Health Care Current: March 4, 2014
This weekly series explores breaking news and developments in the U.S. health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory and legislative changes.
by Harry Greenspun, MD, Senior Advisor for Health Care Transformation & Technology, Deloitte Center for Health Solutions, Deloitte LLP
My wife, Kerry, and I were having dinner with her sister, Patricia, now 25 weeks pregnant. Looking radiant, she’s doing everything she can to stay healthy. Knowing that Kerry and I are deeply involved in health care and information technology (IT), she asked a seemingly simple question: “What’s the best way for me to track health information for me and my baby?”
Based on the look in my wife’s eyes, I could see we had both immediately grasped the frustrating complexity of her situation: during her pregnancy, she had switched obstetric (OB) practices. While she has received care in the OB offices, she will deliver in a hospital. Her baby will be examined there initially, and then subsequently seen in a different pediatrician’s office. Just to add another twist, she and her husband are both very health conscious and monitor their exercise and diet with a variety of gadgets and mobile tools.
In short, Patricia was asking about how to achieve interoperability among a personal health record, four different electronic health records (EHR)—assuming all providers had implemented them, an independent ultrasound clinic, several external laboratories, mobile health apps, online registries and personal tracking devices.
The need for interoperability extends far beyond people like Patricia. Health care organizations are struggling to connect their myriad of information systems and medical devices together, allow data to flow and provide comprehensive information to those who need it. It’s popular to suggest that this data is trapped in a silo. However, if you drive along many country roads, it’s quickly apparent that silos are huge and hold a tremendous volume of grain. Rather than siloes of data, in health care we have created vast collections of cereal bowls, each holding just a small serving of data. This fragmentation and isolation serves as major barrier to transforming and improving health care.
Health IT advocates routinely invoke successes of other industries to help solve their interoperability challenges. Few conference speeches are complete without a comparison to banking, retail or travel. The outrage of, “I can go anywhere in the world and use my ATM card to access my financial information, yet I can’t get my medication list at my local pharmacy!” has become so commonplace, it could be the basis for an exhibitor giveaway competition at HIMSS. Recently, I was struck by the fact that amid all these references, I’d rarely heard from people within those industries. Thus, I was excited to moderate a panel for Health Care Innovation Day in Washington, D.C co-sponsored by the Office of the National Coordinator for Health IT and the West Health Institute. The panelists contemplated what we can learn from other industries, bringing together actual health care “outsiders” to learn how they had dealt with interoperability challenges.
We heard Dr. Bill Check, Senior Vice President, Science & Technology and Chief Technology Officer of the National Cable & Telecommunications Association (NCTA), describe how the cable industry pooled resources across the entire sector to create a common standard, now known as Data Over Cable Service Interface Specification (DOCSIS), rather than creating company-specific programs. Steve Katz, Founder and Owner of Security Risk Solutions LLC, brought a wealth of experience from the financial services industry, where interoperability challenges had to be addressed in the 1850s to serve customer needs. Back in the days where checks were just handwritten pieces of paper, banks came to realize they needed to know which bank to send checks to—an important step to help prevent fraud. As a result, in the 19th century, The Clearing House was formed to “clear checks.” In the early 1900s, the Federal Reserve created the routing codes we all have at the bottom of our checks. As he stated, “interoperability was a result of organizational drive to access and take care of…customers regardless of where they are.”
Finally, Sid Fuchs, President and Chief Executive Officer, MacAulay-Brown, Inc., brought a fascinating perspective from his experiences across the intelligence community (including his work as a CIA officer). For him, the key issues revolved around people: “It’s not technology that keeps us from sharing information. Technology is the easy part. What is hard is the culture and governance.”
A common thread for achieving interoperability was overcoming the false sense of security that the more you own and the less you share, the more powerful you are. This required making interoperability a priority, creating an enabling leadership environment and fostering organizational cultural change.
Based on the experiences of other industries, what might it take to achieve interoperability? Consider the following:
- Hear the voice of the customer: the interoperability discussion is often dominated by vendors. While well-intentioned, the focus often falls on how their individual products can serve as a central aggregator of information, rather than facilitating free flow. Hospitals, providers, patients and other stakeholders need to make their needs clear and then make them explicit in their RFPs and purchasing. Until these groups get their advocacy organized and set the interoperability agenda, we will likely continue to face challenges in sharing data.
