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 What next for healthcare?

At this time it is hard to find a more divisive subject than healthcare, nor to write about it without incurring anger from one quarter or another, along with  accusations of some form of political prejudice. Whichever side of the healthcare see-saw you personally sit upon, one thing is abundantly clear: The times, they are a-changing.

After all the strain we as an industry went through to get ready for ICD-10, submit our Medicare/Medicaid attestations in a timely and accurate manner, and all of the other collective hoops we jumped through just to keep up with the pace of change... we are now in an unprecedented holding pattern, waiting to see what comes next.

gavelSweeping changes are definitely coming which will affect health care for millions of U.S. citizens. That is the issue which hits the headlines every day. The elephant in the room is that whatever form they take, those changes will also deeply affect the healthcare providers that must somehow keep the train on the rails.

They must continue to provide the best service to their patients. They must continue to employ the best trained personnel on the planet. And they must continue to make at least enough of a profit to keep the lights on and the doors open for new arrivals. That will be quite an accomplishment when they do not know from one day to the next what the latest developments in Senate and the House will be. We live in interesting times.

Until the dust settles on a final plan, everything is up in the air as anxious executives across America try to plan for every contingency, no matter how unlikely. All that nervous energy and forward planning must surely be taking away from day to day operations, and thereby affecting the facilities, staff, and ultimately the patients under their care.

We are not going to comment on developments. We are not going to take sides, nor enter into political debate.

We just wish they would sort it out so that we can get on with what we do best: Helping people.

Obama wins 6-3 in Supreme Court battle

Today (Thursday 25 June 2015) the Supreme Court ruled 6 to 3 in favor of upholding federal subsidies in the contentious King v. Burwell case, which addressed whether the wording of the Affordable Care Act intended the State to subsidize insurance premiums in states with Health Exchanges that were not federally implemented or controlled.

One of the three dissenters, Scalia, said that "Words no longer have meaning if an Exchange that is not established by a State is 'established by the state.'" His approach rested on the literal interpretation of the wording of the Act.

In contrast, Chief Justice Roberts (one of the six that voted in favor of the administration) said things were less literal for him. "In every case we must respect the role of the Legislature and take care not to undo what it has done. A fair reading of legislation demands a fair understanding of the legislative plan. Congress passed the Affordable Care Act to improve health insurance markets, not destroy them. If at all possible we must interpret the Act in a way that is consistent with the former and avoids the latter."

By the end of March 2015 an estimated 10.2 million had enrolled in Health Exchange plans. Approximately 85% (9.7 million) of those enrolled received advanced tax credits on their insurance premiums, without which they could not have been able to afford the health care they needed. According to the Kaiser Family Foundation, if the Supreme Court decision had gone against the Administration the loss of those insurance subsidies would have destabilized insurance markets in those states with Federal exchanges, and driven up insurance premiums substantially to cover the additional costs incurred by the insurance companies.

How this outcome will affect the state of healthcare in the future remains to be seen. There is strong feeling on both sides of this debate. However, the die has now been cast. Let us see what will happen next.

Concierge Medicine: A hedge against Medicare/Medicaid reductions?

Ever increasing costs and ever more regulatory controls are adding ever more pressure to many practices already seeing reductions in their Medicare and Medicaid reimbursement levels. This pressure has in turn led many practices to seek alternatives revenue streams, and one increasingly popular source of revenue in particular: Concierge medicine.

In this business model a practice is not dependent on payers, insurance companies, or Medicare incentive payments. In fact, many concierge doctors don't even accept insurance payments or patients. Rather, in concierge medicine, doctors set fixed monthly or annual fees. For payment of this flat fee, patients receive unlimited access to their doctor. Occasional co-pays balance things when needed, but in the course of regular business everybody wins. The practice receives a steady and independent source of income. Patients receive the healthcare they need with a simplified payment structure, often at a lower cost than through a health plan, one which makes their health costs far more manageable and worry-free.

