CMS Meaningful Use Payments to Providers: Incentives or Sophie’s Choice?

thSN5W8HTYSophie’s Choice: You have to choose when there are no good options.

Sophie’s Choice was an award-winning 1983 movie based on the William Styron novel about a Nazi concentration camp survivor who was forced to choose which of her two children to send to the death camps. In this most heart-wrenching scene ever filmed, the woman must choose and begs to choose “neither”.

For healthcare providers who are caught in a regulatory net by participating in government-funded programs, they were given a choice between installing an electronic health record system, attesting to meeting a list of nearly-impossible targets to get reimbursement for their multi-million dollar investments, or choosing not to participate which resulted in losing participation in said government-funded programs and incentives.

Most providers bit. They had no choice. And when it came time to collect the Meaningful Use incentive dollars, they attested to meeting at least the minimum requirements. The government bit back.

Department of Human Service auditors in the Office of Inspector General most recent review estimated that the Centers for Medicare and Medicaid Services has overpaid more than $729 million to providers whose paperwork didn’t pass muster. That’s more than a big whoops for many organizations. That can be an organizational nightmare to reconstruct and prove that your claims were accurate.  Click here to read the story.

Here’s an excerpt from the HealthcareITNews story reporting the overpayments:

All of these providers should begin – if they haven’t already – gathering the required documentation. While it varies by the program, [Erin} Whaley [partner at international law firm Troutman Sanders]  explained it will range from security risk assessments to screenshots. For other measures, providers will need a patient list of an audit log.

And documentation is required for every year attestations are made.

[Matthew] Fisher [partner at corporate law firm Mirick, O’Connell, DeMallie & Lougee] recommended that healthcare providers run an internal audit or review to ensure all documentation and information resides in one place and can be easily accessed.

Financial and Administrative Burdens

Yesterday, I met a young physician at a barbeque. Our conversation led to the typical “what do you do?” When I asked her what specialty she was most interested in, she said she was considering geriatrics or ob-gyn but that the business of medicine had become so dominant that instead she was thinking about getting her MBA and switching her focus completely. This woman spent her early career as a trauma nurse. She loves medicine and loves patient contact. She is currently doing toxicology research and interested in Alzheimer’s Disease research.  But her experience in the medical field is leading her to the conclusion that her brain and talents might better be used analyzing spreadsheets and business plans.

I used to think that healthcare was a positive driver of gross domestic product and a thriving sector of the economy. Now, I wonder if our focus on healthcare as a business isn’t costing us our focus on patients and causing us to lose some of our talented and dedicated medical professionals to regulation and bottom-dollar mentality. Loss for the patient. Loss for the doctor. Loss for society.

This is not a new thought.  But this is a problem that is becoming so acute that to save medicine, we need to reprioritize what we incent, how we incent it and whether the recordkeeping is worth the price of time, focus and energy toward the business rather than the medicine.

Health technology – like all technology – is making quantum leaps forward while we are looking backward to reconstruct Meaningful Use criteria that are quickly becoming meaningless.

In this article on the future of Precision Medicine here, architects of the future of healthcare at the Precision Medicine Summit in Boston last week said that the future of Precision Medicine is more accurately Precision Health. Precision Medicine was about the use of system data to help doctors make decisions about patients; Precision Health is about patient access to their own data to make good decisions about their own health.

This one move from focus on the system to focus on the individual calls into question the future value of the content of the electronic health record stored in your health system database as it relates to patient care. After all, we knew all along that the patient record was, at best, incomplete. It also further calls into question the value of the Meaningful Use criteria as they relate to the practice of medicine where it is today.

Perhaps CMS needs to call a timeout on the HHS auditors, call the MU money well-spent where it incented progress, sunk costs where it impeded progress, and walk away from this program that was as well-designed as it could have been nearly 10 years ago before we knew what we know now.




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XPostFactoid Inaugural Hosting of Health Wonk Review: Get It Here

th45W76ZWMWelcome Andrew Sprung to the Health Wonk Review crew for his debut hosting effort. Click here to read his roundup in the Alternative Facts, Alternative Realities Edition of HWR.


