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Surviving 2014: The Toughest Year in Healthcare

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The following is a guest blog post by Ben Quirk, CEO of Quirk Healthcare Solutions.
Ben Quirk
How bad is 2014 for the healthcare industry? We’ve all read about ICD-10, EHR incentives, Medicare cuts, and the Affordable Care Act. But the most telling moment for me occurred during this year’s HIMSS conference in Orlando. There was quite a bit of B2B enthusiasm, but among the civilians it was mostly a lot of stunned looks and talk about how to get through the year. Here are some of my observations:

ICD-10. CMS has made it abundantly clear there will be no further delays to the October 1 deadline for ICD-10 implementation. This is possibly the most significant change to the healthcare industry in 35 years, affecting claims payment/billing systems, clearinghouses, and private and public software applications. Anyone who provides or receives healthcare in the US will be touched by this in some way.

In a recent poll of healthcare providers conducted by KPMG, less than half of the respondents said they had performed basic testing on ICD-10, and only a third had completed comprehensive tests. Moreover, about 3 out of 4 said they did not plan to conduct tests of any kind with entities outside their organizations.

Incorrect claims denial will be the most likely result. CMS will not process ICD-9 Medicare/Medicaid claims after October 1, and there is a high potential for faulty ICD-10 coding or bad mapping to ICD-9 codes. Error rates of 6 to 10 percent are anticipated, compared to an average of 3 percent under ICD-9. ICD-10 will result in a 100 to 200 percent increase in denial rates, with a related increase in receivable days of 20 to 40 percent. Cash flow problems could extend up to two years following implementation. This will be a costly issue for providers, and a very visible issue for patients.

We advise our clients to be proactive in their financial planning. This should include preparation for delayed claims adjudication and payments, adjustments to cash reserves, or even arranging for a new/increased line of credit. Having sufficient cash on hand to cover overhead during the final quarter of 2014 could be very important, as could future reserves to cover up to six months of payment delays. Companies not in a position to set aside reserves should consider working with lenders now before any issues arise.

Meaningful Use. As with ICD-10, CMS has stated there will be no delays to MU deadlines in 2014. That means providers who have never attested must do so by September 30, or else be subject to penalties in the form of Medicare payment adjustments starting in 2015. Providers who have attested in the past will have a bit longer (until December 31), but the penalties are the same.

There is much dissatisfaction with the government’s “all or nothing” approach to MU, where even the slightest misstep can invalidate an otherwise accurate attestation. While the ONC has proposed a more lenient model for EHR certification in coming years, everything will be measured against a hard deadline in 2014.  CMS is offering some mitigation through hardship exemptions, based on rules that are somewhat broad at this point. Providers should consider applying for an exemption if no other options are available.

We advise against taking shortcuts or rushing to beat the clock on MU. Up to ten percent of eligible professionals and hospitals will be subject to audit, and large hospitals may have millions of dollars at stake. Being prepared for an audit means more than just making sure an attestation is iron-clad; internal workflow and communication are also important. A mishandled audit notification can result in a late response and automatic failure.  Data security should also not be overlooked. Medical groups have failed audits due to lapsed security risk assessments as required under HIPAA.

Medicare Payment Cuts. Medicare Sustainable Growth Rate (SGR) cuts continue to hover over Medicare providers. Enacted by Congress in 1997, the SGR was intended to control costs by cutting reimbursements to providers based on prior year expenditures. But every year costs continue to rise, as do ever-worse SGR cuts (almost 24% in 2015). And every year Congress prevents the cuts via so-called “doc fix” legislation.

In early 2014 there was surprising bi-partisan agreement on a permanent doc fix, whereby Medicare reimbursements would be based on quality measures rather than overall expenditures. However, the legislation was derailed by linking it to a delay of the ACA’s individual mandate. As of mid-March there is still no permanent or temporary solution. Congress will almost certainly intervene to prevent SGR cuts, but by how much is uncertain.

The ACA. As the cost of insurance has increased over the past decade, high-deductible plans have become more and more common. Due to the Affordable Care Act, this trend has become the norm. Media outlets focus on the impact to consumers, and argue about whether more “skin in the game” leads to better choices or less care. What we’re hearing from the front lines is much more concrete: high deductibles are having a negative impact on revenues.

