Couldn't make it to Denver, CO for the Medical Group Management Association 2009 Annual Conference in October? Don't worry, our editors have summarized some of the best presentations from the 2009 MGMA Conference.
Patient/Provider Connectivity: Leading the Transformation of Healthcare Delivery
Presented by David Nace, MD, RelayHealth
Nace began his presentation with a review of the current challenges facing medical practices. He noted that healthcare cost pressures and the economic downturn have caused a need for administrative efï¬ ciencies and reimbursement management at the point of care. Healthcare reform and the HITECH stimulus also present challenges in trying to achieve meaningful use and interoperability for care collaboration.
Nace cited the results of the RelayHealth survey on point-of- service (POS) reimbursement challenges, which found that practices want better visibility into payment at the POS, patient collections are a signiï¬ cant challenge for physicians, and practices are willing to collect payment at the POS based on credible estimates.
Returning to the topic of administrative efï¬ ciencies, Nace noted that the total cost of medical practice interaction with insurers is $21-$31 billion per year. The total practice impact is more than $68,000 per physician each year.
When discussing laying the foundation for interoperability, Nace explained that health information exchange (HIE) is moving faster than EHRs, with HIE funding beginning in 2010, typically received as up-front grants via the states, and EHR funding beginning in 2011, paid directly to providers AFTER proving meaningful use. Options for those who adopt are a “connected” EHR, going with a modular approach, or starting out with the basics and then adding advanced applications, explained Nace.
Focusing on HIE, Nace stated that the evolving world of Web services (SaaS)—through Web applications, clinical data distribution, interoperability services, and network identity management—allows for the avoidance of costly, complex, locally installed software; the avoidance of infrastructure needs (just access to the Internet); rapid deployment and adoption; no need of local or practice IT staff, and predictable costs. Further, HIE use can help reduce staff time that would be spent on handling lab and radiology results and clerical administration and ï¬ling; decrease what is spent on redundant testing; decrease costs of care for chronic care patients; and reduce medication errors, according to Nace.
What the Economic Stimulus Package Means for Physician Practices: Optimizing the Opportunity
Presented by Justin T. Barnes, Chairman, EHR Association, VP, Greenway Medical Technologies
Barnes, who has presented to Congress and actually worked on the stimulus package, began his 20-minute session with an overview of the HIT stimulus, which provides more than $30 billion of direct adoption incentives ($17.7 billion for Medicare and $12.4 billion for Medicaid).
Breaking it down further, $2 billion is for the Ofï¬ ce of the National Coordinator for Health Information Technology, the National Institute of Standards and Technology, and health information exchange infrastructure; $2 billion is for distance learning, telemedicine, and broadband program account loan guarantees and grants; $1.5 billion for the Health Resources and Services Administration, $1.1 billion for the Agency for Health Research and Quality, $500 million for the Social Security Administration, and $85 million for Indian Health Services.
“Conservative Congressional Budget Ofï¬ce estimates show that American Recovery and Reinvestment Act (ARRA) funding will save over $15 billion in government spending throughout the health sector through improved quality and care coordination, reduced medication errors, and duplicative care,” continued Barnes.
Key milestones for ARRA, according to Barnes, include:
• Sec 3003: HIT policy committee — announced April 3, 2009
• Sec 3003: HIT standards committee — announced May 8, 2009
• Sec 3004: Adopt an initial set of standards, implementation speciï¬ cations, and certiï¬ cation criteria — set for December 31, 2009
• Sec 4101: Medicare incentives for eligible professionals pay out year begins — starts January 1, 2012
• Sec 4201: Medicaid incentives for eligible professionals pay out year begins — starts as early as 2010, but bulk comes in 2012
When looking at Medicare-eligible professional incentives for meaningful use of a certiï¬ ed EHR, Barnes says the breakdown will be as follows: install in 2009-2010, receive $18,000 in 2011, $12,000 in 2012, $8,000 in 2013, $4,000 in 2014, and $2,000 in 2015, up to $44,000 per provider. For those who don’t meet meaningful use criteria, they can expect a 1% penalty in 2015. Then, a study will be conducted, and if more than 70% of practices don’t have a certiï¬ ed EHR, reductions will continue for two years, up to 5%.
The breakdown for Medicaid, says Barnes, looks like this: install in 2009-2010, receive $25,000 in 2011, $10,000 per year through 2014, and then $8,000-$10,000 for 2015, up to $63,750 per provider of uninsured, rural, FQHC, and low-income providers/eligible professionals who have a 30% Medicaid population. Pediatricians must have a 20% Medicaid population to receive incentives, but must have over 30% to receive the full $63,750. No penalty reductions will be handed out to those who don’t adopt.
