New Medical Taxes for 2013- 1 Trillion Tax hike

 On January 1, regardless of the outcome of fiscal cliff negotiations, Americans will be hit with a $1 trillion Obamacare tax hike.
Obamacare contains twenty new or higher taxes. Five of the taxes hit for the first time on January 1. In total, Americans face a net $1 trillion tax hike for the years 2013-2022, according to the Congressional Budget Office.

The five major Obamacare taxes taking effect on January 1 are as follows:

The Obamacare Medical Device Tax: Medical device manufacturers employ 409,000 people in 12,000 plants across the country. Obamacare imposes a new 2.3 percent excise tax on gross sales – even if the company does not earn a profit in a given year. In addition to killing small business jobs and impacting research and development budgets, this will increase the cost of your health care – making everything from pacemakers to artificial hips more expensive.

The Obamacare Flex Account Tax: The 30-35 million Americans who use a pre-tax Flexible Spending Account (FSA) at work to pay for their family’s basic medical needs will face a new government cap of $2500. This will squeeze $13 billion of tax money from Americans over the next ten years. (Currently, the accounts are unlimited under federal law, though employers are allowed to set a cap.)

There is one group of FSA owners for whom this new cap will be particularly cruel and onerous: parents of special needs children. There are several million families with special needs children in the United States, and many of them use FSAs to pay for special needs education. Tuition rates at one leading school that teaches special needs children in Washington, D.C. (National Child Research Center) can easily exceed $14,000 per year. Under tax rules, FSA dollars can be used to pay for this type of special needs education. This Obamacare tax provision will limit the options available to these families.

The Obamacare Surtax on Investment Income: This is a new, 3.8 percentage point surtax on investment income earned in households making at least $250,000 ($200,000 single).

The Obamacare “Haircut” for Medical Itemized Deductions: Currently, those Americans facing high medical expenses are allowed a deduction to the extent that those expenses exceed 7.5 percent of adjusted gross income (AGI). This tax increase imposes a threshold of 10 percent of AGI. By limiting this deduction, Obamacare widens the net of taxable income for the sickest Americans. This tax provision will most harm near retirees and those with modest incomes but high medical bills.

The Obamacare Medicare Payroll Tax Hike: The Medicare payroll tax is currently 2.9 percent on all wages and self-employment profits. Under this tax hike, wages and profits exceeding $200,000 ($250,000 in the case of married couples) will face a 3.8 percent rate instead. This is a direct marginal income tax hike on small business owners, who are liable for self-employment tax in most cases. The table below compares current law vs. the Obamacare Medicare Payroll Tax Hike:
First $200,000 ($250,000 Married) Employer/Employee
All Remaining Wages Employer/Employee
Current Law
1.45%/1.45% 2.9% self-employed
1.45%/1.45% 2.9% self-employed
Obamacare Tax Hike
1.45%/1.45% 2.9% self-employed
1.45%/2.35% 3.8% self-employed

Fiscal Cliff less than 17 hours to go...

With less than 17 hours to go and both sides being pretty far apart I suspect we will being going off the cliff.  I'm frankly pretty disgusted with the US Senate and Harry Reid. The Senate hasn't done a budget in 4 years and is blaming the house(who has sent a budget to the senate every 4 years)?????  Harry Reid is really playing games with the US. It's so bad the Republicans went to Joe Biden to try and get a deal done.  The truth is upping taxes on the top 1% only raises 60 billion more. Guess what that is  7 days worth of Federal Spending.  I think folks realize that taxes might have to go up(unfortunately) however spending needs to go down.  The automatic tax cuts are going to hit the defense side(and cost 800,000 jobs)  but entitlements are going to be safe(though 99 weeks of unemployment will be gone)?  Seriously how many stories do we hear about EBT cards being used to buy alcohol, cigarettes and lap dances and this isn't being looked at? Everyone agrees that people need help once in a while but entitlements are not a lifestyle. Just look at Greece and see how that is working out....  Healthcare at the state levels will get hit and state revenue will get reduced. Plus don't expect new pilot programs for the 2013-14 fiscal years.  Money is going to be tight.

Good Bye 2012 and Welcome 2013. The only constant is change

As 2012 sets into the sunset(and hopefully the world doesn't end tomorrow) Health Care is face with even more uncertainties.  Medical device companies are facing increasing taxes, 25 states have decided not to build Health Information exchanges, the ACA has yet another legal challenge going to the supreme court.  The one certainty is that performance measures are not going to go away and will have even more expanded importance.  Federal and State dollars will hinge on getting the best results. With the Federal government being even more intractable with RAC audits every dollar will need to be fought for.  Every state will be faced with finding "cost-savings"  which means the private sector will be under increased pressure. Compliance will take a greater role as every company will need to manage risk aversion.