- Create a culture of data-sharing: stakeholders across the industry need to understand that they each play a critical role in getting the right information to the right person at the right moment. Anything that inhibits this sharing creates a bottleneck and even a detriment to patient safety. It will take strong leadership to help the industry understand that holding on to information does not give them a competitive advantage—instead it makes them part of the problem, and others will take notice.
- Get priorities straight: Sid said it best when he talked about leading teams to overcome challenges: “The first thing I ask them is ‘What’s broken?’” We face a number of issues impeding interoperability: slow end-user adoption of IT, inadequate or conflicting standards, misaligned incentives and weak governance among others. Each manifests differently in the various sectors of health care. We need to identify what the key barrier is in each and fix that first.
- Remember concerns about privacy and security: as we move closer to achieving the free flow of data across devices, systems, facilities and beyond, let’s not forget we are moving very personal information. This is a network ultimately held together by trust. Without proper governance, protection and controls, it could fall apart.
How quickly health care can create sufficient urgency and act remains to be seen. In the interim, the needs of society move on unmet, and Patricia’s due date is fast approaching. Her child isn’t going to wait for this issue to be resolved.
Poll results from February 25 Health Care Current:
Last Tuesday, CMS Administrator, Marilyn Tavenner released on the U.S. Department of Health and Human Services (HHS) blog an update on enrollment in the health insurance exchanges (HIX). According to the post, approximately 4 million individuals have enrolled in HIX plans since open enrollment began on October 1, 2013. The update did not contain further breakdowns of demographic or state-level numbers. These new numbers show a substantial increase from the 3.3 million enrolled at the beginning of February, the most recent release of detailed enrollment data. According to the blog, the call center has answered more than 12 million calls to date. Despite the technical barriers that prevented many from enrolling in the federally-facilitated exchange at the start of open enrollment, Administrator Tavenner indicated that the website, HealthCare.gov, now has low system error rates and fast response times. HHS will release the full HIX enrollment figures for February in mid-March.
Related: late Friday, HHS released a report highlighting that between October and January, CMS determined that more than 8.9 million individuals were eligible for Medicaid or the Children’s Health Insurance Program (CHIP) through state agencies and state-based HIXs. The numbers in the report encompassed individuals who were newly eligible through Medicaid expansion, determinations made based on laws pre-Affordable Care Act (ACA), groups that were not affected by ACA changes in the law and individuals completing Medicaid renewals. It did not include individuals determined to be eligible for Medicaid through federally-facilitated HIXs. CMS indicated that the agency will continue to make updates on Medicaid and CHIP enrollment numbers throughout future months.
Note: for more information on the breakdown of HIX enrollment and Medicaid expansion by state as of February 1, see Mapping out health care reform: Activity in the states.
On February 21, CMS released a report detailing estimates of the ACA’s impact on premiums for individuals and families with non-grandfathered plans in employer-sponsored health insurance. This report is a requirement in the Department of Defense and Full-Year Continuing Appropriations Act of 2011; the law called for CMS to analyze three provisions of the ACA—fair health insurance premiums, guaranteed issue and renewability of coverage—and their effect on premium rates for the individual and small group markets. Findings include:
- Small firms are expected to experience varying results, with an estimated 65 percent seeing increases in premium rates and 35 percent seeing rate reductions
- Approximately 11 million individuals could see an increase in their premium rates, while an estimated 6 million could see a decrease in their premiums
A total of 18 million were enrolled in small group health insurance market through employers in 2012, but approximately 8 percent (1 million) of these individuals are employed by firms who self-insure. Self-funded plans are not subject to the provisions the report analyzed. CMS noted that the estimates have a high degree of uncertainty, as it is unclear whether or not small employers will decide to terminate their existing plans. Furthermore, the report highlighted that the number of affected individuals will be smaller in 2014 because some group plans renewed early, and half of the states allowed extensions to pre-ACA rating rules under CMS’ transitional policy that was issued in November 2013.
