8000 hits on this blog!!

I just want to say thank you for getting to the 8000 hits on my blog mark. My hope is to 10000 by December.  I'll do more posting over the next few weeks.  I'm working as a volunteer camp councilor next week(cub scouts) So I'll have some down time at night.

Thank you all!

Andy

A possible silver lining to the HEDIS changes

Well in any situation you do need to find the silver lining in this case.  I'm going to look at this from the patients point of view.  If there were plans not exactly being honest in their reporting then the fact is people weren't getting better.  The point of these measures was to report if people were closing clinical gaps in their conditions. if they were closing these gaps they would be getting healthier or at least not any worse.  The point of all this is to provide better health care and make people better. Maybe this gets a little lost sometimes with all the different issues that seem to crop up in health care.  What I see changing are organizations turning back to old fashioned health coaching and talking to their members about getting treatments and following up with them. The 20 minute conveyor belt just isn't going to work(not the doctor's fault). The plans and the practices are going to need to work together in outreaching to members after they have left the doctor's office. PCMH is an interesting approach but I think it lacks some teeth in reporting outcomes and outreach post office visit. It's still a good start to seeing changes down the road.  The other winner in this change is really the tax payer surprisingly enough. If plans weren't really supposed to get their bonus payments then HHS isn't going to be paying them extra money. I do recognize the fact however that this may impact plans that were doing nothing wrong.  It's going to be interesting how this all shakes out.

More on the HEDIS Supplemental Changes

I think there will be extra angst as the changes are fully implemented over the next year.  First for measures that have multiple year look backs you will need primary source data in those look back years. That may be difficulty especially if records are stored and not accessible easily.  One area that I think will cause additional pain when plans take on new members.  You will need accurate records to prove that members got required tests and screening from the year that they weren't members of the plan.  Now we all have been dealing with EHR's in some shape or form and this may not be as easy as you think.  What about the pneumonia vaccine you got 4 years ago or the double mastectomy 12 years go. How about doctor tests and results? Hopefully you got your portable records with you. Now as the impacts become more apparent I think some of the rules maybe modified as NCQA gets the feedback rolling in. Personally I don't see any major changes allowing anything but primary source validation.  Because there is state and federal money implications with these scores and there appears to be some indications that there was improper reporting going on NCQA was placed in a pretty difficult position. Either ratchet down the rules or face possible litigation from the OIG is probably what occurred. While NCQA was formed from Health Plans trying to put industry standards and its roots are in health plan promotion I don't think they had much choice in these changes.

HEDIS Supplemental Changes

Sorry I haven't been blogging a while tied up with submission dates and some time off.  I would like to talk about the recent changes to HEDIS supplemental data rules.  Back in April NCQA notified its participants of the changes. In a nutshell unless you have primary source validation for your supplemental data you can't use it. What is primary source?  Basically the hard copy receipts or results of tests and exams.  Without that you can't use the data.  Why did this happen? I suspect there were legal issues with HHS were organizations were playing fast and loose with the rules.  Someone had to have complained and most likely there are open investigations and I suspect you will see OIG cases going to court.  There is a lot of money tied in Medicare STAR ratings and somebody or a few somebodies had to be doing some rather sketchy things.  While the organization that I work for is doing HEDIS Data collection we also were putting this into a disease management registry system, recording calls and had a documented process on what was valid information plus following clinical guidelines for health coaching of patients(our phone staff are RN's).  I suspect there were companies out there just doing cold calling and recording information... With the changes that have occurred we will be out of that line of business.  My guess is there will lowering of scores across the board for Health Plans.  If Plans were using to supplemental data to even boost them half a star its going to hurt. 

More on this on the next post

17th Annual Compliance Conference Thoughts

Well now that I have gotten through my 200+ emails since getting back to work all I can say it is really refreshing to be in a place where everybody is in the same boat as you. Whether you do billing, privacy, audit, or anything else we all feel the same pressures and stress.  Having Dan Levinson the US Inspector General for HHS as the keynote speaker there, really reinforced the importance of compliance and another topic, Data Quality.  I don't think he could be any clearer that data quality is going to be extremely important. The push for EMR's is the first step, the next step are HIE's. All medical data is going to be tracked and checked. There are going to be more than a few compliance officers reading books on Data warehouses in the next couple of years.
The other take away I have is reach out to colleagues and ask for help. It's a huge networking event at the conference and to be honest most compliance departments are pretty small staffing wise to have a huge knowledge base. . Reach out and ask questions!!!  The only bad question is the one that is never asked.

ACO discussion with HCCA at the 17th Annual Compliance Conference

Listening to a panel discussion on ACO's
with Shawn DeGroot, Frank Sheeder, Troy Barsky, and Mary Fischer

Interesting Points

• They are run by providers no VC money involved
• Their board has to be made up of 75% of membership
• ACO's are involved in shared savings, shared risks models
• They are judged on performance benchmarks as a measure of success
• ACO's don't totally follow the OIG 7 elements for compliance but have their own structure and a mandatory compliance position that reports to the board.
•  Privacy concerns along with standard federal guidelines are all still present
• Anti-trust concerns with ACO's DOJ and FTC have published papers on this
• ACO's and physicians share money which raises concerns but waivers are available
• Need to focus on quality data
• Potential for false claims based on bad data(IT Data warehouse be aware!!)
• Need to think about Stark and anti-kickback more about co-mingling of money
• Compliance concern needs to be at the table early and often because of the multiple of potential issues.
• ACO  has to service at least 5000 members 
• Litigation's will be a concern with ACO's if they run a foul of regulations
• Serving people vs. financials concerns are a tightrope
• Compliance is a critical part of making an ACO a success
  

Day 3 HCCA National Conference - Personal Reflection

All I can say it is such an uplifting experience to spend time with people in the same field, who go through the same aggravations and give you inspiration to be passionate about what you do.