Very few people understand their liabilities under a typical health insurance plan. Last year George Loewenstein, a health-care economist with Carnegie Mellon University, published a survey showing that only 14 percent of respondents understood the basics of traditional insurance policies. At the same time, hospitals report that about 25 percent of bad debt originates from patients who are currently insured. With millions of new enrollees in high-deductible plans and an ongoing economic slump, the situation can only get worse.

The ACA had a further impact by reducing the amount of Disproportionate Share Hospital (DSH) charity funds available, based on a projected increase in insurance coverage.  But with some states not participating in Medicaid expansion, combined with an increase in patients lacking the knowledge or resources to manage large medical expenditures, the reduction in funds comes at exactly the wrong time.

Providers can cope by adjusting revenue cycle processes. For example, new programs should focus on estimating patient liabilities pre-arrival, educating the patient at check-in, and instituting proactive billing/collection at the point of service. In general, providers must pay more attention to the self-pay process, focusing on patient education and offering transparent, easy-to-use billing and payment methods.

Value Modifier. This program has not been a worry for most providers thus far. Not because it won’t have an impact on revenue, but because they don’t know about it. A little-known provision of the ACA, the Value-Based Payment Modifier mandates adjustments to Medicare reimbursement based on quality and cost measures. The program is being phased in, and so far has applied only to group practices of 100 or more Eligible Professionals (EPs). In 2014, smaller groups of 10 or more EPs will be subject to the legislation. These groups must apply and report to the program by October 1. Otherwise, they will be subject to a 2 percent cut in Medicare reimbursements starting in 2016.

One of the most important aspects of the program is its definition of “eligible professional” when defining the size of a group practice. For the purposes of Value Modifier, eligible professionals include not only physicians but also practitioners and therapists. That means that a practice with 8 physicians, a nurse practitioner, and a physical therapist would qualify as a practice with 10 EPs.

Value Modifier is part of the growing trend toward quality-based reimbursement. Even commercial payers are considering some version of the program. The scoring calculations are complex and poorly understood, so we advise clients to get up-to-speed as soon as possible. Groups with high quality and low cost will receive incentives rather than cuts, with additional upward adjustment for services to high-risk beneficiaries. Groups that are not paying attention may be surprised by an additional hit to revenue in 2016. In addition, quality scores will eventually be published to the general public on the Physician Compare website.  Sub-par or missing scores could have a negative financial impact on a practice.


These are only the most high-profile impacts to the healthcare industry during the current year. Much else flows from them: changes to workflow, to computer systems, to financial expectations. Tremendous pressures are coming to bear within a limited timeframe.  We’re seeing an industry in the midst of tectonic change, with 2014 as the fault line. It’s unclear whether these disruptions will be for better or worse. But there certainly will be winners and losers, and those who plan ahead are most likely to survive.


Ben Quirk is CEO of Quirk Healthcare Solutions, a consulting firm specializing in EHR strategic management, workflow optimization, systems development, and training. The company’s clients have enjoyed remarkable success, including award of the Medicare Advantage 5-star rating. Quirk Healthcare presents a weekly webinar series, Insights, to inform clients and the general public about government programs and industry trends. Mr. Quirk is also Executive Director of the Quirk Healthcare Foundation, a learning institution which fosters innovation in the healthcare industry.

March 26, 2014 I Written By

PQRS Incentives, Penalties and the Coming Value Based Payment Modifier

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The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff
Much of the focus of healthcare has been on meaningful use and the EHR incentive money. Considering we just reached $19 billion of payouts, it’s definitely a topic worthy of attention. However, a topic which hasn’t gotten nearly as much attention, but is nearly or possibly more important than meaningful use is PQRS and the Value Based Payment Modifier.

Before I dig into some of the details and timelines for PQRS and the Value Based Payment Modifier, it’s really important to note that both of these programs are really just a preview of what’s happening with Medicare reimbursement. These programs are the core of the shift towards paying physicians differentially based on the quality and cost of the care they provide and away from the traditional fee for service model. We’ve seen similar value based payment arrangements with the advent of ACOs, CINs and other clinical networks establishing innovative payment models with payers. Understanding where these programs are going will give you a preview of what’s happening with healthcare reimbursement.

