If you listen to the Centers for Medicare & Medicaid Services (CMS), the organization’s plans to update evaluation and management (E/M) codes could simplify documentation and free up doctors’ time to spend with patients.
Or, it could leave physicians who treat high-acuity patients underpaid.
That’s the reaction from physician groups after CMS released its proposed rule on the 2019 physician fee schedule last week in which CMS announced plans to change E/M codes as a way to simplify documentation and give doctors more time with patients and less in front of a computer screen.
Almost immediately, the Community Oncology Alliance, a nonprofit association of independent oncology centers, slammed the idea.
“Their scheme to pay a physician the same amount for evaluating a case of sniffles and a complex brain cancer simply defies all logic. It is the antithesis of value-based healthcare and cheapens the medical care seniors are entitled to under Medicare,” Ted Okon, executive director of COA, said in a statement, posted the day after CMS released the proposed rule.
In its statement about proposed changes to the physician fee schedule, the American Hospital Association said it would mean underpayment for some doctors.
“Providing substantially less ability to distinguish evaluation and management codes for different levels of resource use and intensity of services means that physicians who provide care for a disproportionate number of high-acuity patients would consistently, and unfairly, receive underpayment,” the group said.
The American College of Rheumatology also came out in opposition to the proposed change. With groups such as MedPAC recognizing that E/M services are already undervalued, rheumatologists are worried additional cuts will exacerbate a growing rheumatology workforce shortage, said ACR president David Daikh.
Other physician groups, including the American Medical Association, the largest physician group in the country, are examining the proposal.
“The AMA is evaluating how this proposal will affect patients, especially those with complex conditions, and we will be carefully evaluating the impact across various types of patients and specialty practices,” said the AMA President Barbara L. McAneny, M.D.
CMS makes its case for change
To make its case, CMS took to Twitter on Wednesday for a livestream panel discussion that included CMS Administrator Seema Verma and four government doctors who had input into the proposed rule to talk about the benefits of the new E/M system.
The doctors included Kate Goodrich, M.D., CMS’ chief medical officer and director of the Center for Clinical Standards and Quality; Don Rucker, M.D., the National Coordinator for Health Information Technology; Anand Shah, M.D., chief medical officer of the Center for Medicare & Medicaid Innovation at CMS; and Thomas Mason, M.D., chief medical officer in the Office of the National Coordinator for Health Information Technology (ONC).
The change will dramatically reduce the amount of time that doctors need to spend inputting unnecessary information into their patients’ records, she said.
E/M visits make up 40% of all charges for Medicare physician payment, so changes to the documentation requirements for these codes would have a wide-reaching impact, she said.
So, what exactly will change? The current system of E/M codes includes five levels for office visits.
Level 1 is primarily used by nonphysician practitioners, while physicians and other practitioners, such as nurse practitioners and physician assistants, use levels 2 through 5. The differences between levels 2-5 can be difficult to discern, as each level has unique documentation requirements that are time-consuming and confusing, Verma said. Physicians must justify the level of the E/M code by documenting care in the patient chart, which then allows them to bill Medicare. Codes with a higher level translate to a more expensive visit.
Now, CMS has proposed to move from a system with separate documentation requirements for each of those four levels to a new system with just one set of requirements and one payment level each for new and established patients. CMS estimates that the change will save 51 hours of clinic time per clinician per year, Verma said. Doctors will need to document to the current level 2 requirements.
A costly proposal?
“Most specialties would see changes in their overall Medicare payments in the range of 1%-2% up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden. If you add up the amount of time saved for clinicians across America in one year from our proposal, it would come to more than 500 years of additional time available for patient care,” Verma wrote to doctors.
But for some doctors, that new system is just too simple—with one payment level no matter the complexity of a patient visit. The Community Oncology Alliance said physicians could face drastic cuts in payment, especially while overseeing life-threatening, complex cases.
