October 27 - 31, 2014
The BreakPoint: Issues With Electronic Health Records Cited in Dallas Ebola Case; HIT May Help Bring Efficiencies But Implementation Won't Always Be Smooth
On October 8, 2014, Thomas Eric Duncan, a citizen of Liberia, became the first person to die of the Ebola virus in the United States. Texas Health Presbyterian Hospital (TH Presbyterian), the hospital where Duncan died, immediately came under scrutiny after it was discovered that Mr. Duncan had first visited the hospital on September 25, only to be released the next morning. He returned to TH Presbyterian on September 28 and subsequently was diagnosed with the Ebola virus. Less than two weeks later, Mr. Duncan was dead, and the Centers for Disease Control, the media, and the public questioned why the hospital had initially released Duncan—allowing the disease to progress and potentially exposing many others to the dreaded virus.
On October 16, a Texas Health Resources official testified before the House Energy and Commerce Committee that TH Presbyterian's configuration of its Electronic Health Record (EHR) system did not adequately display patient travel histories. The official stated that TH Presbyterian has modified its system to address the problem, but the arguably critical omission has drawn considerable attention from the public and media to the use and potential pitfalls of EHRs. Concern regarding EHRs, however, is not new among health care providers. Providers have been voicing their dissatisfaction with the technology since 2011, when the Department of Health and Human Services (HHS), pursuant to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, began incentivizing the adoption of EHRs by providing Medicare and/or Medicaid subsidies to physicians and hospitals who implement EHR systems and reducing Medicare payments to providers who do not adopt the new technology.
According to a recent HHS report, as of 2013, 59 percent of hospitals and 48 percent of physicians had implemented at least a basic EHR system, and as of June 2014, 92 percent of hospitals and 75 percent of physicians had received some type of incentive payments for implementation of their EHR systems. In 2015, the incentive turns from carrot to stick when HHS begins penalizing physicians and hospitals that have not implemented EHR systems by reducing Medicare payments. Whether a provider is penalized depends on what percentage of eligible professionals employed by the provider are making "meaningful use" of EHRs. Meaningful use encompasses many aspects of the use of EHRs including capturing health information in a structured format and using that information to track key clinical conditions.
For physicians, if fewer than 75 percent of the eligible professionals are complying with the meaningful use standards then the penalties start at 1 percent of Medicare's payments under the physician fee schedule and will grow to 5 percent by 2019. However, if more than 75 percent of eligible professionals are meaningful users then the penalties only grow to 3 percent. For hospitals, starting in Fiscal Year (FY) 2015, the annual market basket update will be reduced by 25 percent if they fail to meet the meaningful use standard. This reduction amount will increase to 50 percent in in FY 2016 and 75 percent in FY 2017 and beyond.
Despite the potential benefits of EHRs (e.g., patient convenience and care coordination), there is considerable dissatisfaction among health care providers. According to a recent report released by RAND in conjunction with the American Medical Association (AMA), surveyed physicians report frustrations with EHRs in practice, with many expressing concern that EHRs may be impacting their ability to interact with patients. It seems that nurses agree with this concern, as according to one recent survey, over 90 percent of nurses are dissatisfied with the new technology and believe that EHRs have "negatively impacted communications between nurses and patients."
The AMA has given voice to physician concerns regarding EHRs. In September, the Association released what it referred to as a framework outlining eight priorities for improving EHR usability to benefit caregivers and patients. In announcing the proposed overhaul to the EHR system, the Association noted that the "very incentives intended to drive widespread EHR adoption have exacerbated and, in some instances, directly caused usability issues." On October 14, the AMA followed up its proposed framework for overhaul the EHR system with a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner and National Coordinator for Health Information Technology Dr. Karen DeSalvo. The letter outlined a number of proposed modifications to the meaningful use program, including: (1) a more flexible approach for meeting the meaningful use regulations; (2) expansion of the hardship exemptions for meeting meaningful use requirements; (3) improved quality reporting; and (4) changes to address physician EHR usability challenges.
Adding to provider concerns regarding EHRs are the recent moves of two top officials from the Office of the National Coordinator for Health Information Technology (ONC). One of these moves was National Coordinator Dr. Karen DeSalvo who, ironically, was tapped to serve as acting Assistant Secretary of Health, specifically to help with the national response to the Ebola virus. The AMA stated that it was worried that these departures could leave a leadership gap in dealing with EHR-related issues. HHS later clarified that DeSalvo would continue to chair the Health IT Policy Committee despite giving up the day-to-day management of the Office of the National Coordinator.