When it comes to PQRS, much like meaningful use, there is both a PQRS incentive and PQRS penalty (carrot and stick if you prefer). 2014 is the final year to receive the PQRS incentive money (0.5% of Medicare Part B claims) and participants must submit 12 months of 2013 CQM data by February 28, 2014 if reporting by claims data, March 21, 2014 if reporting by GPRO web interface, and March 31, 2014 if reporting by registry data. (Note: The 2013 MU reporting deadline was moved to March 31, 2014, but the PQRS deadlines have not changed.). However, more important is that providers who don’t report PQRS 2013 data will be penalized 1.5% in 2015. Those who don’t participate in PQRS in 2014 will be penalized 2% in 2016.

Value Based Payment Modifier
While most people have heard about PQRS and are hopefully participating to avoid the penalties, many people haven’t heard about the Value Based Payment Modifier that is built on the PQRS foundation. While you could look at the Value Based Payment Modifier final rule, this Value-Based Payment Modifier summary is a much better overview of the program.

Essentially, the Affordable Care Act (ACA) required that CMS implement a value based payment modifier that would apply to Medicare fee for service payments. This program will start with physicians in groups of 100 or more eligible professionals under the same TIN beginning January 1, 2015, and apply to all physicians and groups by January 1, 2017. CMS also recently announced that this applies to both par and non-par Medicare providers with 100 or more eligible professionals.

Here’s a look at how this new Value Modifier will work for groups of physicians with 100 or more eligible professionals and will likely be a preview of what’s to come for all Medicare physicians:
CMS Value Modifier

While the program starts with relatively small 1% adjustments, this quote from CMS also provides a clear indication of where they want to take this program:

We also anticipate that we would propose to increase the amount of payment at risk for the Value Modifier as we gain additional experience with the methodologies used to assess the quality of care, and the cost of care, furnished by physicians and groups of physicians.

What should you do to be prepared for this new Value Based Payment Modifier?
1. Participate in the PQRS program since it’s the foundation of what’s to come.
2. Keep an eye on changes to the PQRS and Value Based Modifier programs. They are changing regularly and it’s worth knowing what’s changing with these programs.
3. Work with your professional organization to provide feedback on these programs. No doubt they’re keeping an eye on them and providing feedback as part of the government rule making process. Make sure your voice is heard.

CMS looks at this new value based modifier as a budget neutral program. That means that there are going to be winners and losers. By understanding how these programs work, you can better assess if you want to work to avoid the payment adjustments or if you’re ok taking them on.

Like it or not, PQRS is the start of the movement towards quality based reimbursement and likely a small preview of coming attractions. Of course, if the SGR Fix gets funded by congress, then PQRS, Meaningful Use and the Value Based Modifier will be sunset at the end of 2017 and rolled into a new Merit-Based Incentive Payment System (MIPS) that will start in 2018. More on MIPS in the future, but I think we can safely say that MIPS will be an amalgamation of all these incentive programs.

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

February 20, 2014 I Written By

Health Insurance Exchange Q&A with John Kelly from Edifecs

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The following is an interview about Health Insurance Exchanges with John Kelly, Principal Business Advisor, Edifecs.
John Kelly
1. Where are we at with Health Insurance Exchanges (HIX)? What are the timelines for their implementation?

The Patient Protection and Affordable Care Act (ACA) mandates creation of a retail market for health insurance, where individuals can shop, compare and buy healthcare coverage much the same way as they would a car. The goal is to provide greater access to healthcare coverage and eventually lower costs. While the ACA initiated the health insurance exchanges (HIXs) as the first step in creating a new retail market for healthcare, it specifically did not stipulate the Federal and State exchanges as the stated goal of the legislation. The stated goal was to reform the way Americans purchased their healthcare. Before the October 1st deadline has even arrived, the HIX model is already evolving beyond the federally funded exchanges. Private exchanges are already up and running and private websites (eHealth Insurance, et al.) have begun to integrate with public infrastructure. Much of the country has focused on the open enrollment date, but the real challenges come afterward, as the industry deals with the operational realities of participating on HIXs over the long term.

The public exchanges are due to launch next week, and open enrollment runs through March 31, 2014. Starting January 1, 2014 all health plans purchased through the insurance exchanges will go into effect, meaning those who bought their health insurance on an exchange will be covered.

2. This is implemented on a state-by-state basis, right? Are all 50 states ready?

There are numerous exchanges. Each state had the option to establish its own state-operated HIX or participate in the Federally Facilitated Marketplace (FFM). Thirty-three states chose the FFM, 15 states plus the District of Columbia are running their own marketplaces, and two states are partnering with the federal government to run their exchange.