With every gloomy cloud I do think there are some rays of sunshine.  I think the public is slowly starting to realize that good health means taking responsibility for yourself. Wellness is starting to gain traction in employer groups. While it is hard to measure in the short term, living healthy has long term positive effects.   Also I think in light of everything that has happen I think mental health may get serious consideration. Its awful that a tragedy has to happen but as a country we really have failed here. Even HEDIS began tracking more mental health measures this year.

 I'm hoping 2013 ushers in new strength,joy and certainty.

Happy Holidays, Merry Christmas, Happy Hanukkah, and Merry Kwanza

Andy

Next 6 months in Health Care

Next 6 months in Health Care

My gut feeling is that we will fall off the fiscal cliff and then reach some sort of resolution in 2013 but what are the implications for Health Care? Well we've already seen a few, medical device companies are laying people off because of the new taxes hitting January 1, 2013. Not surprisingly 18 US Senators(All democrats) have sent a letter to the White House asking them to not enforce the tax. I guess they noticed they stuck it to their own constituents finally with that tax. Plus your premiums are going up another $65 as an added fee gets started this year(to pay for the uninsured). I think its only the start and the confusion will get worse. I suspect a lot of grant programs will get gutted in HHS as the money disappears.  Plus you will see more RAC audits take place as the federal government wants to pay out less money.  The ACA Act I think will undergo some revision as the economy did not recover in time to lessen the blows of the new provisions. It's going to be a messy ride. 

CHC Certification at last!

CHC Certification at last!!!

I just finally got my notification from HCCA that I passed my Certification in Health Care Compliance.  It's the only certification in the United States for this.  I'm pretty excited about it!!! So now when I babble about compliance issues I have an extra little swagger in my step :)

NCQA 7th Annual Policy conference - Follow-up

Well it was going to take more than a few days to write a follow-up to the conference.  After this trip I burnt my United Airlines One Pass Rewards card. After loosing my luggage both ways on my last trip and this time the engines failed during takeoff as we lifted off the tarmac I won't be flying them again. Plus their customer service/mechanics/baggage handlers staff at Ronald Reagan are truly the worst collection of inept employees assembled under one roof. OK enough of this rant.

The Policy Conference was just an excellent event.  The panel discussions were extremely informative.  To be honest having Congresswoman Schwartz was more of a distraction and really didn't offer up a lot but some canned lines and usual political rhetoric plus she was late.  I would have preferred more speakers on the panels with longer discussion. 

The panelists really gave great insight into PCMH and talking about current trends in the Healthcare.  Sadly nobody could offer a magic bullet to fix the mess(none exists). There was considerable talk about bipartisan solutions.  I had to laugh considering last time the bill was made available for 4 hours and had 2700+ pages. People really need to be called on the carpet on crap like this.  Both parties need to be held equally accountable and the press really needs to do their job and not be mouthpieces for a particular political bent.

What i took away from this conference was that PCMH is the new trendy thing in Healthcare.  However is it viable or financially prudent?  It's way to early to guess.  What I did get a nice sense was that doctor's need help not criticism in the way they do things. We have unreasonable expectations at the practice level for them with current regulations. Either they get help of they will fail and pull out of the medicare/medicaid market.

NCQA 7th Annual Policy conference

At the one day conference today in DC.  Will be very curious what is said and talked about.  Will Blog more on this later today.

Follow-up I think I'm going to need a day to put down i words what was talked about. Very Cool topics and discussions

Out of Commission for few weeks

I'm sorry I haven't been posting a lot lately.  I've had a few things going on at work the last 3 weeks and plus I'm running for public office in New Hampshire this year. So I've been stretch thin lately. I actually have quite a few things I really want to blog on Compliance and HEDIS. So please be patient with me and I'll be back posting November 7th.