Under the proposal, oncologists would see a reduction for the critical evaluation and management of more complex cancer cases from $172 to $135 (a 22% cut) for a new patient and from $148 to $93 (a 37% cut) for an existing patient, the group said.
Yesterday, in the half-hour Twitter discussion, the panel doctors talked about the reasons why doctors should support the new coding system. But Verma was careful to note the plan is a proposal and the agency is looking for doctor feedback during the 60-day comment period on the proposed rule.
Shah, who is also a radiation oncologist at the National Cancer Institute, said CMS is aware of concerns, particularly in oncology, that doctors would not receive the same level 4 and 5 payments. But he said the shift that CMS estimates at 1% to 2% would be made up for in improved productivity, as doctors would save time documenting in patient records. He said officials anticipate that many commercial payers will opt to follow CMS’ lead to simplify E/M coding.
Government doctors tout the benefits
There has been a consensus among doctors that the current system “is just not working,” Rucker said. Doctors are required to include lots of documentation for billing purposes that leads to “note bloat,” he said.
The real clinical information that doctors need to share as part of the electronic health record gets hidden in the reams of information, he said. New doctors can spend more time worrying about documentation than the patient. There is also a lot of money spent on E/M codes, as practices have billing and coding specialists working on submitting the charges for office visits to Medicare.
When they see a complex patient, doctors need to decide the level of an office visit and are required to document specific details, such as how many organ systems they evaluated during the physical exam, Goodrich said. The E/M changes would require minimum documentation for levels 2-5 and a single payment rate for any of those levels. Doctors would no longer have to cut and paste redundant information, such as past medical history or family history, for patients if it is already in the medical record, she said. They would only need to document new information.
One recent study found that that U.S. physician clinical notes are, on average, four times as long as those in other countries, and speculated that regulations that require doctors to document patient care may be responsible.
And that may be part of the reason why the EHR is driving doctors’ dissatisfaction and burnout. Studies have found that U.S. doctors now spend as much time interacting with the computer as they do face-to-face with patients.
“We think the gains in time are going to be large,” Rucker said. Practices spend varying amounts on billing, but he said CMS thinks savings will accrue. Officials also think the change will have a significant impact on the EHR and usability, he said. Not only will the changes “take the clutter out” of EHRs for doctors, it will also help computers mining records for big data, he said.
North Carolina-based LabCorp Diagnostics, one of the largest clinical laboratories in the U.S., was forced to shut down its network on Sunday after officials detected suspicious activity, according to a recent U.S. Securities and Exchange Commission filing.
Over the weekend of July 14, hackers got into LabCorp’s network. Officials immediately took certain systems offline as part of its breach response policy to contain the hack. As a result, test processing and customer access to test results was temporarily impacted.
According to its site, LabCorp services more than 115 million patient encounters annually, which potentially put all of those patient records at risk if they were located on the impacted network. LabCorp did not respond to a request for comment.
Officials have continued to restore full system functionality, with test result services “substantially resuming” on Monday. Additional systems and functions will be restored over the next few days.
“Some customers of LabCorp Diagnostics may experience brief delays in receiving results as we complete that process,” officials said.
The suspicious activity was only detected on LabCorp systems not Covance Drug Development, which the company bought for $6.1 billion in 2014. The company has also notified relevant authorities of the cyberattack.
In June, LabCorp successfully won its court battle over an alleged HIPAA violation. The company was accused of not providing enough privacy protection at its Providence Hospital computer intake system. LabCorp argued an individual can’t bring a lawsuit under HIPAA and filed a motion to dismiss. The judge agreed.
Healthcare providers and industry groups are warning Congress of an urgent need to improve standards and practices to protect medical devices and EHRs from cyberattacks.
Suggestions ranging from better coordination between organizations to federal help in covering the costs of protecting patient data are spelled out in nearly 300 pages of comments submitted to the House Energy and Commerce Committee. The panel in April issued a request for information on how to improve cybersecurity in the medical device sector. Congress is concerned that older “legacy” technologies may be more vulnerable to security threats than their modern counterparts.