In addition to the state-run marketplaces, another major component is the Data Services Hub, which is a tool developed by The Centers for Medicare & Medicaid Services (CMS) to interact with all 51 exchanges, verify applicant information and determine eligibility for enrollment in select health plans and subsidy programs.

Some states are more prepared than others, having made investments in customer service hotlines, technology testing, and consumer education campaigns. Generally, these states made early decisions to participate, so their implementations are more mature, though I doubt any would say they are all set to go. As enrollment gets underway, all of the exchanges will engage in constant improvements (much like any large technology project) to iron out bugs and improve functionality. For the states that didn’t make those investments, it will be a more difficult process.

3. What do health insurance exchanges mean for the health plans? What’s their reaction to the health insurance exchanges?

HIXs are creating a disruptive force for insurers and purchasers, a force that will change the way they conduct business. For insurers, it will change everything from attracting consumers to their end-to-end administrative processes (member enrollment, system integration, payment transactions, etc.).

It hasn’t been easy, particularly because of the compressed timeline between the federal government releasing detailed guidelines and the go-live date of October 1, 2013. Insurers are trying to balance caution with the prospect of 30 million enrollees and $200 billion in revenue within the next decade.

Many health insurers have realized they already participate in Medicare and Medicaid, a form of retail healthcare purchasing, so why not exploit the opportunity of these new exchanges? The reward potential is compelling, especially for regional plans that can now compete with national plans for employers who may choose to migrate to “defined contribution” plans. This is likely to be the largest open enrollment period in history nationwide. While it is not an ideal situation to increase enrollment under such a tight timeline, many realize the potential opportunities and are committed to making it work.

Perhaps the biggest change for plans is that they will have to learn to compete for members and customers, rather than employer groups and brokers. The shift away from competing for members began in the early 1990’s with “sole source” health plan marketing. Plans will need to re-learn some old skills. Plans will need to compete much more consciously on value as opposed to just cost. This was the primary and clear intent of the ACA.

4. What do the health insurance exchanges mean for an employer?

Up until recently, the consensus in the industry was that most employers would stick with the conventional employer-sponsored benefits system, rather than switch to a defined contribution plan. But as this recent Wall Street Journal article explains, many employers are now moving toward providing employees a sum of money to go buy their own coverage. This trend indicates that many companies are looking at HIXs as a way to control the increase in their healthcare benefit costs, while perhaps more importantly, providing their employees with greater choice. This is a huge sea change. While employers have known they need to continue offering healthcare coverage to attract the most talented workforce, they have been struggling with the spiraling costs. Many now see HIXs as an ideal solution.

5. What do the health insurance exchanges mean for patients?

These exchanges are part of a greater trend toward patients playing a larger, more active role in their own healthcare. For selecting a healthcare plan, HIXs are shifting decision-making from employers to their employees; in essence returning healthcare to a direct-to-consumer sales model that will redefine consumer expectations, customer service and healthcare consumer marketing. The overall success of this shift will be based upon the ability of consumers to be better purchasers. There is certainly more risk and effort involved, but the upside is a significant increase in choice and a strong incentive for the plans to compete aggressively on value for dollar.

6. What broader goals do you see the health insurance exchanges bringing to healthcare?

As I mentioned above, one mandate in the ACA is to establish a retail marketplace for healthcare as a means to improving access to healthcare and inevitably lowering costs. HIXs are the current manifestation of that goal, and it’s a positive disruption in the market. As we’ve seen with other such market force change, we may be able to predict the disruption, but we can only guess at the form it will take after the first wave of innovation and market reaction.

7. What are the biggest challenges for health insurance exchanges?

There are a lot of moving pieces, and as with any large technology project, there are always going to be bugs to be fixed and improvements to be made. There is no reason to believe each state’s marketplace won’t go live on October 1 or soon after; however, many won’t be perfect. This launch is similar to the “soft launch” of a retail store opening, and it may take a few months to get everything working. It will probably take a couple of open enrollment cycles to achieve a steady state. The long-term challenge is the same as any insurance product; will the actuarial base support the financial health of the system over time? As this is a market rooted in Federal Law, similar to the experience seen in the Commonwealth of Massachusetts Connector (“Romney Care”), I suspect the system will demonstrate remarkable inertia and will roll slowly toward equilibrium.