Outreach programs and how they can help HEDIS scores

I had this question come up a few weeks ago and now that I some down time I can work on this. Can effective outreach programs move HEDIS scores?  The answer is of course yes it can. Does a doctor talking to a patient affect that person's health? Is that an outreach program, of course it is. Is a nurse talking to a member about their health an outreach program, yes it is also. So with that settled a health professional engaging with a patient is an outreach program. Does the patient remember to do what their health professional asks them to do is a whole other matter.
Once a patient walks out the door of the practice they are now on their own to make whatever decisions they feel like doing.  This is where your organizations outreach programs can make a huge difference.  The plain truth is that most HMO's and practice's don't have the experience or the expertise in doing effective outreach. There are organizations out there that do this. These outreach program's typical have telephonic and mail operations along with analytics to identify members for outreach based on criteria set by the plan or practice. NCQA's and URAC's disease management program's are examples of good outreach programs in theory.  The unfortunate part is that a plan can play lip service to these program's, pass the accreditation, and still not have a robust program.
A plan/practice must have a way to identify and stratify its patients through its analytics with those who have a need for outreach. You need solid data from your reporting systems to be effective. This means getting lab and pharmacy data along with normal reported billing data.  This also means you need to be vigilant when getting data from 3rd parties. It has to be accurate and timely. For health plans this isn't too hard but at the practice level this might be harder. If you think about it there is some logic behind pushing for state level health information exchanges.
Next is can you actually contact the member?  Might sound a bit silly but its a real issue for many outreach plans. If you are planning telephonic campaigns just assume that 10% of the phone numbers are invalid(This is being generous). Many people have cell phones now and less have landlines. People often change their numbers. This is a struggle for a lot of places. There are companies that acquire valid numbers for members(though their results can be dubious). Does the person have a mail address? Is it valid? Do they even read the mail? What about email?  Will your outreach get through a spam filter? How about HIPAA concerns with email?  See how this gets a bit more difficult? Really the best way for outreach is to talk to a person one on one. You really need trained clinicians on a phone talking to patients at times when they are available and about topics they are concerned with.
Then do you have the infrastructure to support outreach? Do you have a system in place that can show a patient's information, schedule followups, appointments, send out health literature?  Seems like a lot doesn't it? Well it is and its a big pitfall for many companies. Just don't assume you can do this and do it well.  Plus just having anyone on the phone isn't going to work either. You have someone dialing the phone and making initial contact but then have to hand it off quickly. That work's sometimes.... You'll have dropped calls and annoyed patients. It might be cheaper but you get what you pay for.
Now that you have them on the phone you need to engage them about the clinical gaps you've identified. Hopefully you have the correct data so the member don't think you are barking up the wrong tree. You need a thoughtful and knowledge clinician on the phone that can help with appointment scheduling, health coaching, health materials and have ability to do follow up calls. That's an ideal system it's also tough to setup and maintain. Have a 24x7 service is really essential just doing the 9-5 outreach doesn't really work anymore.

HEDIS/STARS Measure LDL-C Control

MEASURE: Diabetes Care – Cholesterol Controlled
NUMERATOR: % of denominator whose most recent LDL-C level during the measurement year was 100 or less
DENOMINATOR: Diabetic enrollees


LDL-C Control <100 mg/dL
Identify the most recent LDL-C test during the measurement year. The member is numerator compliant if the most recent LDL-C level is <100 mg/dL. If the result for the most recent LDL-C test during the measurement year is ≥100 mg/dL or is missing, or if an LDL-C test was not performed during the measurement year, the member is not numerator compliant.

LDL-C Control <100 mg/dL
The most recent LDL-C level performed during the measurement year is <100 mg/dL, as documented through automated laboratory data or medical record review.
Administrative
Date of most recent LDL Screening
Results of the LDL Screening
The member is compliant if the most recent LDL-C level is <100 mg/dL.
If the results are missing or the results are ≥100 mg/dL then they are not compliant

Medical record
Documentation in medical record must include, at a minimum, a note indicating the date when the LDL-C test was performed and the result.

This is a pretty straight forward measure.  Get the screening and report the results. Either you passed or you didn't. items

Things that can impact the score.

• Not getting the lab results sent to the plans when the plan pays for them(Pretty rare in most cases since the plans usually get the results with the billing info)
• Not getting the results because the tests were done by a third party not connected to the plan. Supplemental Insurance, VA, Community Health Organizations.
• Bad Data sent to the health plans.

How can you improve upon these scores?

Outreach, Care Coordination and  patient education plain and simple.

If a practice or a health plan doesn't not have a serious outreach program to re-engage their patients once they leave the exam room they will miss the out on closing gaps. The practice will need help to reach these members and that's where care coordination comes into play. It maybe be the practice staff or another organization that works with the practice or plan to reach out and engage these members. The final piece is education.  You need to make the members understand that these preventative measure help them live longer, happier lives. Once they make these gaps closures part of their yearly routine the plans and the practices will save money and increase their reimbursement rates.  This is very hard to do. You will need a mature education program in place.

Breast Cancer Screening(BCS) HEDIS Measure

OK here's another measure

MEASURE: Breast Cancer Screening

NUMERATOR: % of Denominator that had a mammogram during the measurement year or the year prior to the measurement year.

DENOMINATOR: Number of female enrollees aged 42 to 69 

It's applicable for Commercial, Medicare and Medicaid 

It has a 45 day allowable gap in enrollment for the denominator. So if they don't have coverage with your plan for 46 days you can get them out of the population.

It does have exclusionary criteria:

Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies

The data elements are pretty straight forward

Year 
Collection 
Eligible population
Numerator events by population

Now this is another straight forward measure on the surface.  The provider needs to get the patient a mammogram screening every basically every two years and these records need to be verified.