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Healthcare Visionaries Lead the Way

Technology is moving much faster than the snail’s pace of government and regulation. It is an exciting time to be – not just in healthcare – but to be alive.

I’ve been hanging around the virtual water cooler in healthcare for two decades, and now the promise of technology as it affects and improves our lives is beginning to come to fruition. With that, here is a roundup and just a few developments and their significance to the future of healthcare from a medical, business and financial perspective.

Med-Tech: At the head of the futurist pack is Dr. Peter Diamandis, known for oh-so-many things including a founder of the X-PRIZE, Singularity University and the Human Longevity Institute. In his May 19 Abundance Insider, he looks  at a bionic hand developed in the UK “capable of grasping objects without the wearer’s focused thoughts.  The researchers created a convolutional neural network training the hand and its algorithm on the images of over 500 objects in various orientation and lighting conditions with four programmed grasps that you might use to pick up things.”  Go to the link to see the video. Under that entry, you can read the next story about an 18-year-old Mexican student who designed a bra that detects breast cancer.

Health Biz-Tech: The business of healthcare is all about how we pay for medical services and the structure of the business model. Our current system is focused on an insurance-based payment model. Already, insurance companies are toying with issuing insurance policies in real time based on your current medical history that involves instantaneous analysis of your condition, the company’s risk and what it will cost you to be covered by them. This could blow all the regulations out of the water. It could also call into question the current model of trying to cover everyone with insurance and could instigate a movement to have us begin to look at a different business model completely, especially in light of the kind of Med-Tech advances in the pipeline that will completely alter our outcomes and lifespan.

Health Fin-Tech: How and why certain goods and services get paid keep many an insurance agent, claims administrator and government regulator up at night., not to mention the security people who need to lock down our data to maintain patient privacy. The blockchain has the promise of changing the financial world, and healthcare payments and security will be part of this revolution. I am attending a Meetup of blockchain people in my area this Saturday and I’ll report back at some point.

They say those in a movement need to either lead, follow or get out of the way.

At some point in the history of the evolution of healthcare, government was in a position to lead. In the past few years, it has been in the unfortunate position of having to follow as technical advances outpaced the ability of government to legislate and regulate at the pace of change. Now it is time for government to get out of the way. At some point, we’ll need to regulate for safety and security reasons. But this is not that time.

Posted in biotechnology, consumer health apps, elearning, electronic patient records, health economics, health insurance, health IT, health IT training, health policy, health reform | Leave a comment

“I Will Build a Great Health Wonk Review”…And He Has!

donald-trump-black-and-whiteBrag-a-docious much?

Nah, not Jason Shafrin. Our humble Healthcare Economist touts his very biggest, very best, nobody-does-it-better edition of Health Wonk Review right here.

Mightily nicely done, there, Mr. Shafrin!

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Health Wonk Review: Groundhog Zombie Goes Back to the Future

Halloween concept, zombie hand rising out from the groundWith a title like that, who is strong enough to resist clicking on this link to read more? I challenge the most susceptible among you to ignore this post!

Julie Ferguson at Workers’ Comp Insider is our creative mistress of ceremonies this week. Here’s what she has to say:

It’s quite the day to be going to press with a new Health Wonk Review. We were trying to think of  a movie themed metaphor for today’s edition but can’t decide between Back to the Future, Groundhog Day or a zombie flick, so we’re going for a mashup.  Click here to read more.

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It’s That Time Again: Play Ball with Health Wonk Review



Enjoy the Whos’ On First Edition with Brad Wright with Wright on Health. Here’s the link to all the facts.

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InsureBlog Hosts the Pre-Passover Edition of Health Wonk Review






Yes, it is that time again! Oh, sure, the biweekly Health Wonk Review is on your newsstand today. But also, those religious rites of spring are right around the corner. So without further ado or comment from the cheap seats here at Health System Ed, here’s Henry Stern’s pre-Passover edition of HWR. Do yourself a favor and enjoy.