These Exchanges have no choice but to continuously improve. By March 2014, I expect the industry will be thinking, “It could have been a lot worse, but we made it,” and they’ll be moving forward to make the next open enrollment much smoother.

September 27, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Physician Acquisition: Is It The Right Strategy For Your Health System?

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Today I was talking with a vendor of EHR conversion services. I’ll be writing a lot more about our conversation soon, but I wasn’t surprised by his comment that mane of the EHR conversions that they’re doing are due to physician practice acquisition. Whether it’s a large hospital system acquiring the practice or a group practice acquiring a practice, there’s often the desire to move that practice to the same EHR platform.

As I thought about the trend of acquired physician practices, I ran across a whitepaper by athenahealth which asked the question: Physician Acquisition: Is It The Right Strategy For Your Health System? The whitepaper highlights how varying interpretations of the Affordable Care Act (Obamacare), the launch of Accountable Care Organizations (ACO), bundled payment pilots, and the persistent pressure on commercial reimbursement rates makes planning for healthcare leaders a challenging task. However, what does seem clear is that doing the same thing you’ve always done won’t be a viable long term strategy.

All of these pressures are driving the physician acquisition strategy of most organizations. Does anyone see these pressures changing anytime soon? I don’t see any changes in this regard on the horizon.

Despite the widespread physician acquisitions that are happening, there are legal barriers (antitrust) that prevent a clinic from controlling all of healthcare in a community. What does this mean for an organization? How do they integrate with providers that they haven’t acquired? Plus, it’s naive to think that the acquired physicians are going to remain with your organization forever. We have seen the cycle before where acquired doctors leave the mothership and venture out on their own again. Organizations without a strong external strategy are going to be in a difficult position.

The whitepaper does make an interesting case for clinical integration versus full on practice acquisition. This is a great concept that every organization should consider. Can you clinically integrate with an organization that you don’t own? How would that clinical integration work? I think these integrations are still evolving, but the whitepaper had two case studies from organizations that were working on it.

What’s the right strategy for health systems when it comes to physician acquisition?

September 9, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

EMRs and Patient Satisfaction

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When it comes to keeping patients happy, EMRs matter, a new study suggests.

More patients are logging on to access their own records – and they tend to like it, according to data from research firms Aeffect and 88 Brand Partners. About 24 percent of patients have used EMRs for tasks such as checking test results, ordering medication refills and making appointments. And 78 percent of those patients reported being satisfied with their doctors, compared with 68 percent of those who hadn’t used EMRs.

“EMR users are telling us that they are more confident in the coordination of care they’re being provided, and think more highly of their doctors, simply because of the information technology in use,” Michael McGuire, director of strategy for Chicago-based 88 Brand Partners, said in a press release.

Patient satisfaction is fast becoming a top priority in health care as it determines a growing portion of providers’ reimbursement. So far, it’s mainly been an issue for hospitals. Their patient satisfaction survey results make up 30 percent of  their quality score in Medicare’s “value-based purchasing” program, part of the Affordable Care Act. In fiscal 2013, hospitals saw 1 percent of their Medicare reimbursement put at risk based on the overall score, which also considers performance on clinical measures. The figure will increase to 2 percent by fiscal 2017. Private insurers are also starting to link payments with quality scores.

The trend is now taking hold outpatient clinics, as well. About 2 percent of primary-care doctors’ compensation is tied to patient satisfaction measures, and the figure is likely to grow in coming years, according to a recent report from the Medical Group Management Association. Specialist physicians reported, on average, that 1 percent of their salary hinged on patient satisfaction.

Patients cited several reasons for preferring that their doctors use EMRs, according to the EMR Patient Impact Study from Aeffect and 88 Brand Partners. Among them were ease of access to information and the perceived clarity and thoroughness of communication that the records systems provide. And adoption rates could be set to go higher: 52 percent of survey respondents said they aren’t using an EMR yet, but would be interested in trying one. Only 18 percent said they had no interest.

A host of other factors, such as level of attention and ease of making appointments, also factored into patient satisfaction, according to the survey of 1,000 consumers. But for doctors who have implemented EMRs, getting their patients to log on might be a simple way to create a more loyal following. In many cases, according to the survey, EMR-using patients had adopted the technology after being encouraged by a physician.