Poll: consumer preferences split between more affordable, narrow network plans and costlier, more inclusive networks
According to a recent Kaiser Family Foundation tracking poll, half (51 percent) of those polled indicated they would choose a plan that is more expensive and allows enrollees to see a wider range of providers over one that is less expensive and offers a limited range of doctors and hospitals (37 percent). However, uninsured individuals and those who purchase their own insurance — those most likely to be customers of the health insurance exchanges — would prefer (54 percent) less expensive but more limited health plans. The poll also found that, once presented with the possibility of losing the ability to visit their regular provider, both the total population and uninsured/self-insured individuals decreased their preferences for the less costly and narrower plan, dropping from 37 to 23 percent and 54 to 35 percent, respectively.
Related: Deloitte’s 2013 Health Care Consumer Survey found that most consumers were unwilling to accept a network that would exclude their current primary care provider (see chart). Overall, 12 percent were willing to trade-off physician relationship with price; many were not. Consumers were more willing to trade price and network preferences for hospital care. Around half were willing to some degree to accept fewer in-network hospitals for lower costs, but this varies from 39 percent (Medicare enrollees) to 67 percent (those who directly purchase insurance).
How willing would you be to accept a network that does not include your current primary care provider if it resulted in lower payments for either health insurance and/or health care services?
Note: Chart shows a percentage of each subgroup who gave a rating on a 10-point scale where 1 = not at all willing and 10 = extremely willing.
Source: Deloitte Center for Health Solutions 2013 Health Care Consumer Survey
Study: early patient-centered medical home shows few improvements in cost, utilization, quality of care
Last week, the Journal of the American Medical Association (JAMA) published findings from an early patient-centered medical home (PCMH) pilot. The results indicated that the pilot did not bring about reductions in total costs or significant reductions in participant utilization of emergency or ambulatory care and that it produced limited improvements in care quality. Researchers compared claims data from four health plans for more than 64,000 patients in 32 pilot primary care practices in southeastern Pennsylvania to those of more than 55,000 patients in 29 comparable practices not participating in the study. The pilot was one of the earliest in the country to test the patient-centered medical home model, with an evaluation period between 2008 and 2011. Throughout the pilot, researchers measured the results against standards from the National Committee for Quality Assurance (NCQA) on 11 quality measures. Other findings include:
- Practices that participated in the pilot achieved PCMH recognition from NCQA and successfully adopted new capabilities such as chronic disease patient registries to notify when such patients were overdue for services
- Pilot practices achieved performance improvement by year three in one out of the 11 quality measures: 82.7 percent (vs. 71.1 percent for non-participating practices) in nephropathy screening for patients with diabetes
- Primary care physicians in pilots received an average bonus of $92,000 during the three-year intervention period
Note: this study is one among many others that have analyzed the results of PCMH initiatives; while some have had similar findings to this report, other studies have found improvements in quality and cost. Last week, University of Minnesota researchers also released findings from their Health Care Homes (HCH) study that suggested quality of care in clinics that had HCH certification was higher than non-certified primary care clinics across the state. An analysis of academic and industry reports by the Patient-Centered Primary Care Collaborative also found that many PCMHs had decreases in cost and the use of unnecessary care and increases in access to care, among others, during the periods studied. NCQA responded to the findings published in JAMA on February 26, noting the quality measures used in the study were based on outdated standards. As of February 2014, in the U.S., there are an estimated 6,800 PCMHs designated as such by NCQA; this comprises approximately 10 percent of all primary care physicians in the country.
Progress toward Meaningful Use: survey finds positive sentiment among provider groups; national organizations request extension of timelines
Last Monday, the Healthcare Information and Management Systems Society (HIMSS) released findings from a survey of information technology (IT) professionals representing more than 650 health care provider organizations. Overall, 71 percent indicated they are on track to qualify for Stage 2 of the Meaningful Use program by the end of 2014, and 90 percent of the respondents have already attested to Stage 1 of the program. More than 90 percent of the respondents indicated they are prepared to meet ICD-10 conversion by the October 2014 deadline.
