Culture (Hierarchical structure, Care givers & Clinical adoption)
• Organizational Strategy (Strategic plan, change initiatives, executive level risk)

The assessment in these themes should be applied to various technical, functional, soft skills, adoption areas to be able to position the organization early, moderate and high adoption Meaningful Use preparedness. Once we are able to identify the right self positioning for a provider organization, only then we should look at the ARRA MU measures, not only perform the gap - fit analysis but also perform value realization exercise and be able to take step on the right direction where results illuminate areas of the organization that are prepared to generate value and areas that require action to improve readiness and transform the provider organization into the successful Meaningful Use level.

Posted by Shishir Kumar at 9:37 AM | Permalink | Comments (0) | TrackBacks (0)