The effort is part of a response to the 2017 global ransomware attack dubbed WannaCry that underscored the cybersecurity risks facing device makers, hospitals and healthcare facilities. The massive cyberattack froze computers at hospitals across the United Kingdom and disrupted businesses in more than 100 countries. Hundreds of thousands of devices were infected, according to the House committee.
Cybersecurity issues continue to hound healthcare organizations. The American Medical Association said 83% of physician practices report they have experienced some form of a cybersecurity attack, and the majority of doctors are concerned about future cyber attacks on their practices.
“The healthcare sector exchanges health information electronically more than ever before, putting the entire healthcare ecosystem at risk,” the AMA said in comments to the committee.
The AMA urged adoption of public policy that emphasizes greater transparency, physician educational resources, more equal distribution of liability risk and government enforcement between physicians, technology vendors and manufacturers, and positive incentives to encourage adoption of best practices.
A compromised EHR could prevent a physician from seeing a patient’s medical history, including drug allergies, historical blood pressure readings and previous medical treatments — which could lead to adverse outcomes, the American Alliance of Orthopaedic Executives said in its comments.
Devices including X-ray, MRI and ultrasound machines also need to interface with the EHR to store patient information for later reference or transfer to another provider.
“Healthcare is one of the few sectors of the economy in which a failure of our networks may mean the difference between life and death,” the group said.
Median technology costs for its members were $60,789 per practice in 2016. The executives suggested federal assistance such as tax breaks or an expense component to Medicare reimbursements to encourage adoption of new security protocols.
A cybersecurity risk could affect not only the security of sensitive patient information, but also the performance of medical devices that are life-sustaining, such as anesthesia machines, ventilators and therapy-delivery devices like infusion pumps, according to the American Hospital Association.
Many legacy devices were not built with cybersecurity in mind but are still clinically useful, the AHA said. For most hospitals and health systems, replacing these technologies is not financially feasible, and many can replace only about 10 percent of devices each year, the hospital group said.
Manufacturers must support end-users by wrapping security precautions around legacy devices, adding security tools and auditing capabilities, conducting regular updates, patching all software and communicating security vulnerabilities quickly through consistent channels, the AHA said.
Medical device lobby AdvaMed said any policies that would require its members to support legacy technologies indefinitely would slow development of new innovations and could influence the financial viability of smaller manufacturers.
The American College of Radiology, representing more than 35,000 radiologists, nuclear medicine physicians, radiation oncologists and medical physicists, urged Congress to “exercise restraint” in enacting any legislation that would put an undue burden on end-users such as radiologists.
“The ACR does not support government policies that would inappropriately shift more responsibility/liability associated with medical device cybersecurity away from manufacturers and onto physicians,” the group stated.
ECRI Institute, a research organization focused on cybersecurity for medical technologies, said manufacturers should be encouraged to proactively share device-specific security information such as patches and known vulnerabilities because healthcare organizations lack the knowledge to assess and manage the risk of legacy devices in their inventory.
Kaiser Permanente said policies to improve legacy system cybersecurity should strengthen the ability of healthcare delivery systems to counter current market dynamics, which it said strongly favors manufacturers.
“There are few incentives to encourage manufacturers to invest in supporting older versions of software when they can profit from the continuous need of the healthcare industry to upgrade hardware, software and (operating systems) due to obsolescence. A more level playing field will enhance cybersecurity across healthcare, help ensure greater patient safety, and improve the business value of clinical technology in healthcare delivery,” the healthcare organization said.
Device maker Becton Dickinson recommended manufacturers and healthcare organizations take a coordinated approach to improving transparency and making decisions on security patches and upgrades in response to new risks introduced during a product’s lifetime.
- The value healthcare sector deals increased to $315.74 billion, compared with $154.87 billion in the same period last year during the first half of the year, the New York Times reports, citing data compiled by Thomson Reuters. More than $2.5 trillion in total deals were cut in the first half of 2018.