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AHCA: Aye or Nay Edition of Health Wonk Review

ACA passedSeven years ago today, President Obama signed the Affordable Care Act into law, ushering in a host of reforms for the U.S. health care system. And today, House Republicans are planning to vote on the American Health Care Act (AHCA), which would repeal many of the ACA’s spending-related provisions and implement replacements for some aspects of the ACA. The bill was still undergoing changes as of last night, and it’s still unclear whether it has the votes to pass in the House. To say it’s been an eventful few week (and year) in the health wonk world would be an understatement. So welcome to the Health Wonk Review, where we make sense of all the goings-on!

We have a variety of posts this week that focus on the AHCA, but there are also several that tackle other subjects. Without further ado however, a shout out to David Williams, who has been writing at Health Business Blog for a dozen years! David’s blog turned 12 earlier this month, and David celebrated with a roundup of his favorite posts from the past year. Cheers, David, and here’s to a dozen more!

Read the whole edition here at Health Insurance Colorado. Thank you, Louise!

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A Policy Decision: Choosing Between Health Insurance and Medical Care

Those who control the language, control the debate.

The question on the table in the U.S. today is, “What is the most efficient and least costly way to provide health insurance coverage to everyone?”

Coverage is such a nice word. Uncovered is cold and uncaring. Coverage means having health insurance, but the reality is that having health insurance coverage does not automatically guarantee a person has access to medical care.

To change the discussion and find different answers, perhaps a better question is, “What is the most efficient and least costly way to provide medical care to everyone?”

In this context, let me suggest a radical overhaul of the way we think about providing medical care in the U.S. so we get more care for less money than we are spending now. It also requires re-examining the role of insurance.

As a premise, we can gauge our success by controlling the cost of healthcare as a percentage of GDP.

Historically, healthcare has risen from about 5% of national GDP in the early 1960s to nearly 18% today. More patients, new technology, higher prices and a rise in costly comorbidities all contribute to the rise. Beyond these inputs, some structural and regulatory changes also contributed to the cost increases. We have to wonder whether we are getting a commensurate rise in value for the nearly fourfold increase in investment over the last 50 years.

With some changes in basic philosophy, the government’s expenditures and policies can support working people who need to keep their money to access the care they need when they need it, and to make sure the money they spend goes directly to pay doctors and hospitals who right now have to go hat in hand to the insurance company to get paid for caring for them.

A low premium catastrophic health insurance policy coupled with a health savings account plan allows working people to put aside several thousand pretax dollars a year in an interest-bearing savings account to use for medical bills and costs such as prescriptions, eyeglasses, dental work and other health-related expenses. They retain their hard-earned money and designate it for the care they need instead of paying health insurance plans for services in a defined benefit policy that may not cover all their needs.

A Few Stories of the Uncovered Insured

Health insurance is not coverage.

One grad student and research assistant who needs to stay current on his medical care due to an ongoing medical condition is concerned about an issue but can’t afford to go to the doctor for tests because the copays for his health insurance plan are prohibitive.

Another person needs dental work…thousands of dollars of dental work. Dental work is not covered as part of her health insurance plan. She had half the work done, and is paying monthly installments until it is paid off so she can start phase 2 of the dental work. Meanwhile, she continues to pay premiums for health insurance coverage that leaves some of her most acute medical needs out in the cold.

A third self-insured, self-employed person is afraid to use his insurance for his annual exam. If something is wrong and he can’t work, he can’t pay his premiums and would therefore not be insured against medical costs any longer.

A fourth person with employer-sponsored insurance worries with every annual physical that she won’t be able to work any longer and will lose her job and health insurance, leaving her sick and uninsured. Each clean bill of health is a celebration.

The Insurance Function

Some public health insurance plans work for people who qualify for full subsidies and public assistance. For average people making working wages and buying health insurance, the system is not affordable. The government boasts that 85% of ACA enrollees are subsidized. It begs the question why there are so few buying in at full price.