Practices and doctors engaged in concierge medicine are exempt from Medicare billing issues. No ICD coding disputes. No claim denials. Future plans to reduce Medicare incentives hold no fear. Meaningful Use incentives, along with the regulatory requirements governing them, can be ignored. Simply, without Medicare or Medicaid, there are no hoops through which a practice needs to jump.

This of course does not mean that concierge doctors do not need health IT. Quite the opposite. The use of patient portals and health information exchange systems will allow faster and more effective data transfer. Practices which adopt health IT will see patients flocking to their doors. Interoperability with hospital and clinical systems will make patient medical data flow much faster, giving improvements in workflow which will allow treatments of more patients, faster. Patients will also like this, be assured.

Whether a practice is engaged in concierge medicine, Medicare, Medicaid, or any alternate business model, it is clear to see that technological improvements to practice systems will ultimately hold the key to effective revenue cycle management and overall profit margins, as well as improved clinical quality of care and patient treatment. As with most spheres of business, technology offers golden opportunities for those that adopt early, and this applies even more so to healthcare.

Six Months to ICD-10

With only six months to go, many industry leaders believe another delay to the implementation date for ICD-10 to be unlikely. October 1st seems to be a lock. The only remaining obstacle is the impending congressional vote to reconfirm the date, and if that goes through without issue, as many state senators expect it will, then October 1st it indeed is. Ready or not.

Many that were preparing for ICD-10 placed their preparations on hold on April 1, 2014, when the deferment brought about by the Protecting Access to Medicare Act was signed, pushing back the ICD-10 date by a year. The mixed message sent by that act has some still thinking ICD-10 will eventually just go away. This now appears highly unlikely.

Many providers have yet to begin their preparations. One survey found that though 21% of practices surveyed are on track for October 1, 23% claim they have insufficient resources to even begin getting ready. They have not taken even the first step.

Things are not all bad. CMS statistics reveal that of the 15,000 ICD-10 test forms submitted during initial testing (January 26 - February 3 2015), 81% were accepted. First time out, that is a phenomenal result. Test claims were processed, from providers, clearing houses and billing agencies. This would seem to indicate CMS is ready for ICD-10, and the testing phase will help iron out the wrinkles.

The fly in the ointment is that though CMS is ready to process provider claims, a recent survey by the Healthcare Billing and Management Association (HBMA) shows that providers may not be ready to submit them. 84% of HBMA survey respondents say they have not conducted any kind of end-to-end testing for their submission processes. This next six months will be crucial to those providers, to help them fine-tune their work flow and submission processes.

For those that have not yet begun, the clock is ticking. The countdown has begun.

 

PQRS GPRO Registration Ends in 30 Days

With all the news surrounding the October deadline for ICD-10 it would be easy to overlook a more imminent deadline, which practitioners now have only 30 days left to meet.

Practitioners using the Group Practice Reporting Option for the 2015 Physician Quality Reporting System have until June 30 to complete registrations or miss out.

The CMS definition for those eligible to use GPRO can be found on their web site. Quote:

"Groups can register to participate in the 2015 PQRS GPRO via the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System between April 1, 2015 and June 30, 2015 (11:59 pm EDT). The Registration System can be accessed at https://portal.cms.gov using a valid Individuals Authorized Access to the CMS Computer Services (IACS) account. Please see the instructions provided below on how to obtain an IACS account.

A “group” or “group practice” is defined as a single Medicare-billing Taxpayer Identification Number (TIN) with 2 or more individual eligible professionals (EPs) (as identified by their individual National Provider Identifier (NPI)) who have reassigned their billing rights to the TIN.

Groups can participate in the 2015 PQRS GPRO by selecting one of the GPRO reporting mechanisms:

•Qualified PQRS Registry

•Electronic Health Record (EHR) [via Direct EHR using certified EHR technology (CEHRT) or CEHRT via Data Submission Vendor]

•Web Interface (for groups with 25 or more EPs only)

•Consumer Assessment of Health Providers and Systems (CAHPS) for PQRS Survey via a CMS-certified Survey Vendor (as a supplement to another GPRO reporting mechanism)"

End quote.