One interesting fact that Barnes mentioned: for certain eligible professionals who predominantly furnish services in an area that is designated by the secretary as a health professional shortage area, the amount of incentives they receive is increased by 10%.
“Seize the opportunity today,” said Barnes. Begin fostering the EHR discussion, understand the goals for adoption, review the process, and get leadership set in ï¬ nancial, quality, patient satisfaction, clinical research, and community areas, he advised, adding that practitioners need to make sure the EHR meets their practice needs, keeping in mind that no product is perfect and that one may need to meet the system “in the middle.” Properly deploying an EHR system takes time.
Barnes said to begin the move to an EHR by learning all you can at sites such as www.cchit.org, www.mgma.com, www.klasresearch. com, www.himssehra.org, and www.ehrdecisions.com. He noted that although CCHIT won’t be THE certifying body, it will be one of them and that physicians should ask their vendor if they are not only 2008-certiï¬ ed, but 2009-certiï¬ ed as well. He added that “companies that are CCHIT-certiï¬ ed are committed to success just like you.”
Things to look for in an EHR, according to Barnes, include:
• References from practitioners in your specialty and practice size
• Product workï¬‚ ow that is consistent with your practice requirements
• A product that can be “meaningfully used” at the point of care
• Product certiï¬cation (he notes that many see the new certiï¬cation process building from the current CCHIT framework and efforts)
• 2008 CCHIT certiï¬cation & meaningful use
“So, what does meaningful use call for?” asked Barnes. It includes the following:
• Use of electronic prescribing
• Information exchange
• Reporting of usage and clinical quality measures using the EHR
Finally, Barnes recommended that physicians reach out to their senators and congressmen and educate them on the challenges
faced by physicians.
Leveraging a Software-Enabled-Service (SeS) Platform to Improve Clinical and Administrative Outcomes for a Practice
Presented by Jeremy Delinsky, athenahealth, Inc.
Healthcare should be about taking care of patients, began Delinsky; this simple thought certainly makes sense, but it can easily be forgotten when trying to keep a practice aï¬‚ oat these days. Healthcare is a challenging business to operate, with physicians (and patients) feeling the pressure from all sides, including:
• Government regulations (HIPAA, NPI, ICD10)
• Payers (Lower reimbursement, more hurdles to getting paid, increased “self pay” balances)
• Industry (Consumer-directed healthcare, retail clinicians, P4P reporting requirements)
In order to make it all work, extensive connectivity is needed, explained Delinsky. So, what plays a role in that? For starters, groundbreaking legislation was passed with the ARRA and the HITECH Act, the latter tying $17.2 billion to “meaningful use” of an EHR. Meaningful use, the presenter noted, is focused on improving quality, safety, and efï¬ ciency; engaging patients and families; improving care coordination; improving population health; and ensuring privacy and security. Adoption and use are key, he added.
Proposed health reform is tied to payment reform, said Delinsky, calling attention to a quote from the April 21, 2006 issue of Modern Healthcare that reads “9 out of 10 health care leaders back a ‘complete transformation’ of the U.S. health care system.” Adding to the argument that health reform is tied to payment reform, Delinsky presented a quote from President Barack Obama on paying for results rather than utilization: Obama said on March 24, 2009, “How are we going to reduce health costs?...Let’s invest in mechanisms that look at who’s doing a better job controlling costs while producing good quality outcomes…and let’s reimburse on the basis of improved quality, as opposed to simply how many procedures you’re doing.” Delinsky also quoted Dr. David Blumenthal from the NCHIT, on changing the payment system: “Realizing the full potential of HIT depends in no small measure on changing the healthcare system’s overall payment incentives so that providers beneï¬ t from improving the quality and efï¬ ciency of the services they provide.”
Currently, it’s too hard for physicians to get paid, said Delinsky, adding that there is “a mess of complex, analog-based requirements” and that “controlling the clinical workï¬‚ ow requires mastering a similar mess.” So, what’s a physician to do? Buy new software? Outsource billing? Delinsky said that doctors need a partner.
And that partner needs to be focused on results, not products; have aligned incentives (they only get paid when you do); be ï¬‚ exible by quickly adapting to the ever-changing healthcare landscape; and apply collective knowledge for the beneï¬ t of everyone. This partner, Delinsky feels, can come in the way of a software-enabled service that can help physicians get paid more, faster, and with less hassle.