Here’s the radical thought I suggested earlier: We need to revisit the function of insurance. People who are not employed do not need health insurance. They need primary medical care that is not prohibitively costly. Most doctor visits and treatments are simple. Babies with sniffles. Kids with broken arms. Moms with diabetes. Dads with high blood pressure. A doctor visit here. A generic prescription there.

After all, the function of insurance is to provide protection against loss of valuable assets. Most of our health insurance in the U.S. is provided by employers who are insuring their human resources. When people are unemployed, their wages and productivity do not need to be insured. In that case, health insurance for the indigent effectively protects providers against loss for providing medical services to those who can’t afford to pay.

Put another way, when an indigent person needs expensive medical care, it is the provider who needs to be insured against the loss of treating them if they are going to uphold their mission to treat everyone who comes through the door. The indigent person needs medical care; they do not need to be insured against any personal loss if they are judgment proof.

Finally, health insurance companies or health plans have become a clearinghouse for patient information, albeit an imperfect one. Health technology allows patient information to exist without a health plan as a hub, and the information can exist more completely and privately when held by the patient.

A Revolutionary Thought to Redefine the Debate

We need affordable and accessible medical care for everyone. Then we need to assess who and what needs to be insured against loss, and revamp the health insurance mechanism accordingly. Insurance has a valuable function; when applied properly it protects the assets of people who cannot self-insure against loss.

Right now, the government, employers and patients themselves are subsidizing the insurance industry to provide coverage for services that some members can’t afford to access and with whom providers often need to fight to get reimbursement. The insurance industry has a function but it is not functioning optimally under the current paradigm.

If you think the current way of structuring healthcare is keeping down cost, I refer you to an earlier paragraph where we see the cost of care closing in on 20% of GDP.  When we critically assess what we are getting for nearly quadrupling the country’s investment in the health of our citizens, the answers are at best uneven.

Different countries have ways of handling health care that works in the context of their histories, culture, political and economic systems and available delivery mechanisms. Given our own unique circumstances and assets, it may be time to consider stepping back from what has evolved as an expensive and uncoordinated system cobbled together to appease different political and corporate interests, and instead build one from the ground up that best utilizes our available resources and leverages our desire to provide the best care to everyone at the lowest possible cost.

The government is the largest payer of health care in the U.S. There may be ways to get a much bigger bang for a much smaller buck by reconsidering the validity of our fundamental premises regarding the role of health insurance in healthcare.

The American experiment in government requires a uniquely American experiment in universal medical care.


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The “May You Live in Interesting Times” Edition of Health Wonk Review

May You Live in Interesting Times

Just when you thought things can’t get any weirder, they do. Combine staunch opposed ideologies held by fierce political warriors, and we find ourselves under the ancient curse of living in interesting times.

It seems our nation is transitioning from a government run on compromise – remember Ronald Reagan working with Tip O’Neill or Bill Clinton reaching across the aisle to Newt Gingrich? – to one run on diametrically opposed ideologies duking it out in unceasing, heated political and legislative battles. Maybe people will pull back the throttle on the ideological thrusters and land this thing safely. For now, both clearly defined sides in this fight seem to have refined the act of demonizing the opponent to an art form. But this isn’t art. It’s life, and it’s happening in real time. Welcome to interesting times.

Now, off to the land where hyperbole and rancor take a back seat to reason.

Let’s hear from the more tempered voices of the HWR crew’s civilized, balanced and informed debate.

Kicking off the discussions this week, we turn to the Health Affairs Blog where Timothy Jost presents a detailed analysis of the Republican legislation on the table to replace the ACA. In Examining the House Republican ACA Repeal and Replace Legislation, he compares the relatively lengthy ACA draft process to the 3-week run-up to the ACHA legislation. He points out what changes (mostly Medicaid), what doesn’t (pre-existing condition protections, coverage guarantees, etc) and looks at the revenue implications.

The ACA has been an employment driver, so repeal will hurt employment. Joe Paduda breaks out the math for us here at Managed Care Matters. Making healthcare more efficient will cost jobs and reduce incomes for a large segment of the economy. Joe asks, will this affect policymakers’ priorities?