Additional details can be found on the CMS web site here

This clock is ticking. If you are among those that plan to register, make certain you don't lose the date: June 30th.

ICD improvements mean faster reimbursements.

In 2012 the ChiroCode Institute joined forces with the American Chiropractic Association (ACA) to forge an amalgam of their coding manuals, respectively the ChiroCode Deskbook and the ACA Chiropractic Coding and Compliance Manual. Since then, the partnership has flourished. The most current resource, titled the ICD-10 Coding for Chiropractic (Chirocode ICD-10 Coding Resource Endorsed by ACA) is currently available on the ACA web site at a member price of $119. Non-members pay $129.

ChiroCode Premium members can save themselves a further $10 by purchasing instead through the ChiroCode site, where the price is $109.

The manual promises to be valuable reading for chiropractors, offering a comprehensive list of relevant ICD-10-CM codes for Chiropractic, along with practical tools and advice on converting codes between ICD-9-CM and ICD-10-CM. The book promises to be a complete guide to understanding ICD-10-CM and also offers 'Other aids you need for a painless transition'.

Until the final list of 'Medically Necessary' codes is announced, everyone is second-guessing the way the dice will roll. Some of the more prominent codes are likely to include 724.2 (Lumbago), 724.4 (thoracic or lumbosacral neuritis or radiculitis unspecified), and 724.3 (Sciatica). And this highlights an interesting point.

These ICD-9 codes are quite broad and do not allow for detailed diagnosis. This is a perfect example of where the ICD-10 code set offers much better accuracy and granularity. Rather than a quite vague diagnosis of, say, Lumbago, the improvements to the ICD code set will allow practitioners to identify specific issues, including for example disk displacement.

Medicare normally codes Lumbago as a Category 1 code when calculating Local Coverage Determinations (LCD's). This code is generally recognized as for use in circumstances requiring only a short term of treatment. ICD-10 granularity will support medical arguments for longer durations of care, which will mean more accurate and timely reimbursements with fewer claims denials or delays.

Readers are urged to investigate ICD-10 soon, as the October 1 implementation date is rapidly approaching. For those who wish to discuss this in detail, our team is ready now to answer any questions. Please contact us to schedule a demo, or discuss your options.

Prescription Drugs Outpace Class A Abuses

A study soon to be released in the Journal of Public Policy and Marketing claims that legal prescription drugs like OxyContin are now accountable for more deaths than both heroin and cocaine combined.

The authors of the study, "The Legal High: Factors Affecting Young Consumers' Risk Perceptions and Abuse of Prescription Drugs." are Richard Netemeyer (University of Virginia), Scot Burton (University of Arkansas), Barbara Delaney (Partnership for Drug Free Kids), and Gina Hijjawi (American Institutes for Research).

Their study polled shopping mall teens across the US with a questionnaire on their use of recreational drugs, alcohol and tobacco. Other questions aimed to gauge the mental state and behavioral compass of the respondents

"The CDC has classified the situation as an epidemic. Prescription drugs are seen as blessed by a trusted institution, the FDA, while increasingly aggressive advertising by drug companies simultaneously floods parents and children with messages that these substances are safe, popular, and beneficial.”

Prescription drug use appears to be directly linked proportionately to psychological states and the prevalence of use of other substances, including alcohol. Peer pressure and higher anxiety levels also appear to drive peak usage of prescription drugs.

The authors conclude that, "Teens need help before they reach these tipping points for prescription drug abuse. Adults spotting teens with very high levels of anxiety and at least moderate use of other restricted substances should realize that these are students with a high likelihood of prescription drug abuse. Male teens with a high need to be popular and teens in general appear to be at exceptional risk. Campaigns must target parents as well, since they clearly underestimate both the physical risks of prescription drugs and the likelihood that their children will abuse these drugs."