MGMA’s Washington Update Session
Leah Cohen, a Government Affairs Representative for MGMA, led off her presentation by announcing to the large crowd that she is “only the messenger.” It was a great way to break the ice, and her comment got many laughs from the physicians in the audience who were looking to her to sort out some of the legislation that affects them. However, they may not have gotten the closure they wanted from this meeting, because Cohen rightfully informed them that much of the information she had on her slides changes daily.
Her presentation touched on a number of key issues that physicians hear about all the time — PQRI, Medicare, reimbursement, employer requirements, and so on. She did a nice job explaining complicated issues and spoke at length about what the House and Senate Finance Committees are trying to accomplish in the next few years. There were enough pie charts, graphs, and numbers to make anyone’s head spin, but aside from all the talk about government legislation, Cohen also provided some interesting resources. There are two in particular that all physicians should familiarize themselves with:
MGMA’s Grassroots Services
Cohen continually encouraged the audience to get involved by sending letters to legislators regarding healthcare reform. She also said to send them often and to keep them updated. However, because this can be tedious, she referred listeners to www.mgma. com/grassroots, where visitors can input their information and generate a pre-written letter.
Project SwipeIT is “an industry wide initiative launched by the Medical Group Management Association (MGMA) in January 2009 to advance the adoption of standardized patient health-insurance identiï¬ cation (ID) cards containing machine-readable information. MGMA estimates that the healthcare industry wastes as much as $2.2 billion annually as a result of nonstandardized cards.” Want to learn more about this initiative? Visit http://tinyurl.com/ykxjcn9.
MGMA Saves the Best for Last: A Panel Discussion with Three Wise Men
One of the conference’s ï¬nal sessions was a panel discussion on improving the quality of care through quality, innovation, and service. If this panel were a baseball team they’d be the Yankees. We’re talking about some big names: Dr. Delos M. Cosgrove, president and chief executive ofï¬ cer of Cleveland Clinic; Dr. William Wright, Executive Medical Director Colorado Permanente Medical Group; and Dr. Gary S. Kaplan, Chairman and CEO of the Virginia Mason Health System. Each panel member made an opening statement, introduced themselves, mentioned what roles they have in their respective organizations, and spoke on a few different issues.
Are solo practitioners an endangered species? Moderator William F. Jesse, MD, astutely noted that many of the members at MGMA likely came from much smaller practices and organizations than the panel members, and asked them how their experiences would translate to the audience. Dr. Cosgrove was the ï¬rst to respond, noting that, in reality, only 10% of physicians are either in a solo practice or are with one other physician, and that this statistic speaks to a trend that seems to be growing each year. He mentioned that there are many reasons for this: an exploding body of knowledge; the ï¬ nancial aspect (ie, the complexity of contracting, measuring quality, EHRs, etc); and a huge change in generations - no longer do physicians want to be on call 24/7. They want a better work/life balance. Dr. Cosgrove used cardiac surgeons and cardiologists as an example, as these two medical specialties have been teaming up all over the country.
In order for healthcare reform to be successful, incentives must change — and soon. This was the most popular topic of the discussion, and it seemed that every answer came back to incentives. All three panel members felt very strongly about this issue, and were all in agreement. Part of the problem with the healthcare system right now is that 75% of the cost of care is a result of patients with chronic conditions. In addition, there’s relatively little focus on prevention of these conditions. The panel stressed the importance of making patients a facilitator in their own care. The members stated that the incentives are in the healthcare system are all wrong: hospitals and practices create more care, and insurance companies only care about money. Truly positive healthcare reform will consist of two major changes: caregivers must cut out unnecessary tests, and patients must be incented to be active in preventative health.
To the ï¬rst change, Dr. Kaplan mentioned a Virginia Mason program that involved a collaboration with both Starbucks and Aetna. Starbucks believes its baristas should have health insurance, but is concerned about the cost. Through some research, Virginia Mason discovered that back problems were very common among the baristas, and that many times they were recommended an MRI. Unfortunately, an MRI in this situation is rarely beneï¬ cial in determining a cause of the pain, and Virginia Mason made sure that these referrals stopped. So, by cutting out this costly test, they may have taken a hit in their bottom line due to the cost of the MRIs, but in the end they were helping to provide care in a much more cost-effective way, and changed the model in which care was delivered, beneï¬ tting everyone involved. The focus was shifted to the patient instead of proï¬ t margins.