The problem is that this can be an "uncomfortable" screening and compliance can be difficult to do.  Once again you might have to deal with dual coverages in the older populations and reporting can be difficult.  
Plus you may have several competing organizations offering these services that may not communicate. Below is an example

CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides access to breast and cervical cancer screening services to underserved women in all 50 states, the District of Columbia, 5 U.S. territories, and 12 tribes

 

It's a federal program but they may not communicate with your provider or the insurance company.  It's just an example of where something very simple can get a bit complex.  This is another example of where supplemental data can be used to provide additional information.  You need evidence of this service has taken place and this must pass your HEDIS auditor scrutiny. I can't emphasis enough that you should have very clear channels of communication with your auditor and provide detail information of how

 

Glaucoma Testing measure

Now that I'm done with vacation and happily(no more summer camp for a year) back at work let's get back to talking about HEDIS and Medicare. Let's talk about a particular measure, Glaucoma Testing. 

MEASURE: Glaucoma Testing
NUMERATOR: % of denominator who had at least 1 glaucoma exam by an eye Dr. during year or year prior
DENOMINATOR: Enrollees aged 67 or older without a prior diagnosis of glaucoma

This seems to be pretty straight forward but this can be very deceptive.  How many health plans get information from eye doctors? Most plans do pay for eye exams but a lot of members do pay out of pocket. Plus members may have supplemental insurance and programs that may be better than what the plan offers.  Plus not all the eye doctors take all insurance. So how the heck does a plan figure out how to increase this score?

You got a couple of different ways. You could have a proactive system where you engage the members get their eye doctors into your provider program.  You could just link up with a national eye insurance program and get them to send you their data.  The other option is HEDIS supplemental data.  This can be pretty tough for a Health Plan if they don't have a good outreach program in place.  If you are going to use supplemental you will need a clinician that will have to collect date, results, type of eye doctor and verify it has no exclusion.Plus you'll need to get this data collection signed off by your auditor.  Be prepared to have a lot of material available for review.

Medication Vacations

This is just more of a personal post and something I ran into last week. I have 2 boys in Cub Scouts and I volunteer every summer to be a Cub Scout Day Camp counselor for a week(It's a week away from work). I ran into something that I had never heard of before and hope to never to again. "Medication Vacation" is a term when parents take their kids off their medication for issues that they deal with during the school year for the summer.  The unfortunate consequence is that the unpaid volunteer at the camp has no idea why your child is bouncing off the wall, hitting other kids, or generally telling you to shove it. Then the poor camp nurse has to delve through the medical records to figure out if there is an issue and has to ask the child if he's been taking his medication. That's where I heard the term "Medication Vacation" So please don't take your kids off their medication for the summer and then do a dump and run on a unpaid volunteer to be a babysitter for your child from 730 to 5pm.  I'm fine with dealing challenging kids but have some consideration for the volunteer and talk to them about your child.  I have to make sure all kids have a safe environment to have fun in. Plus you keep doing this you won't have volunteers to run programs for your children.

Medicare Stars and HEDIS

I thought I would start putting together some of the ideas I've been talking about into more concrete forms. I know when I talk about about NCQA and Compliance I get some interesting looks. But the facts are they are tied together. Whether or not you tie in performance measurements to clinical or compliance they still impact you when reporting to the Federal government. Let's talk about HEDIS measures in the STARS program.

1. MEASURE: Breast Cancer Screening NUMERATOR: % of Denominator that had a mammogram during the measurement year or the year prior to the measurement year. DENOMINATOR: Number of female enrollees aged 42 to 69

2. MEASURE: Colorectal Cancer Screening NUMERATOR: % of denominator that had an appropriate screening for colorectal cancer DENOMINATOR: Number of enrollees aged 51 to 75

3. MEASURE: Cholesterol Screening NUMERATOR: % of denominator who had LDL-C test during year (and for diabetics the year prior) DENOMINATOR: Enrollees with either ischemic vascular disease or diabetes

4. MEASURE: Glaucoma Testing NUMERATOR: % of denominator who had at least 1 glaucoma exam by an eye Dr. during year or year prior DENOMINATOR: Enrollees aged 67 or older without a prior diagnosis of glaucoma

5. MEASURE: Access to Primary Care Doctor Visits NUMERATOR: % of denominator that had an ambulatory/preventive care visit during year DENOMINATOR: All enrollees

6. MEASURE: Diabetes Care – Eye Care NUMERATOR: % of denominator who had a retinal or dilated eye exam by an eye care professional DENOMINATOR: Diabetic enrollees

7. MEASURE: Diabetes Care – Kidney Disease Monitoring NUMERATOR: % of denominator who either had a urine microalbumin test during the measurement year, or who had received medical attention for nephropathy during the measurement year DENOMINATOR: Diabetic enrollees

8. MEASURE: Diabetes Care – Blood Sugar Controlled NUMERATOR: % of denominator whose most recent HbA1c level is greater than 9, or who were not tested during the measurement year. DENOMINATOR: Diabetic enrollees

9. MEASURE: Diabetes Care – Cholesterol Controlled NUMERATOR: % of denominator whose most recent LDL-C level during the measurement year was 100 or less DENOMINATOR: Diabetic enrollees

10. MEASURE: Diabetes Care – Cholesterol Screening NUMERATOR: MA enrollees 18-75 with diabetes (type 1 and type 2) who had an LDL-C screening test performed during the measurement year DENOMINATOR: MA enrollees 18-75 with diabetes (type 1 and type 2)

   

11. MEASURE: Controlling Blood Pressure NUMERATOR: % of denominator whose most recent chart notation of systolic BP was 140 or less and diastolic BP was 90 or less during the measurement year DENOMINATOR: Sampled MA enrollees with hypertension on or before June 30th of the measurement year.