- Some 36 deals — including a number in healthcare — are valued at $10 billion or more. Combined, those 36 deals make up about 38% of M&A activity for a total of $950 billion in deals — up from $243 billion in 2017.
- The healthcare sector ranks third behind energy and media entertainment in terms of total deal volume.
The healthcare industry has been in the throes of a merger frenzy for more than a year now, fueled by a myriad of factors, including depressed patient admissions, lower reimbursements and pressure to improve outcomes while reducing costs.
After several horizontal mergers were nixed, the recent activity has involved vertical integration.
A federal court ruling clearing the way for the proposed union of AT&T and Time Warner is likely to embolden more industry giants to seek big deals and possibly make way for deals like CVS-Aetna and Cigna-Express Scripts to pass regulatory muster.
Other recent tie-ups include Sanford Health and Good Samaritan Society, which would combine two of Sioux Falls, South Dakota’s largest employers. The merger would blend Good Samaritan’s senior care services into Sanford’s 44 hospital system, which spans nine states.
Catholic health systems Bon Secours and Mercy Health have also announced plans to merge. If approved, the deal would create the nation’s fifth largest Catholic system with 43 hospitals across seven states.
And last week, Amazon announced a definitive agreement to acquire online pharmacy PillPack, putting it in direct competition with CVS, which a week earlier said it was expanding its prescription drug delivery platformnationwide.
All the while, hiring in healthcare continues to rise. The sector added 25,200 jobs last month, with hospitals contributing 10,600 to the industry.
- Over eight years, CareFirst’s patient-centered medical home (PCMH) program has saved more than $1 billion in healthcare spending, the insurer’s CEO Chet Burrell announced this week.
- One of the largest plans of its kind in the nation, the PCMH includes more than 4,300 primary care physicians managing care for more than 1 million CareFirst members. It gives participating doctors value-based financial incentives and clinical supports such as nurses and data analytics.
- Patients in the model have expressed high overall satisfaction in the plans, with ratings averaging 4.5 out 5.
The PCMH has contributed to projected overall savings of $5.5 billion for CareFirst. The savings are significant in the growing yet murky field of value-based payment models, which generally have mixed results when tested.
Yet, a Change Healthcare report in June showed that value-based care initiatives reduced unnecessary medical costs by 5.6%, with almost a quarter of organizations reporting savings of 7.5% or more. The successes of CareFirst’s PCMH program point to the potential value-based programs have to save costs without sacrificing patient engagement or care.
CareFirst, the mid-Atlantic region’s largest private payer, first launched the PCMH program in January 2011 in an attempt to stop the continued rise of already-steep healthcare costs. On a per member, per month basis, overall CareFirst cost was increasing an average of 7.5% every year.
Since the introduction of the PCMH, rises in costs have slowed to an average of 3.5% annually, without any meaningful shifts in membership or enrollment, the company said.
CareFirst’s region includes Maryland, parts of northern Virginia, and Washington, D.C. — an area that accounts for some of the highest hospital admission rates in the country. Yet, in the eight years the PCMH has been active, CareFirst’s hospital admissions dropped 23%, Burrell said in a webcast announcing the results.
The PCMH program was able to do this, he said, by stabilizing patients in their homes or in the community, and by focusing on accountability for total cost of care, data availability, patient behavioral change and scalability. The program used payment rewards in lieu of asking providers to accept any downside risk.
CareFirst organized its participating doctors into panels consisting of about 10 primary care physicians and supporting nurses. Each panel received a patient care account, where all expected costs (credits) and all actual costs (debits) were recorded.
CareFirst tracked the expenses and compared debits and credits monthly. If a panel’s credits exceeded their debits, they got to keep a percentage of those savings. Additional incentives were given for long-term program participation, cost-effective referrals, engagement in care coordination and consistent performance.
More than $440 million has been paid out to primary care providers in additional performance-based payments, Burrell said. The average PCP in the program earning a reward received an additional $37,650 in annual income. Participation has been fairly stable, with fewer than 1% of PCPs leaving the program citing dissatisfaction.
