The iBlueButton experience – Part I


During the course of the past few weeks, there has been some commotion and excitement in the healthcare community over the successful introduction of the mobile Blue Button. Many individuals within the industry are familiar with the concept of the Blue Button, however, since half of the clinician populace across the nation has not opted for EHRs, a large percentage of physicians are still oblivious to this common health IT terminology. Essentially, Blue Button is a tool which allows users of electronic medical records to obtain their personal health information via downloading it in various formats on their computers. It was initially designed as a platform to allow American Veterans easy access to their personal health information.

Blue Button has already been used extensively by hospitals throughout the country. Numerous federal agencies such as HHS (Health and Human Services), DOD (Department of Defense) and VA (Veterans Affairs) have applied Blue Button to facilitate their beneficiaries. The most basic format in which Blue Button allows the user to download their personal health information is a text file. By default the file downloaded from this technology is ASCII which is machine readable, meaning that the file may be downloaded in a variety of formats as required, such as text, PDF etc. As mentioned earlier, a Blue Button ASCII file is machine readable, which essentially means it can be parsed (broken down and analyzed) with a straightforward program on any basic computer. The downloaded text file may be accessed on any mobile device or computer without the need for any specific program. These files provide an effortless medium for transmitting health information amongst an assortment of members within the healthcare continuum.

Now, there is a new development in the world of health IT with regards to Blue Button, which is the iBlueButton mobile application. Humetrix is the health IT vendor which is responsible for shaking up the entire industry by introducing this revolutionary technology. Humetrix, a California based organization, revealed its iBlueButton 3.6 physician and consumer apps last October and won the national Blue Button ‘Mash Up’ Challenge. According to Todd Stein, the official spokesperson for Humetrix, thus far no one has been successful in making an application which makes a patient’s complete medical record accessible on their mobile device directly from their provider being solely under the patient’s control. As a result of this remarkable modernization, millions of military veterans and 37 million Medicare patients may now download their Blue Button medical record via their iPad or iPhone.

During a summit convened by the Bipartisan Policy Center in Washington DC, the National Coordinator for Health Information Technology (ONC) Dr. Farzad Mostashari was full of praise for the iBlueButton and its implication within the healthcare community. To quote, Dr Mostashari while sharing a personal story exclaimed that the iBlueButton “opened my eyes”. During a medical emergency pertaining to his father, Dr. Mostashari downloaded his father’s full medical record using the iBlueButton application. Upon obtaining the record, Dr. Mostashari shared it electronically with his father’s doctor who was astonished to see it, as this was unprecedented for him. Pleased with the resourcefulness of this app, Dr. Mostashari comments, “This is patient engagement at its best. This is the future of healthcare. I’m a doctor myself and when I first saw this, it was a real eye opener. I had first tried to download my father’s file from CMS’s Blue Button but it was everything I kind of feared – long, not pretty, it’s got all these codes that you don’t understand, the name of the provider is a number.”

Medical Device Interoperability


Medical devices are of paramount importance to patient care and well being such as the equipment used for clinical measurement, for instance x-ray imaging, temperature, blood pressure and critical life support. Although we depend heavily on modern medical equipment to treat patients, the devices used in practice are usually not interoperable and cannot connect with other devices. This inadvertently causes accidents which may easily be prevented through an interoperable network of devices.

In a traditional intensive care unit, patients are given treatment with the help of numerous devices such as ventilators, electrocardiographs and vital sign monitors. Most of the time, the manufacturers are different for each of these devices, which makes it harder for these devices to be integrated accordingly.

According to a report by the World Health Organization, there are approximately 1.5 million various medical devices in more than 10,000 different types of device groups available globally. These devices are instrumental for effective prevention, diagnosis, treatment and rehabilitation of diseases, and can be used in different settings such as clinics, hospitals and homes by patients, individuals and healthcare workers. They can also be integrated to a cloud Electronic Medical Records network which can make it easier for healthcare providers to record and monitor the performance of these devices.

Peter Pronovost, MD, Medical Director for the Center for Innovation in Quality Patient Care at John Hopkins University sheds some light on the reasons we need interconnected medical devices. “Medical devices need to share data, so that they can better inform clinicians and help patients,” said Mr. Pronovost. “By doing so, we can both improve quality and reduce costs.”