12. MEASURE: Rheumatoid Arthritis Management NUMERATOR: % of denominator who received at least one prescription for a disease modifying anti-rheumatic drug (DMARD) DENOMINATOR: Enrollees diagnosed with rheumatoid arthritis during year

13. MEASURE: Osteoporosis Management NUMERATOR: Female MA enrollees 67 and older who suffered a fracture during the measurement year, and who subsequently had either a bone mineral density test or were prescribed a drug to treat or prevent osteoporosis in the six months after the fracture. DENOMINATOR: Female MA enrollees 67 and older who suffered a fracture during the measurement year

 

14. MEASURE: Adult BMI Assessment [Checking to See if Members are at a Healthy Weight] NUMERATOR: Members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior the measurement year. DENOMINATOR: Members 18-74 years of age

15. MEASURE: Care for Older Adults – Medication Review [Yearly Review of All Medications and Supplements Being Taken] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older.

16. MEASURE: Care for Older Adults – Functional Status Assessment [Yearly Assessment of How Well Plan Members Are  Able to Do Activities of Daily Living] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one functional status assessment during the measurement year. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older.

17. MEASURE: Care for Older Adults – Pain Screening [Yearly Pain Screening or Pain Management Plan] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one pain screening or pain management plan during the measurement year. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older

18. MEASURE: Plan All-Cause Readmissions [Readmission to a Hospital within 30 Days of Being Discharged]    (Lower percentages are better because it means fewer members are being readmitted) NUMERATOR: Senior plan members discharged from hospital stays who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. DENOMINATOR: Plan enrollees 66 years and older

     All these measure are part of STARS and these are HEDIS.  So who owns them? Clinical or Compliance? The reality is both. Sure these are clinical measures that are monitored and coached upon but these are also results that get reported to Federal agencies.  Sure these get reported and audited and sent to NCQA but then they get used for medicare STARS scores which then affects how much money the HMO might receive.  The lines are blurring between many groups.  Also who actually pulls this information and puts them into a report??  It might be a group's IT department so maybe they own a chunk.  It's going to become an increasingly complex world with blurred lines of responsibilities. Many things will fall through the cracks and you really need to be forward thinking.

I'm going to suggest bring back the old Tripartite Pact just replacing them with Clinical, Compliance and IT as the three partners.  Anyone who works in the HIPAA world knows how important having IT and Clinical on board to be being successful.  But I'm going to take it one step further that in order to be successful in Health Care Compliance you need this pact in the 21st century.  Next I'm going to take a specific measure and break it down.

Compliance-- Recent events

Well after a some vacation time its back to blogging again on topics I enjoy. I'm going to ramble a bit on the next few posts about the ever changing world of Health Care Compliance and throw in a little HEDIS and NCQA for good measure.  Well since the Supreme Court punted on the Health Care Act and said it was Congress's responsibility it still doesn't really settle the issue. However in the world of compliance, funding may change but regulations and requirements don't... One thing is for certain is that Federal Dollars are going to be tighter and hard to get. In some ways the regulations that HHS have developed are cost saving benefits. If you don't have a 4 or 5 star Medicare rating you aren't going to get the maximum federal payout as the years go by.  As the populations gets older and the strain on the system is going to get heavier and compliance with federal guideline with get more stringent. Plans will need to show improvement with their HEDIS measures covered by STARS. Some measures will get new weight others less but these ranking will never go away.

Congress really doesn't get this deep into regulations and rules and allows this to be the responsibility of the governing federal agency. That's why the funding may change but the rules won't.  Or they might become an unfunded mandate(a nightmare for many entities).   Most of the people serving in congress do not have technical or clinical backgrounds and really have no idea what is being discussed. They rely on staff members to make recommendations with constituent feedback(hopefully). Throw in a whole bunch of lobbyists and you get the current mess we have. That's why congress punts most of the time on regulations and relies on the governing body to put those in place.

Let's take the topic of the ICD-10 conversion. It's scheduled to go live in October of 2013. However they might move to 2014 now. However that's only a proposed change so what do you do? Well you better assume that its going to be next year.  Compliance is about risk avoidance and good practices.  The safe path is to be ready for next year and if it changes you are already prepared and have less work to do.. Besides you'll get better identification and stratification by converting as the level of detail with ICD-10 is greater(unfortunately a bit more complex). I find it surprising that they  want to delay it again(there must be some lobbyist group putting pressure on HHS). At this rate you might as well convert to ICD-11...