To the second change, Dr. Wright mentioned that Safeway had recently put a program in place that he hopes will lead to a chain reaction. He encouraged the audience to ï¬ nd more information about it online. Safeway introduced a plan in which “preventative care was covered completely, and included a health saving account of $1,000 per person that Safeway funded. Health care costs above that are covered by employees.” Read more about this program at http://tinyurl.com/ybc8yc7. The bottom line is that patients who are living an unhealthy lifestyle and are subsequently causing a strain on the cost of healthcare in this country should be hit hard where it hurts them the most — their wallet.
This discussion was a very interesting session to sit in on, and it involved some physicians who are at the forefront of enacting change in a broken healthcare system. On second thought, maybe these presenters are more like hockey players. Dr. Kosgrove answered an attendee’s question about health reform with a reference to Wayne Gretzky, who is known as “The Great One.”
“One day a reporter asked Gretzky what made him so great. Do you know how he responded?” After it was apparent that there were no hockey enthusiasts in the audience, he continued. “He told the reporter that he always had a sense of where the puck was going to be. So not only did he always know where it was, but he knew what to expect next. That’s the type of leader we need in healthcare reform.”
EHR Incentive Payments and Practical Implementation Issues
“Lawmakers wrote EHR incentive plans at 3 in the morning — there are lots of gaps.” – David Schoolcraft
The discussion on EHR incentive payments and implementation included several issues that regular MDNG readers are familiar with: HITECH, “meaningful use,” and annual incentives. Although it may seem like the same old song and dance, the reality is that all those dates you’ve been hearing about are fast approaching. For those of you looking for a meaningful use timeline, here’s a cheat sheet for you:
2009: HITECH policies; HHS to deï¬ ne terms and issue regulations
2011: Capture/Share Data; Incentive payments
2013: Advanced care processes with decision support
2015: Improved Outcomes; Penalties
Presenter David Schoolcraft works at Ogden Murphy Wallace, PLLC, and specializes in helping physicians implement EHRs that aren’t going to leave them in disarray down the road, a problem that happens all too frequently. He didn’t reveal any new groundbreaking information; this session just served as a refresher course for those who needed answers to some timeline questions, and also as an educational activity for those physicians that have been procrastinating a bit. However, Schoolcraft made some excellent points that all physicians should take to heart. He told the audience that, if they were to take one thing away from his presentation, it should be that many EHR companies seem like an excellent ï¬ t for physicians who are looking to implement right now and cash in on those early incentives. Unfortunately, many physicians ignore some of the ï¬ ne print, and this results in a loss of money and time. Schoolcraft stressed that physicians need to speak with a representative from a vendor who can guarantee that the EHR they are providing will be able to evolve as rules and regulations evolve. Because, after all, what’s the point of getting incentive payments for two years if you are going to have to uninstall your EHR in three years and start over because it won’t reach “meaningful use” requirements down the line?
Schoolcraft then handed it over to Rosemarie Nelson, MGMA Healthcare Consulting Group, who focuses on best practices for EHR implementation. She began by explaining that many of the physicians she works with don’t even know what they are looking for in an EHR, which is a major problem. Physicians need to know what features they are looking for and they need to evaluate properly. Another problem is that physicians can sometimes “buy the sales team” instead of “buying the support staff.” When problems arise, and they will, it’s important that you have people who can help you quickly resolve them. Another good piece of advice that Nelson gave was that physicians should seek the advice of peers who have gone through the implementation process.
Nelson gave a great analogy to the physicians in the audience who are getting ready to embark on their EHR implementation journey. She said to think of implementing an EHR as approaching a trafï¬ c light. Obviously everyone knows that green means go and red means stop. The problem for physicians is the yellow light. Nelson told the audience that if they see a yellow light, to stop and re-evaluate. “Too many physicians punch the gas and blow through the light!”
Find More Online
Visit www.hcplive.com/mgma_2009 for a slide show from in and around the Colorado Convention Center and coverage of the following sessions:
• Beneï¬ ting Financially from an Electronic Health Information Exchange
• Come On, Make a Decision: Practical Tools to Move Beyond an Impasse
• Group Therapy: Discussing EHR Interoperability
• Managed Care De-selection and Further Implications of Financial and Quality Report Cards
• EMR with Clinical Risk Management = Patient Safety: A Model for Success
• ICD-10 and the New HIPAA Transaction Standards Are Here!
• How Sustainable Is Your Practice?
• Life’s a Breach and then You’re Fined
• Joint Commission Accreditation for a Private Practice: Worth the Pain?
• MGMA’s Web 2.0 Session: An Eye-opening Experience
• Managing in Hard Times