Meanwhile, leaders from 48 national provider organizations, including the American Academy of Family Physicians, American Hospital Association, American Medical Association and Federation of American Hospitals sent a letter to HHS Secretary Kathleen Sebelius expressing the group’s concern over the upcoming deadlines for the federal incentive program. Specifically, the organizations made two recommendations to HHS:
- Extend the timeline to meet Stage 1 and 2 program requirements through 2015
- Make the program requirements more flexible so that as many providers as possible can be successful in the program
CMS established Stage 1, 2 and 3 of “Meaningful Use” objectives that providers must meet to receive financial incentives under the Medicare and Medicaid Electronic Health Record Incentive Programs. Last December, CMS delayed Stage 3 of the program until the beginning of 2017 (fiscal year (FY) 2017 for hospitals and calendar year 2017 for providers and other eligible professionals). For more information, see the December 10, 2013 Health Care Current.
Analysis: the reactions seem consistent with those that can sometimes happen when health care organizations begin implementing a technology solution in their care setting. Often, IT follows a path to get the project implemented, while providers confront workflow changes. Learning curves impact their ability to see patients and keep up with documentation and extra work hours can be required to keep up their utilization. While going down this path, it is critical that health care organizations consider not only fixing and testing the technology impacts of the regulation, but that they consider employing robust training, change management and a support system to help providers adjust to the new requirements. Administrator Tavenner recently confirmed that CMS will not adjust timelines for hospitals, physicians and other eligible professionals who have difficulty meeting Meaningful Use requirements for 2014 under the Medicare and Medicaid Electronic Health Record Incentive Programs, but that they are working to add more flexibility around hardship exemptions. It is also worth noting that improved health care delivery via technology is critical to supporting broader initiatives as quality-based care and accountable care organizations.
According to a report released by the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) last Wednesday, the Health Care Fraud and Abuse Control (HCFAC) Program recovered more $4.3 billion during fiscal year FY2013 through health care fraud investigations. This is an increase from the $4.2 billion recovered during FY2012. As a result of the increased investigation efforts, $2.85 billion was transferred to the Medicare Trust Funds and more than $576 million in Federal Medicaid money was transferred to the U.S. Department of the Treasury. Since its inception in 1997, the HCFAC program has provided more than $25.9 billion in recovered funds to the Medicare Trust Funds. Other highlights from the report:
- The DOJ opened 1,013 new criminal health care fraud investigations during FY2013, a decrease of 11 percent from the previous year
- Federal prosecutors filed criminal charges in 480 cases in FY2013, an increase of 6 percent from the previous year
- In total, 718 defendants were convicted of health care fraud-related crimes during FY2013, a decrease of 13 percent from the previous year
The report highlighted that the HCFAC program lost more than $30 million in funding as a result of sequestration, which could have caused some of the decrease in output from the program over the previous year. The return-on-investment for the HCFAC program has been significant over the last three years: according to the report, approximately $8.10 for every $1.00 spent is returned.
Note: to learn more about fraud and abuse in health care, see the February 18, 2014 Health Care Current
Last Thursday, the Congressional Budget Office released its score of S. 2000, the Sustainable Growth Rate (SGR) Repeal and Medicare Provider Payment Modernization Act of 2014, finding that repeal of the SGR would increase direct spending by $60 billion over the next five years, adding up to $138.4 billion from 2014 to 2024. According to the report, most of the increase would stem from updates to rates for services paid on the physician fee schedule, as specified in the proposed bill. S. 2000 and H.R. 4015, the House’s version of the bill, were introduced in early February after members from the Senate Finance, House Ways and Means and House Energy and Commerce committees reached an agreement. Despite reaching agreement on a plan for the repeal and replace, Congress has not come to an agreement on how to pay for the measure. Lawmakers have until the end of this month to establish a solution, whether temporary or permanent. When the current fix expires, physicians will face a 24 percent cut in their Medicare payment rate.
CBO estimates of cost, by fiscal year (in billions):
Note: for more information about specific parameters of the bill, see the February 11 Health Care Current, “Congress agrees to bipartisan SGR replacement bill.”