Similarly, a report by Deloitte states that 61% consumers are interested in using a medical device for checking their condition and electronically share that information with their healthcare providers through the use of technologies such as the EMR or Patient Portal.

Through the use of medical devices integrated with Electronic Medical Records, precious lives can be saved. For example, surgery procedures require surgical instruments and radiotherapy units are required to treat cancer patients. In the example of a cancer patient, an infusion pump giving pain medication to the patient can share and exchange data with the vital signs monitor to ensure that the patient is not being given a higher dose.

Joseph M. Smith, MD, Chief Medical and Science Officer of San Diego-based WHI said, “We see an enormous opportunity to use information technology and device innovation to bring about the much needed transformation in healthcare delivery.” He further added, “Today’s hospitals are filled with medical devices that are unable to share critical data, creating potential dangers to patients, as well as inefficiencies that put a tremendous financial burden on our healthcare system.”

RBRVS

RBRVS – A Primer


Any discussion of physician compensation tosses around RBRVS – Resource-based relative value scale – as if it is understood as readily as the time of day.  Yet few understand where and how this payment device originated.

RBRVS and their parent RVUs – relative value units – became the standard tool for Medicare reimbursement fee schedules in 1992 and have subsequently been adopted by the vast majority of insurance payers as their model, in one form or another.

Before 1992, physician compensation was based on historical charges physicians billed for their services, under a concept known as UCR – usual, customary, and reasonable.  Payers applied various statistical measures, such as the median charge; to set a single payment level for each service rendered. In the current discussion of RBRVS reimbursement, it is often forgotten that UCR was far from a satisfactory means of fixing payment rates.  Each payer interpreted UCR differently, so payments for the same service differed greatly, with no apparent rationale.  Besides being a source of complaint about physicians, and for patients who were often reimbursed far less than physician charges, UCR was equally problematic for the business community.  With health costs rising, UCR was viewed as inflationary as it relied on physician’s self-reported fees.  Medicare reported the real dollars spent on physician services per enrollee increased by 62.3% from 1980-86, while the number of enrollees increased only 12%.  The increase was half attributed to increasing physician fees and a half to the volume of services provided. This pattern of increasing costs of Medicare has continued unabated over the years.

Politically this was an unsustainable situation when coupled with growing problems of access as the gap in primary care access and specialist reimbursement widened.

Responding as Washington usually does, a commission was appointed, and the Physician Payment Review Commission was established in 1986 at the Harvard School of Public Health in cooperation with the AMA.  Their purpose was to develop a compensation system that was based on what inputs were required for each service, to build rationality into a non-system of physician compensation.

Initially, the study evaluated 12 major specialties, expanding use, and the CPT manual to assign relative values to each service, some 7,000 codes.

The three components of physician cost were considered the input into the development of a numerical value, an RVU for each CPT.

  1. Work expended by physicians by CPT code, including time spent before and after patient visits and procedures;
  2. Practice costs incurred in rendering services; and
  3. Opportunity costs of training or income foregone by physicians to obtain additional training

The Harvard/AMA researchers of the Commission surveyed 3,200 physicians, focusing on the work expended component of input.  Experts selected by each specialty society then scrutinized the survey results.  Finally, the investigators went to 120 individuals representing interested constituents – consumers, physicians, payers, and researchers – to critique both the findings and the methods.

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Reviewers found a high degree of reliability and validity in the survey.  A considerable amount of time was spent evaluating the work component of cognitive services, such as office visits because physicians in disparate specialties use the common codes in reporting these services.  The results independently obtained from thousands of physicians in multiple specialties differed less than 10 percent.  The RVUs were then extrapolated by the researchers to the related CPT codes.

The work component alone does not determine the RUVs.  That component is then modified for geographic variations based on the practice location and the malpractice costs, which also tend to follow a geographic spread.

The RVU is modified with a geographic practice cost index (GPCI).  This GPCI then is used to adjust the RVU for the location of the practice.  This to accommodate the urban/rural differences in the cost of practice operation.  A factor in this index is the geographic implications related to malpractice costs. The GPCI can significantly modify the total RVU.

None of these numbers is cast in concrete.  Annually the RVUs are adjusted based upon studies that seek to measure the changes in the work input of physicians for specific CPT codes.  The new technology that speeds up a procedure or reduces the technical skill necessary can be factored into the CPT code through changes to the RVU.