For providers and policymakers seeking changes to the EHR standards, opportunities may be on the horizon. Considering that there may be at least one additional legislative patch to Medicare physician payments sometime during the first three months of the next Congress (as the current patch expires on March 31, 2015), there is a possibility that changes could be made to the standards imposed under the HITECH Act. If it seems unlikely that Congress will once again be able to enact a permanent fix to the Sustainable Growth Rate (SGR), Congress may look to provide physicians with some other type of relief. Under those circumstances, a delay in or mitigation of the Medicare payment reductions or even an extension of the incentives for EHR adoption could gain some traction in Congress. At a minimum, some key members of Congress already are letting the Administration know that they have strong views regarding the details of stage three of the Meaningful Use program. This week, the staff of the Senate Health, Education, Labor and Pensions Committee and the Senate Finance Committee circulated a memo with a series of bipartisan recommendations for ONC and CMS. Breakaway will continue to monitor and report on developments in this area.
The Past Week in Health Policy
Federal Rules and Regulations
● FDA announced a request for comments regarding best practices for communication between FDA and investigational new drug application sponsors during drug development.
● FDA announced that it plans to collect comments regarding Adverse Experience Reporting for Licensed Biological Products.
Key Developments, News, and Research
Affordable Care Act
● HHS launched early access for the Small Business Health Options Program (SHOP) Exchanges for five states: Delaware, Illinois, Missouri, New Jersey, and Ohio. The SHOP Exchanges will open for all states at the start of 2015 open enrollment on November 15, 2014.
● CMS will delay transparency requirements for insurers to disclose data on the number of enrollees, denied claims, and costs to consumers for specific services during the 2015 open enrollment period.
● USA Today reports that some doctors are reportedly refusing patients with Exchange plans due to their lower reimbursement rates as compared to traditional commercial plans.
● The House Science Committee issued a subpoena for former White House Chief Technology Officer Todd Park regarding his oversight in developing HealthCare.gov.
● The National Association of Medicaid Directors (NAMD) wrote a letter to the leaders of the Senate Finance, Senate Health, Education, Labor, and Pensions, House Energy and Commerce, and House Ways and Means Committees calling for Congress to examine federal solutions for high cost specialty drugs, including those used to treat Hepatitis C.
● The CDC issued updated monitoring guidance for individuals who may have been exposed to Ebola.
● The Family Medicine for America's Health, a coalition of eight family-physician groups, launched a five-year, $20 million campaign to promote primary care physician awareness and interests.
● Kaiser Health News reports that many insurers are restricting access for high cost Hepatitis C drugs primarily to patients who already have serious liver damage.
● The Securities and Exchange Commission (SEC) is pursuing three overlapping insider-trading investigations involving CMS.
● Kaiser Health News reports that an ongoing federal review of covered Medical devices under Medicare may result in patients with Amyotrophic Lateral Sclerosis (ALS) losing access to certain speech-generation devices.
● CMS intends to release new regulations for Medicaid managed care in January 2015 that aim to ensure timely access to care and better integration of services by January 2015.
Next Week in Health Policy
November 3 - 7, 2014
ECRI Institute: "21st Annual Conference on the Use of Evidence in Policy and Practice"
Thursday, November 6 – Friday November 7, 2014, 8:00 AM
The National Academy of Sciences, 2101 Constitution Ave NW, Washington, DC
Alliance for Health Reform: "21st Century Cancer Care: Will New Models Lead to Better Care at Lower Cost?"
Friday, November 7, 2014, 12:00 PM
Dirksen Senate Office Building, Room G-50
There are currently no D.C. area health care-related hearings scheduled.
There are currently no D.C. area health care-related hearings scheduled.
Upcoming Key Deadlines
October 10 – November 3, 2014: CMS finalizes health plans for insurers participating on the federally-facilitated Exchanges.
October 15 - December 7, 2014: Medicare Open Enrollment period for beneficiaries to select Medicare health plans and prescription drug coverage.
The Supreme Court may announce as soon as November 3 whether they will consider appeals on the recent U.S. Appellate Court rulings on whether the federal government can provide premium tax credits to individuals who enroll in health insurance coverage through the federally-facilitated Exchanges under the ACA.