On the eve of his retirement from CareFirst, Burrell concluded the performance report with CareFirst’s key takeaways from the program. He stressed consistency in population health-based incentives to build trust with physicians, easily accessible data and accountability.
- The amount of time it takes for providers to complete EHR tasks varies widely across health IT systems, and so does the error rate and amount of work required, according to a recent study in the Journal of the American Medical Informatics Association.
- The study collected keystroke, mouse click and video data from two different EHR vendors, Epic and Cerner, across four healthcare systems. Between 12 and 15 emergency medicine physicians participated from each site, completing six EHR ordering scenarios: two diagnostic imaging, two laboratory and two medication tasks.
- Error rates varied by task but reached as high as 50%. For certain tasks, there was an eightfold difference in clicks and a ninefold difference in time.
The gaping variability across EHR vendors, tasks and healthcare systems highlights the need for improved standardization across systems and better implementation practices — especially since these factors are critical to the safety of the product and the patient.
Many fast decisions are made during the rollout of an EHR, but it can take several months to a year and a half to complete. That affects usability — the efficiency and effectiveness of the technology in the hands of a clinical user. Problems with usability in areas such as diagnostics or medication can contribute to physician burnout and patient dissatisfaction, along with increased risk to quality of treatment.
The study showed errors across three sectors: imaging, labs and medication. It cited usability challenges such as “screen displays that have confusing layouts and extraneous information, workflow sequences that are redundant and burdensome, and alerts that interrupt workflow with irrelevant information” as reasons for the errors.
Study author and scientific director at MedStar Health’s National Center for Human Factors in Healthcare, Raj Ratwani, told Healthcare Dive that, ultimately, “what’s contributing to these types of errors is the way the system is designed, developed and implemented.”
During implementation, providers make a number of decisions about how they want their health IT system set up, though they may not have the time or knowledge to make those decisions. This can result in “potentially dangerous” flaws in a system that may not meet a provider’s workflow needs, Ratwani said.
Ratwani, who is also an assistant professor of emergency medicine at Georgetown University, pointed out a second challenge: vendor organizations’ inability to clearly communicate the best implementation practices for a specific healthcare organization, as well as sacrificing usability to the demands of a (potentially uninformed) customer.
A confluence of these challenges among the hospitals’ Epic and Cerner systems likely contributed to the high error rate, the study concluded. That has far-reaching consequences, as the two companies together make up more than 50% of EHRs within U.S. hospital systems.
The Office of the National Coordinator of Health Information Technology put requirements in place in 2010 to promote EHR usability and has continued to expand the program. Vendors must attest they are putting the needs of end users at the forefront of software development and third-party certification bodies must approve their products. Still, usability challenges persist.
In a 2015 research letter, Ratwani found a lack of adherence to ONC certification requirements and usability testing standards among several widely used — and certified — EHR products. Other extraneous factors can shape the final manifestation of the EHR. During local site implementation, for example, configuration and customization impact layout and and information accessibility and account for some of the variability across healthcare systems.
The latest study’s authors suggest stakeholders should consider basic performance standards for all implemented EHRs to ensure usable and safe systems, and Ratwani stressed the need for follow-through.
“Many vendors [have] their products certified as having met that requirement” even if they don’t, he said. “The ONC could modify that to say: Show us evidence of your user-centered design process. And if vendors are doing this, showing evidence is easy because if you’re doing it there are natural byproducts of it.”
All of the health information products examined in the study were usability tested by either Cerner or Epic and were certified by the ONC’s accrediting bodies.
Similarly, Ratwani believes that “rethinking [physician] training is going to be important.” That includes revamping the copious training physicians are bombarded with in a clinical setting, especially because clinicians sometimes get their health IT training on a product that “doesn’t even resemble the real product they’re going to be using.”
Rawani urges that multiple stakeholders be involved, noting that solutions can come from both vendors and providers.