August 7, 2013 I Written By

James Ritchie is a freelance writer with a focus on health care. His experience includes eight years as a staff writer with the Cincinnati Business Courier, part of the American City Business Journals network. Twitter @HCwriterJames.

Does Healthcare IT Need Stability?

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Last night during one of my favorite TV shows, Charlie Rose, he interviewed a guy about the economy. One of the discussion points that came out of this interview and that I’ve heard a lot in all the discussions about the economy is having some stability to the economy. Many argue that one of the biggest things holding our economy back is all the unknowns. When there are unknowns companies get paralyzed and hold back doing things they’d do if the economy felt stable.

I wonder if we’re experiencing the same thing in healthcare IT? Could we use some stability in healthcare IT?

Think about all the various unknowns that exist in healthcare IT. Let’s start with ICD-10. The pending ICD-10 implementation date is looming, but that date has been pushed back so many times it’s still unknown if it’s really going to happen this time. That’s the opposite of stability.

I’m sure that many also wonder if the same will be the case with EHR penalties. Will the EHR penalties go into effect? What exceptions will be made for the EHR penalties? I could easily see the EHR penalties being delayed, but then again what if they’re not?

Is it hard for anyone else to keep up with what’s happening with meaningful use? I do this every day and so I have a pretty good idea, but even I’m getting confused as it gets more complex. Imagine being a doctor who rarely looks at meaningful use. So, we’re in meaningful use stage 1, but meaningful use stage 2 is coming, unless you didn’t start meaningful use stage 1 and then meaningful use stage 2 won’t come until later. Oh, and they’re making changes to meaningful use stage 2. That’s right and they’re also coming out with meaningful use stage 3. However, don’t worry too much about meaningful use stage 3 because a lot of people are calling for it to be slowed down. So, does that mean that meaningful use will be delayed? Now how does the meaningful use stages match with the EHR certifications? Which version of my EHR software does which stage of meaningful use?

I think you get the picture.

Of course, I haven’t even mentioned things like ACO’s, HIE’s, 5010, HIPAA, RAC Audits, Medicare/Medicaid cuts, or healthcare reform (ACA) to name a few others.

It’s a messy healthcare IT environment right now. We could definitely use some stability in healthcare.

February 12, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Keeping the “Health” in “Heathcare”

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‘Tis the season for family gatherings, holiday parties, and a plethora of professional networking events – all of which give me ample opportunity to perfect my “elevator speech”, introducing my business. It seems like each time I discuss what I do for a living, the question that follows is, “So, how do you feel about Obamacare?”

I understand that the Affordable Care Act, AKA Obamacare, is a significant slice of the polarizing pie our nation is currently attempting to consume and digest. And I appreciate that now, for the first time in my career, more people than not take an interest in what I have to say about being “a healthcare data consultant.” In years past, eyes would glaze over as I explained the enormous potential of predictive analytics in wellness and disease management programs, or the power of unstructured data mining for clinical notes data. Mentioning the health insurance plans I worked with brought inquiries into individual versus group rates, and complaints about the latest round of premium increases. It’s been refreshing to experience keen interest and pointed questions as I talk, rather than have each person gulp the last sip of wine and excuse themselves to run for more as soon as they figured out I have nothing to do with how much out-of-pocket expense they’re incurring after each doctor visit.

But as much as I enjoy the sudden interest in healthcare policy and data management, there isn’t enough wine in the world to make me debate the politics of healthcare reform with my 6’5″ uncles, my friends, or my social media connections. I am not a lawyer or political pundit. I am not qualified to comment on the merits of the ACA legislation. I am not an economist. I am not qualified to comment on the fiscal impact of Obamacare. I am a technologist. I am qualified to comment on the translation of ACA’s many provisions into the infrastructure and applications supporting our healthcare system. I am also a healthcare system consumer. I AM qualified to comment on what I believe this historic legislation means to my health, the health of my family, and the health of future generations.

This is what ACA healthcare reform and its many facets – Health Information Exchange (HIE), Electronic Health Records (EHR), Electronic Medical Records (EMR), Meaningful Use (MU) – mean to me: more, better, faster healthcare data capture and communication between all the stakeholders involved in my health and wellness:

- More health data: Meaningful Use-certified EMR applications require that particular medical service activities and clinical data elements are captured and stored discretely, electronically, and made available for retrieval upon patient demand.