Kudos to Health Ed

I follow this blog a bit and wanted to say kudos to them :)

This past week we received word that HealthEd has been named a finalist for the 2012 MM&M Awards in the category of Best Multichannel Campaign, Large Client Organizations for the Xeloda Multichannel Patient Adherence Campaign.
 http://healthed.com/
http://healthed.typepad.com/healthed-blog/

Great Idea from NCQA!!

It's good to see NCQA engaging its members in a interactive way!

Announcing: NCQA's New Accreditation Users Group

The National Committee for Quality Assurance (NCQA) is excited to announce the Accreditation Users Group (AUG). The AUG provides a new communication, learning and development platform for members to discuss updates to existing NCQA Accreditation and Certification products, and how they are applied. AUG members will also have the opportunity to contribute to the enhancement of future products. The AUG will cover the following accreditation and certification products:

• Health Plan (HP) Accreditation
• Disease Management (DM) Accreditation
• Managed Behavioral Healthcare Organization (MBHO) Accreditation
• Wellness and Health Promotion (WHP) Accreditation
• Accountable Care Organizations (ACO) Accreditation
• Case Management (CM) Accreditation
• Disease Management (DM) Certification
• Health Information Products (HIP) Certification
• Physician and Hospital Quality (PHQ) Certification
• Credentials Verification Organization (CVO) Certification
• Utilization Management/Credentialing (UM/CR) Certification
• Medicare Advantage (MA) Deeming
• Multicultural Health Care (MHC) Distinction

AUG members also receive the following benefits during the subscription year:

• A $200 voucher toward an NCQA Accreditation, Certification or HEDIS publication, or toward a license for the Interactive Survey System Survey Tool.
• A $200 voucher toward any NCQA educational seminar.
• A $100 voucher toward NCQA's Quality Compass.
• NCQA WebEx sessions that address key updates and user-expressed topics of interest.
• Access to the Users Group Member Download Center, which include recorded training sessions, presentations and other valuable user-only materials.
• Access to the monthly Users Group newsletter, which lets subscribers know about recent policies and issues that have the potential to affect their organization, and includes information about Webinar trainings, policy updates and publication release dates.

The AUG membership fee is $950 per year, which follows NCQA's standards year (July 1 to June 30).

If you are seeking NCQA Accreditation or Certification for any of the products listed above; provide guidance to organizations covered under the scope of the products; or purchase services from an NCQA-Accredited or NCQA-Certified organization, we invite you to consider joining the AUG.

To sign up for the Accreditation Users Group, click here. If you have any questions about the AUG, please contact Veronica Locke at locke@ncqa.org.

Compliance warning sign

There always comes a time when a compliance professional needs to give his organization a reality dose. When your organization decides the compliance team needs to maintain documentation that's owned by another group because they don't have the time to keep up with it that's a major problem. The compliance team is job is to make sure that all departments keep their documents up to date and reviewed at least annually. Once you take on the role of setting up the reviews and assign work you open yourself to doing this for all departments.  This will become time consuming and drag your group's resources away from their main goal of compliance. There are a lot of fine document management systems out their. Have you company invest in one.

Compliance - Clinical

When it comes to clinical compliance I'm going to look at it from the policy and procedure  point of view.  As a compliance professional you do not have to be clinical to make sure it gets done.  You have to make sure your clinical group gets it done.  Your clinical group really has the ownership of the materials and policies.  They need to recognize the fact these need to get reviewed and updated at least on a yearly basis. As a compliance officer your job is make sure they do theirs.  Nobody really wants to get hounded to do things but sometimes you do need to explain why it is important to do things in a timely manner. Like the Aviation field health care is going to get the same level of scrutiny as that field does. Once you accept that fact as an organization you will be much better prepared.                                                                                                                         What does need to get reviewed on at least an annual basis? Anything clinical that can change on at least a yearly basis. Sounds pretty broad doesn't it? Well it is, and the reason it is you should never assume anything. For example let say you do health coaching for diabetes as a company.  You'll need to review what you coach on. That means you'll need to review changes in diabetes care, changes in diabetes medication, changes in diabetes health, fitness programs for diabetes, etc, etc. This might be a pain but  as a health organization you have to do this.  URAC and NCQA expect this, so do the feds and the state folks also. Besides isn't it best practice to review these items anyways?
Compliance isn't about making people miserable internally, compliance should really be about making people externally healthier by making sure you provide the best care possible.