Similarly, the GPCI is also adjusted annually based on the indexes of the Urban Institute and Center for Health Economics Research

The three components RVUs – work, practice expense, and malpractice- combine to form the total RVU.

RVUs are non-monetary numerical values.  They represent the relative amount of physician work, resources, and expertise needed to provide services to patients.  The definitive payment for physician services results only when conversion factors (CFs) represented by specific dollar amounts are multiplied by specific RVU.  The formula is ($ fee) = CF ($) x RVU.

Understand that the RVUs by themselves do not determine the amount of payment.  For example, an office visit may have an RVU of 1.5.  Payer A applies a CF of $30 and pays $45.  Payer B applies a CF of $40 and pays $60 for the service.

Payers including Medicare choose a CF that they will apply to the RBRVS based on strategic and financial considerations.  This means that each payer is not valuing the services differently, but that they are determining to value all services differently.  To complicate matters further, payers are now choosing to assign differing CFs to specific ranges of CPT codes.  For example, the CF for radiology may be $20, while that of E&M codes is $40. Currently, there is a movement to curtail radiology, laboratory/pathology, restraint procedures, and increase the CFs for office visits.

The Medicare fee schedule comprised of RVU is called an RBRVS – resource-based relative value scale.

Since implementation in 1992, the RBRVS is updated annually, adjusting units for existing CPT codes and setting units for new ones.  While specialty society input is sought in the process, the ultimate decision is made by Medicare.

A reality of this annual review has continued a progression that devaluates procedural services and increases recognition of cognitive services.

The researchers, even in their initial findings and in the production of the RBRVS, recognized the criticism of their recommendations.  However, as there was a recognition that a perfect system was impossible, and the political winds precluded going backward.

Private insurance organizations, indemnity insurers, and HMOs moved rapidly to adopt if not the exact schedule, then a modified version of it.  The Medicare RBRVS schedule or an RBRVS schedule is believed to rationalize the fees that were allowed.  Too often the insurance organizations relied on historical trends, which resulted in high procedural fees at the expense of primary care, preventive and routine services.  Managed care re-introduced these services and repeated documentation supported the managed care notion that primary, preventive, and routine care would result in lower medical costs by early intervention and avoidance of greater severity of illness.  The question was how to properly pay for those services.  The long-term deterioration of primary care access was also believed to be the result of a financial payment model that devalued primary care.

Reliance of an RBRVS based on Medicare is consistently problematic for those CPT codes that are not generally reflected among the services that Medicare beneficiaries experience, such as obstetrical, preventive, and pediatric codes.  Similarly, any new service or one that Medicare does not reimburse is also generally problematic.  While there are codes for some of these services; their basis in Medicare data is generally very limited or based on the small sample by eligible beneficiaries, such as Medicare disability or ESRD.  Private carriers will either use the Medicare RBRVS fee, even if not reflective of the service, or will assign a fee to these codes.  Assignment of codes of new services can often lag significantly behind the usage within the industry.

The argument continues to this day, what is the proper balance between cognitive skills and procedural skills.

The RVU Formula

Total RVU = (RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) +(RVU malpractice x GPCI malpractice)

Definitions

RBRVS – resource-based relative value scale

A system of valuing physician services developed by researchers at Harvard School of Public Health and implement from Medicare in 1992.

RVU – relative value unit

A numerical value that depicts the amount of physician effort, risk, and resources for one service relative to all others.

CPT – current procedural terminology

A series of more than 7000 numerical codes each representing a unique physician service; most have established RVUs.

GPCI – geographic practice cost index

Numerical values that adjust each RVU component to account for geographic differences, primarily in practice cost and malpractice risk.

CF – conversion factor

A dollar amount multiplied by an RVU to calculate the total payment for a unique CPT code: Total payment = CF ($) x RVU.

No, you can’t hold medical information hostage for payment


 

Medical Record

Yes, lawyers can hold a client’s files until their bill is paid, such as the power of the attorney’s lobby, but refusing to provide medical records on behalf of a patient that owes you money is not a proper collection tactic.

From the standpoint of public policy, the belief is that medical care, and the information that is needed to provide that care trumps getting your outstanding bill paid.  Simple as that.

 

In fact, Federal regulations 45 CFR 164.524(c)(4) is very specific as to your right to charge an individual for a copay of their electronic health records, however, you cannot withhold or deny a patient a copy of access to that record on the grounds that they owe you money.  And in NY physicians are limited to a per page charge of $0.75 to make copies of that record.