- Better health data: The majority of medical procedures, products, services, events, and outcomes are codified in order to meet regulatory standards. It may take longer for your provider to enter the information about a patient encounter into an EMR system than it did to scribble notes on a chart; however, because those detailed discrete data elements are now tied to compensation and incentives, there is a higher likelihood that more specific details will be captured individually per encounter, generating a more complete picture of a patient’s medical history than a manual review of their paper charts. No handwriting recognition required.

- Faster access to critical health data: With EHR applications and HIEs, providers can instantly access patient medical records from provider/facility sources and multiple insurance carriers. The difference between electronic transmission speeds and manual chart retrieval could be the difference between life and death.

How could a higher volume of increasingly accurate, integrated, and immediately available healthcare data result in adverse health outcomes?

To me, healthcare isn’t about politics. It is health care. It’s about me, caring for my health, and the health of my loved ones. I believe that technological advances can and will empower healthcare stakeholders of all ilks – provider, health insurance plan, pharmaceutical industry, patients – to increase the speed of condition diagnosis and treatment, and to assist in establishing and maintaining healthy habits for improved health over a lifetime.

This season, put the “health” back in “healthcare”.

December 11, 2012 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Keeping Up with Healthcare Regulations

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I know that meaningful use and the EHR incentive regulatory process has been an eye opening experience for many of us that weren’t as familiar with how the government put regulations in place. However, most hospitals are quite familiar with this process since they have been having to deal with it for a very long time.

Even with all this background and expertise, I’ve heard more and more organizations telling me that “they just can’t keep up with all of the healthcare regulations.”

Think about all of the regulations in just healthcare IT. It’s overwhelming and the healthcare IT regulations pale in comparison to many of the other regulations that hospitals must know about and follow. Plus, we’re just getting started with the fun of 5010 and ICD-10 is right around the corner.

With all of these regulations I was intrigued by a new offering from HCPro I saw during the AHIMA convention in Chicago this year. While HCPro has long been a publisher of healthcare content, they have a new product they are just launching called HCPro Comply. I think the best way to describe HCPro is a portal into every healthcare regulation imaginable. Certainly you could find all these regulations in other locations for free, but there was something beautiful about having them all available in one easily searchable place.

Plus, HCPro Comply does a lot of things to add value to the regulations they make available. For example, they chunk out sections of the regulations that really matter. I remember my shock when I heard that the Meaningful Use regulation was 692 pages. Then, as I looked at the regulation, I realized that there were really only a small number of pages in the middle that really mattered since the beginning was a bunch of overview. From what I understand, HCPro uses its clinical regulation experts to help you identify and bring out those sections of the regulation that matter most.

The other part of HCPro Comply that I found quite interesting was their “Ask An Expert” feature. While many hospitals likely have someone (or multiple people) in their organization that understand regulatory changes very well, there are always situations where it’s beneficial to get outside advice and analysis about a particularly challenging regulatory change. I’m quite familiar with meaningful use, but I’m often emailing a number of other experts to either make sure my interpretation is correct or to ask about nuances I haven’t quite figured out.

One thing that I think HCPro Comply should consider adding is allowing the experts from the various hospitals share their expertise with their colleagues. I can easily see a community of healthcare regulatory compliance experts interacting on their platform to discuss the latest regulatory changes. I’m sure that HCPro has many experts on their staff, but a network of the top hospital compliance experts would be an even more powerful offering.

Now that Obama won the Presidential campaign, ACA, HITECH and other healthcare reform are here to stay. I can see portals like HCPro Comply being a great asset in the ever changing healthcare regulatory environment.

November 7, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

ACOs (Accountable Care Organizations)

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ACO’s Built Around Primary Care Not Payers
It’s always quite interesting when a non-healthcare journalist covers healthcare. The above title comes from this article on In the article they offer the following interesting ACO stats (as of Sep 2011):

-51% of all ACOs are buist as joint ventures between doctors and hospitals
-20% of ACOs are physician led
-18% of ACOs are hospital led
-75% of hospitals surveyed were not planning on participating in ACOs
-13% of hospitals are already participating in ACOs

Then, the article offers this insight into the ACO battle between payers, physicians and hospitals:

The report also noted that hospital- and physician-led ACOs tend to focus more on primary care than acute care, but Horizon Blue Cross Blue Shield’s partnership with Optimus is set up to promote primary care based on patient-centered medical home models, according to spokesman Tom Vincz.