What is compliance? Internal Oversight

I ended my last post about internal oversight so I'm going continue with that. Who owns compliance? The reality is that it is everyone. However if you ask 10 employees nobody will say they have a part in it.  Usually they'd say legal owns it or the compliance dept or maybe their manager. It's sad but its the situation for most companies.  When looking at internal compliance it really gets worse.  Most companies really don't have the time or budget to review all internal policies let alone spend the effort to make sure they are enforced.  It's a thankless job. Nobody likes to be scrutinized and even worse being told they aren't doing their job. It's like being in Internal Affairs police officer. You gotta have them but nobody wants to hang out with them. 
The mindset in Health care really should be how the FDA does their process and oversight. That's really the model that its going to.  Products that are developed need to trace to the business specifications traced to the business requirements to functional requirements, etc.  Policies will all need to trace up and trace down.  This also means the administrative workload will increase to ensure compliance(adherence).  Most Health Care companies are going to need to build out their compliance departments from just usually legal to having members with clinical and IT background also. Auditors aren't just going to accounting guys anymore. Companies are going to have to defend how they do business from the top to the bottom level.  Companies need to take a proactive approach to internal compliance.  You need to make folks realize that they do process as a way being more efficient. On the flip side you also need to be open and receptive that if process isn't working you need to fix it. It's a two way street and managers need to understand that.  It's a way to help promote reliable and consistent service to the members that use your health services.  Think of it as eliminating unwarranted variation at the corporate level :)

What is compliance?

  We hear this term kicked around a lot nowadays "We need to be compliant!", but what the heck do they mean. Unfortunately you ask 4 different people you are getting 4 different answers.  The irony is they probably are all correct.  In today's world increasing confused and complex world of health care compliance takes many forms.  You have legal compliance where you need to maintain HIPAA compliance along with Federal and State statutes.  You have accreditation compliance were you need need to maintain NCQA and URAC compliance.  You will also need to maintain compliance with your own internal policies and procedures.  I'm going to focus a bit on internal compliance because I don't think this gets enough consideration and truthfully in the long run this will save you a lot of heart ache.
   Internal Compliance to me is maintaining your internal policies and faithfully using them as your guidelines to how you do business.  A simple form of compliance would be using a standard set of documents for internal and external use.  It could be as complex as what your clinical guidelines are for Diabetes Care. A lot of companies don't really put much faith in documentation and established procedures. They find it time consuming and a waste of money.  The fact of the matter is that the type of regulation and oversight that is present in the aviation industry is coming to health care.  NCQA and URAC both expect internal policies and procedures to be present and followed, it just happen to be a lot of overlap when it comes to HIPAA. There is considerable expectation that these policies are reviewed on a annual basis. This can be hard for a lot of companies especially if the company culture doesn't support this. Also please realize that if you screw something up at the state or federal level those guys are going to ask what your internal policies are and how they are followed. Believe me you aren't going to get a good reaction if you can't prove you do what you say you do....
  The next question is what should be considered for internal compliance oversight.  Honestly everything should but that's completely unrealistic for most companies(Unless you are Google and have an extra 300 million to burn).  What internal policies and procedures could get you into trouble?.  IT policies on security, data, and usage should all be put into that bucket.  You better add in all your clinical guidelines that you use also. What about contractual agreements? Yup add those in also. See how the list is growing?  It's only going to get bigger with a few more minutes of thought. Let me know if there others that you think should get added to the list!  Alright I think I'm going to babble a bit on who should be doing the oversight in my next post

More HEDIS fun facts

Sorry I've gotten behind in my posting. I went away for a wonderful long weekend to Stowe Vermont with my wife(no kids). So now its back to posting some more HEDIS Fun Facts.

HEDIS Fun Fact #5 CDC what does it stand for? If you said Centers for Disease Control you are warm but not right.  It stands for Comprehensive Diabetes Care. It's actually a bunch of sub measures under main measure.
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following.

• Hemoglobin A1c (HbA1c) testing 
• HbA1c poor control (>9.0%) 
• HbA1c control (<8.0%) 
• HbA1c control (<7.0%) for a selected population
• Eye exam (retinal) performed 
• LDL-C screening LDL-C control (<100 mg/dL) 
• Medical attention for nephropathy 
• BP control (<140/80 mm Hg) 
• BP control (<140/90 mm Hg)

I personally find this one of the more interesting measures because of all the different  components.

HEDIS Fun Fact #6  How many different medicare programs are included for HEDIS reporting??  Correct answer is 6
HEDIS reporting is required for:

1. Medicare Advantage (MA) contracts 
2. Section 1876 cost contracts with active enrollment 
3. Medical Savings Account (MSA) plans 
4. Private Fee-for-Service (PFFS) plans 
5. Special Needs Plans (SNP) 
6. Certain demonstration projects.

 HEDIS Fun Fact #7 What is the  "Eligible Population"?  Coming from the definition from NCQA.  The eligible population for any measure is all members who satisfy all specified criteria, including age, continuous enrollment, benefit, event and the anchor date enrollment requirement.  The part to remember is that every individual measure has their own eligibility criteria.  It is very unwise to male a blanket decision for population. You will get burned in the long run.