Now the regulations that set the per-page price do not contemplate passing on the medical record in an electronic manner so the guidance would be to charge the cost of the media material and a nominal fee.  However, the regulations speak to providing the patient with a copay of the records, there is no provision that mandates that you pay for the cost of mailing or otherwise sending the records. 

 

Therefore, you may want to set up a policy that you will provide the records, but that they must be picked up by the patient or an authorized representative at your office, or that the patient provides you with a paid Federal Express or another secure delivery service.  You can invite the patient to either pick up the records, send the pre-paid delivery envelope, or pay the cost of such.  All should be received by your office prior providing.  Collecting the records by billing is unlikely.

 

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Now if the patient says they cannot afford to pay for the records, you are entitled to ask for documentation of their financial hardship to then waive the cost.  In such incidences, keep your cost exposure to paper copies, no mailing, require to pick up.

 

Similarly, physicians have crossed a red line when they have not reported medical testing results to patients with outstanding balances.  There is an obligation of the physician, often delegated to staff to report test results.  Not only can test results not be held up due to outstanding balances, it is the practices obligation to contact the patient with the results, it cannot and should not pass that responsibility to the patient.  Yes, you can tell them when the results are in if they choose to call, but you have to reach out and present the results if they don’t.  And do so reasonably soon after receiving the results.  This is not only good for patient satisfaction but also good for patient care, especially if those results result in the recommendation for further care or testing.

 

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The unfortunate reality is that once medical services are provided there may be reduced interest by the patient in paying for them.  You are most at risk for non-payment on your commercial patients, where coverage and auditions, as well as nuances of approval and networks, is often confused.  Here you might want to consider contingent credit card authorizations to give you some cushion if the information you rely on from the payer as to coverage, deductible levels, and copays is less then accurate.

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Telemedicine

Telemedicine – Adding a service and revenue to your practice


Physicians have long misunderstood the cost of an office visit.  Copays, generally not more than $20 seem like a limited disincentive to an office visit.  But the cost of an office visit was never just the copay, it includes the cost of the patient’s time, and hassle to schedule, the interruption their day, travel to and from an office visit of say 20 minutes.  To the patient, what are nearly 3 hours of their time worth? A complete morning or afternoon lost to a physician office visit.  And now add to that deductible, large deductibles.  All motivating patients to find a way to access care for less.

And patients are, the use and acceptance of urgent care centers continue to grow.  While studies show that most patient understands that the use of an urgent care center is episodic and that some even say they go because they don’t want to bother the physician when they are not really that sick, convenience is the greatest draw of the centers to patients. And now with most health plans providing coverage, convenience trumps continuity of care. Continue Reading

11 Fundamental Changes in the EMR Market


11 Fundamental Changes in the EMR Market.

For nearly a decade, the $28 billion Electronic Medical Record (EMR) market was on a foreseeable path with roughly 20 similarly-sized competitors and many smaller participants offering software systems and support services. A new report from Kalorama Information says the EMR market is confronting changes that will determine how healthcare providers operate moving forward. Per the report, the market is consolidating, leading to a decrease in EMR support services and creating issues for providers. To illustrate, here are 11 ways the EMR market is changing:

  1. The EMR systems market has been consolidating for years. While there are hundreds of EMR vendors today, consolidation in the industry has accelerated in recent years. In a meaningful use (MU) attestation in 2012, the top 15 EMR vendors of 336 hospitals surveyed represented 75 percent of all providers attesting. On the inpatient side, this concentration was even more pronounced with the top six representing 75 percent of total hospital attestations. Read More

How much missed revenue due to denied claims?


An article in Healthcare IT News stated that 10% to 20% of claims that are denied can contribute to approximately 90% of missed revenue opportunities. However, a company experienced with RCM is able to maintain quality procedures and measures that keep pace with today’s ever-changing business needs and reimbursement models.

 

According to the Northern California Spring Conference, California health insurers rejected approximately 1 in every 5 medical claims, approximating $45.7 million in missed revenue between 2002 and 2009 alone (and that doesn’t include claims denied by Blue Shield of California).

 

Even more alarming are their statistics that a managed care hospital with a net revenue of $50 million may have – at any given time – $5 to $10 million in an open state of denial. Read more