Last week, the Journal of the American Medical Association released findings from the most recent National Health and Nutrition Examination Survey. Overall, the findings suggest that obesity prevalence in the overall population has not dropped significantly between the 2003-2004 survey and the most recent one conducted from 2011-2012. However, one population—children age 2 to 5—did see a significant decrease in obesity, from 13.9 percent to 8.4 percent during the same time period. Other key findings include:
- More than one in six (16.9 percent) children age 2 to 19 are obese
- Greater than one third (34.9 percent) of adults age 20 and older are obese
- Obesity rates in women age 60 and older grew during the same time period from 31.5 percent to 38.1 percent
While it is unclear what exact factors led to the drop in rates among the young children group, researchers credit reductions in caloric intake from sugary beverages and policies aimed at reducing childhood obesity at the local, state and federal level. Reducing obesity rates has become a growing national concern given its long-term implications, including higher risk of chronic illnesses. However, as Cynthia Odgen, a researcher for the Centers for Disease Control and Prevention (CDC) and the lead author of the report, noted, the drop represents a small portion of the overall American population. The same period saw increasing obesity rates among women 60 and older, and rates for the broader population remained unchanged.
According to the National Alliance of State Health CO-OPs, close to 300,000 individuals have enrolled for coverage through health plans that were created by the ACA. Leaders from the 23 CO-OPs met in Washington, D.C. last week to discuss more specific updates, such as:
- New York’s Health Republic Insurance, the largest of the CO-OPs, has enrolled more than 50,000 members since October
- Maine’s CO-OP has enrolled more than 80 percent of the individual and small group market in the state that is offered through an online exchange
- Kentucky’s Health Cooperative has captured 61 percent of the market in the state
- Three of the 23 original CO-OPs are planning to expand outside of their original states in 2014
- Several states have had more difficulty enrolling individuals in their CO-OPs, with enrollment as low as 600 individuals
The ACA created CO-OPs to foster competition in the individual and small group markets. Last week, Representative Dave Camp, Chairman of the House Ways and Means Committee, introduced the Tax Reform Act of 2014, which included nearly 1,000 pages worth of tax reform proposals. One proposal included in the bill would revoke the tax exempt status of CO-OPs, which would increase revenues by $700 million over 10 years according to estimates from the Joint Committee on Taxation.
U.S. launches Global Health Security Agenda to guard against security and health threats from infectious diseases
Last Thursday, federal health officials from the U.S. announced the launch of a global initiative with 26 countries and the World Health Organization (WHO) to prevent the transmission of disease outbreaks. This initiative created the Global Health Security Agenda, which will include nine objectives arranged under three primary goals of prevention, detection and rapid response to disease outbreaks, epidemics and biological threats. Key actions will include:
- Strengthening food safety regulatory frameworks
- Vaccination programs targeting epidemic-prone diseases and nosocomial infections
- Transparency in information sharing and reporting
- Strengthening workforce and laboratory capabilities
Infectious diseases account for one in four deaths globally, and transmission of these diseases beyond endemic regions remains a national security and health threat that many national leaders and officials continue to be concerned about. CDC and U.S. Department of Defense have committed $40 million in 10 countries to implement actions mentioned above to bolster laboratory and communication infrastructure. The White House Administration seeks to increase funds to $45 million within the next year to increase the number of countries participating. Within the next five years, the goal is to have 30 countries participating. Currently, no other high-income country has made financial commitments.
Last Wednesday, the National Institute on Aging (NIA) at the National Institutes of Health (NIH) announced that researchers will now have access to genetic data that is linked to medical information from more than 78,000 adult patients with an average age of 63. The information comes from a collaborative project, the Genetic Epidemiology Research on Aging (GERA) cohort, developed by the Kaiser Permanente Research Program on Genes, Environment, and Health and the University of California, San Francisco (UCSF). The NIA, National Institute of Mental Health and the Office of the NIH Director granted Kaiser Permanente and UCSF a combined $24.9 million in funding to add the data to the database of Genotypes and Phenotypes.
Data from the GERA cohort includes information voluntarily submitted by more than 430,000 adults. Of that population, 200,000 submitted blood and saliva samples for genetic research. Researchers scanned genetic information from more than 78,000 individuals, which translates to more than 5 billion bits of data for this cohort. The scans recover information on single nucleotide polymorphisms (SNPs) that will be fed into genomic-wide association studies that can look at millions of SNPs at the same time. Genetic information will then be combined with longitudinal medical information from EHRs and survey data on health habits and background. The database, which contains both open-access and closed-access datasets, was developed and is maintained by the National Center for Biotechnology Information at the NIH to make available studies that have investigated the interaction of genotype and phenotype.