“Horizon ACO arrangements include incentive payments to support improved patient care coordination and fund other activities to further transform offices into patient-centered practices,” said Horizon in a statement from Vincz. “Entities that Horizon collaborates with are given other valuable resources, such as timely, population-based data, to help them deliver more effective and efficient care to their patients.”

Since I consider myself a physician advocate, it seems appropriate for me to add in a quote from a blog post Kerry A. Willis, MD did on KevinMD:

During the PHO debacle a few years ago, I reminded our physicians that the letters should represent the ownership and direction that these organizations should take as they developed. I frequently offered that they were really pHO’s with Big hospitals and Big organizations with little physician control over the direction and quality that was important to us.

I fear that the same is true with ACOs. If we are not vigilant in their formation and direction, then they will become AcOs with physicians being a small part of their governance but very accountable to their owners. They will be dependent on the revenue streams that spring from them. I see scenarios where physicians will profit but then be caught in a spider’s web of their own design where they will be told how to practice and what kind and amount of care they can provide. I guess you could claim that I don’t trust insurance companies and you would be wrong. I do trust them. I trust them to do what is best for the corporate profits and the nonprofit executives’ with bonus clauses at the end of a successful year.

I fear that when it comes to ACOs many physicians are sitting on the sideline. We saw what happened with EHR incentive money and meaningful use when more doctors weren’t involved in the process. There were requirements that didn’t make any clinical sense. I can see the same thing happening with ACOs if doctors don’t get involved.

It’s a rapidly changing ACO environment, and my hope is that many smart physicians will add their voice to the mix. Otherwise, the shift to hospital owned practices will continue and doctors won’t have much of a choice but to be beholden to a big company.

August 28, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

88 New ACO Organizations – What Does That Mean?

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It has been a really interesting couple months for those interested in ACO’s (Accountable Care Organizations) and healthcare. I love how Gregg Masters of ACO Watch called the ACO the “Child of the ACA (Accountable Care Act).” He even declares the SCOTUS supreme court ruling as a big battle won for the ACO. I certainly can’t disagree with him when it comes to the government ACO initiatives. The loss of ACA would definitely hamper much of the government’s work on ACOs. Although, he also acknowledges that ACA is still up in the air pending the Presidential election. ACA is directly in the republican cross hairs.

Politics aside, the ACO program is going forward. CMS recently named 88 new Accountable Care Organizations (ACOs) that will take part in the Medicare Shared Saving Program (Originally it was 89 ACOs, but one organization dropped out).

You can see the full list of ACOs on the press release linked above, but I really like this image that The Advisory Board Company put together that shows the location of the various ACOs across the US (click image twice for full size):

I think this represents a pretty good distribution across the country. However, there are a few things that I find a bit disturbing about the organizations participating in the government ACO programs. The first is that many healthcare organizations that you think would be perfect fit for an ACO aren’t participating. Kaiser and IHC come to mind. I’ve heard that both organizations are very interested in ACOs, but not the government ACO programs. I think this is a bad sign for the government sponsored ACO programs.

The second is that only five of the ACOs applied for the version of the Medicare Shared Savings Program where they have a chance to earn a higher share of any savings, but they’ll also be accountable for any losses if the cost o the care increases. You might take a look back at my ACO Risks and Reward post. These five organizations have gone all in with the ACO program. With that said, I wonder why only five of them chose to participate in it? Shouldn’t we want more organizations to have some accountability and responsibility if they don’t improve care and lower costs?

As I have pointed out before, the ACO movement is happening and is not likely to slow down. Even if ACA or other government legislation is repealed, the move to ACOs is going to happen. With that knowledge and some of the comments above, it makes me wonder if the government should be the one funding an ACO initiative. Will their involvement help or hurt the overall ACO movement?

I’ll be interested to see how it goes for these new ACOs. As we’ve seen with EHR and meaningful use, we’ll have to be careful to filter through the messages coming out of CMS about the success or failure of the ACOs. As they progress we’re going to have to reach out to the ACOs and hear the first hand stories. If you’re an organization that’s participating, we’d love to hear your thoughts in the comments.

July 24, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.