Henry Stern at InsureBlog tells us that, if measured in numbers of lives saved, patients are faring worse under ObamaCare. In fact, InsureBlog reports that the ACA’s success regarding actual lives saved is a big goose egg.  Here’s the story at The ObamaCare Success Story: Zip, nada, and zilch.

Linda Bergthold, writing for Health, provides a dictionary to help decode the meaning behind the politicians’ words, a difficult task under any circumstances. In Decoding Republicans’ Language of Repeal, she cautions readers that seemingly innocuous language such as “patient-centered”, “access to care”, “freedom” and “choice” may not deliver on those promises quite as presented. She said much of the GOP language masks “ideas that are old and tired” that are being recycled. Read more here and decide for yourself.

Over at XPostFactoid, Andrew Sprung is a man looking for a compromise and a way out that saves face for everyone, something that might include a couple of frills like, say, oh, coverage for the vulnerable. In his post, Psst, Democrats: Help Republicans Out of the Repeal Box via Cassidy-Collins, he looks at the Patient Freedom Act as an alternative to the ACA and the AHCA. Read XPostFactoid here.

Over at Health Access California, Anthony Wright pays tribute to 94-year-old health care advocate Dorothy Rice who passed away this week. Of RIP Dorothy Rice, Pioneer in Health, Anthony says, “Rice was a lead economist in the Johnson Administration who made the case for Medicare. For an encore, she had a second career as a world-renowned academic where she dealt with issues from health reform to aging to tobacco control. We were pleased to work with her on our board during the effort to pass and then implement the ACA, providing a historical perspective to remind us these policy fights are not new – although she always thought after the passage of Medicare that the next reform to cover the rest of the population would come a lot sooner than it did.” This tribute details her considerable accomplishments.

Roy Poses at Health Care Renewal questions the integrity of Trump cabinet nominee for Labor Secretary based on some of his rulings as a former U.S. Attorney regarding pharmaceutical companies that favored the corporations. Roy asks, “What sort of swamp drainage process is this?” as he explores the decisions of the cabinet nominee “who had an important role in enabling the impunity of leaders of top health care organizations…he presided over three major settlements with pharmaceutical corporations. In none of them did any individual who enabled, authorized, directed, or implemented the alleged bad behavior suffer any negative consequences. The suits were settled by payments made by the companies.” The details of these cases are in the Health Care Renewal blog here.

David Harlow at HealthBlawg recently hosted a cybersecurity webinar with government experts. To view the webinar, click on this link to view the Second Annual Cybersecurity and Health Care Panel Discussion with Government and Industry Experts. This blog post includes David’s notes from his introductory remarks as well as the 1 hour and 21 minute presentation. Grab a cup of coffee and listen to this in-depth discussion.

After taking in the webinar, you can jump over to David Williams’ Health Business Blog and click on his podcast where he interviews iCardiac Technologies CEO Alex Zapesochny about his electronic clinical outcomes assessment platform. Electronic clinical outcomes assessment platforms collect data from patients, clinicians and caregivers to make clinical trials more efficient and accurate. In this 14 minute interview, they discuss some of the trends in clinical drug development and how they impact platforms such as eCOA.

At Healthcare Economist, Jason Shafrin discusses the evolving methods for evaluating cancer care. Shafrin asks, “How do you measure the quality of care patients with cancer receive? How long they live? Avoiding side effects? Patient satisfaction? Process measures?” The Healthcare Economist investigates here.

Finally, we’ll visit an issue that has begun to cross the ideological divide. At Worker’s Comp Insider, Tom Lynch reports on a recent study on the therapeutic use of medical marijuana as a treatment for chronic pain – and the impending clash between the states and federal government stances on legality.  Read the discussion in more detail here at Who Knew? Medical Marijuana Works (at least for chronic pain).



Posted in biotechnology, consumer health apps, electronic patient records, health economics, health insurance, health IT, health policy, health reform, pharmaceutical marketing | 6 Comments