HEDIS Fun Fact #8 What is "Continuous Enrollment"? No it is not the fee that you get charged monthly on your credit card you keep forgetting to cancel... Continuous enrollment specifies the minimum amount of time that a member must be enrolled in an organization before becoming eligible for a measure. Generally it is 12 months for HEDIS measures for the calendar year. However don't assume and check the specs

Ok that's all for Fun facts for today. Just remember "Don't assume, look up the darn spec!" 

HEDIS Fun Facts

I'll profess right now all my knowledge comes from listening to a lot of people much smarter than me and reading NCQA's HEDIS technical specs.  If you take the time to read the specs you'll reap the benefits down the road. I've worked on databases that fed cinical data in and out of coaching systems but never really appreciated the work and thought that went into developing HEDIS measures.

 HEDIS Fun FACT 1: What the heck does HEDIS stand for???  I bet if you ask 6 people you'll probably get 6 different answers it actually stands for  Healthcare Effectiveness Data and Information Set. Hence the name HEDIS. However there is a mountain in Turkey named HEDIS(Hedis Dagi) also so once in a while you might see a blog posting in turkish about HEDIS. Don't worry the turkish healthcare system hasn't hijacked the standard..

HEDIS Fun Fact 2: When did HEDIS get started? It actually got rolled out in 1991 but its name back then was the HMO Employer Data and Information Set.  It was really created to compare HMO's against each other to see who had better ratings and how well it did in regional and national benchmarks. They changed the name to its current form back in 2007.

HEDIS Fun Fact 3: How many domains does HEDIS cover?

The Correct answer for 2012 is 5

• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Relative Resource Use
• Cost of Care
• Health Plan Descriptive Information

There were 8
♦ Effectiveness of Care
♦ Access/Availability of Care
♦ Satisfaction With the Experience of Care
♦ Health Plan Stability
♦ Use of Services
♦ Cost of Care
♦ Informed Healthcare Choices
♦ Health Plan Descriptive Information

HEDIS Fun Fact 4: How many HEDIS measures are there
Currently in the 2012 Standards there are 76.

NCQA has been fairly logical in adding measures. Back in 2007 there were 71.  As new ideas and products come into the market to their credit NCQA has been fairly responsive to the changes. A good example of this is the Human Papillomavirus Vaccine measure that became effective for 2012. Measure do get retired also such as Relative Resource Use for People With Acute Low Back Pain. in 2012 also.

So now you too can win HEDIS Jeopardy! More to come :) I'm truly a dork because I published this on my birthday(May 16th)!

HEDIS and Outreach Part 4

Hedis and Outreach
 Michael’s comment sparked a few neurons for me so I’m going to digress a tiny bit. PCMH (Patient Centered Medical Homes) is a very popular buzzword. NCQA has this program that can be accredited. It’s a pretty good program to be honest. It really tries to get practices to use technology to improve health care. It focuses a lot on EHR’s (Electronic Health Records). They really want practices to think about population health and management.　 They do the typical quality improvement language (Quality measures) which will transmit into HEDIS measures being used. The one weakness with this is that the population will have multiple HMO coverage’s (there are very few single HMO practices out there as far as I know). So you could have 3 different patients with different coverage’s. All these plans could have different requirements…. It’s really a mess the practice to keep it straight. Plus who the heck is going to do the quality metrics for these practices?? The medical billing coder?　 This is where the DM companies need to work hand in hand with the practices.　 They need tie the practice outreach with the DM outreach.　 This is a huge opportunity for the DM companies. Do you really think the HMO is going to do this??They already are doing the metrics, they have the outreach capability.　 Just how do you tie this together?　 You need to tie the EHR, the doctor and the disease management together. You need the doctor to feed the EHR, the EHR to feed the DM and the DM to feed the EHR. Sounds easy, doesn’t it?There are very few companies that I know of that can do this at this moment. 　
I got some really nice email feedback from some readers.　 So I’ll do some running posts about HEDIS in general. A bit of a 101 type on Thursday.　

HEDIS and Outreach - DM Programs- Part 3

HEDIS and Outreach

Disease Management is not dead… Contrary to some beliefs.  Disease management companies will be back stronger than ever. Why do you ask? Simply HEDIS performance improvement.  In order to show improvement you need to reach members to get those screenings, tests, and medication persistence.  A lot of companies ditched their DM vendors and in sourced their services as a way to save money and still keep their NCQA accreditation.  In the short term it made sense. There wasn’t much “value”  in just keeping a company around for QI8.  What a lot of plans don’t realize is that DM vendors provide tremendous value in moving HEDIS scores. They have the knowledge, infrastructure and programs already in place to touch those critical HEDIS concerns.  To be totally frank the NCQA DM program is basically a blue print on how to improve HEDIS scores. Here’s a little tidbit NCQA DM Performance measurements is linked to HEDIS, there a reason why they did this.  Think about it….  More on this later