Health Care Current | September 27, 2016

EHRs, health IT, and the future of patient relationship management

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

My Take

EHRs, health IT, and the future of patient relationship management

By Mitch Morris, MD, Global Life Sciences and Health Care Industry Leader, Deloitte Consulting LLP

Back around 1990, I became aware of the potential of electronic health records (EHRs). The ability to use this technology to improve efficiency, effectiveness, quality, and safety felt like it was around the corner. At that point, I shifted my career away from medicine and toward enabling greater adoption of health information technology (IT), sure that the “vision” was near at hand. Now, more than 25 years later, we still have challenges in delivering true value to clinicians and patients. Sure, we have made great progress. But, as an industry we still seem far from the goal line.

This is what Deloitte’s 2016 Survey of US Physicians found. The majority of physicians we surveyed hold relatively negative perspectives on some aspects of EHRs, and this has not improved since our last survey in 2014. Indeed, three out of four physicians believe that EHRs increase practice costs, outweighing any efficiency savings, and seven out of 10 physicians think that EHRs reduce their productivity. Moreover, physicians are less likely to think that EHR capabilities support clinical outcomes than they did in the 2014 survey.

This doesn’t mean that the Health Information Technology for Economic and Clinical Health (HITECH) Act’s Meaningful Use Program – which gave bonuses to clinicians who adopted certified EHR systems – has been unsuccessful. Case in point: Most (78 percent) physicians believe that EHRs are most useful for analytics and reporting capabilities compared to other attributes (such as supporting value-based care or improvements to clinical outcomes); this has also increased since the 2014 survey. In fact, few physicians would stop using their current EHR system: Three out of five would keep the current EHR system they have and not replace it.

What the survey did find, however, is that nearly all physicians would like to see improvements. Improvement wishes fell into two major areas:

  • 62 percent want them to be more interoperable
  • 57 percent want improved workflow and increased productivity

These last points will likely be critical as we enter into the first phase of implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). EHRs and interoperability are a fundamental aspect of virtually every part of this initiative. For example, while Meaningful Use will be phased out for eligible professionals, the US Centers for Medicare and Medicaid Services (CMS) has replaced it with the Advancing Care Information measure under the new Merit-Based Incentive Payment System (MIPS). MIPS is for clinicians who do not meet the Advanced Alternative Payment Model (APMs) thresholds. For most of the categories under MIPS, clinicians will be able to report using their EHR, too. Clinicians in Advanced APMs will not be able to avoid it either – only payment models that use certified EHR technology will qualify under the Advanced APM definition.

Interoperability is also a key issue getting attention under MACRA. The president of the American Medical Association, Steven Stack, has said that the lack of interoperable systems is one of the fundamental reasons why the potential of EHRs has gone unfulfilled.1 For that reason, and likely others, Congress made interoperability a core focus of MACRA. This comes after years of work by the Office of the National Coordinator for Health Information Technology (ONC), the Healthcare Information and Management Systems Society (HIMSS), and others to enhance data sharing and transparency across the system.

Health care’s reliance on technology is not likely to change. In fact, MACRA’s emphasis on utilizing and enhancing EHR systems and the charge to improve interoperability moving forward could strengthen the focus on technology. Those who are EHR “enthusiasts” should consider the findings of our study and others like it that indicate we still have work to do before health IT can deliver a clear and discernable value similar to the value many enjoy with online retail shopping.

Not unlike the practice of medicine itself, effective implementation of EHRs can be part science and a healthy dose of art. The art of the EHR includes our ability to manage change, train clinicians in a holistic way, transform workflow, and truly take advantage of automation. We may get there but, we should consider being responsive to the strong notes of concern from the clinical community.

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Source: 1American Medical Association, Press Release, “AMA and Other Medical Societies Call for a Change in Interoperability Measurements,” June 3, 2016

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Findings on health information technology

Implementation & Adoption

Final rule on new Medicare payment models under White House review

The final rule on MIPS and APM incentives under MACRA is currently under review at the White House. CMS submitted the rule to the White House Office of Management and Budget on September 14, 2016.

MACRA is poised to drive payment and delivery system reform efforts across payers for the foreseeable future and spur greater movement to risk-bearing, coordinated care models.

The final rule is expected to lock in January 1, 2017 as the beginning of the first performance period under MACRA and provide greater detail on some new options for participating in MIPS for 2017. One new option would shield clinicians from negative payment adjustments for the 2017 performance year so long as they reported some data under MIPS, while the other would provide the possibility of smaller positive payment adjustments for clinicians who report data through MIPS for less than the full calendar year for 2017. CMS announced the new options in a blog post on September 8, 2016 (see the September 13, 2016 Health Care Current).

The final rule also is expected to provide a final list of advanced APMs for the 2017 performance year and performance benchmarks for MIPS-eligible clinicians. These performance benchmarks will likely be critically important for clinicians because the benchmarks will illustrate the level of performance required to achieve positive payment adjustments under MIPS.

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Quality of care varies among telehealth providers

A Changes in Health Care Financing & Organization study found that quality of care varies significantly among the eight direct-to-consumer virtual care websites with the highest traffic. According to the study, the vendors are not consistent in how often they gather a complete medical history, perform a physical exam, or determine the correct diagnosis.

Researchers used actors and medical students to assess the performance of the providers. They contacted each of the providers and presented symptoms for six conditions. Physicians followed standard decision guidelines for about half of visits. Adherence to guideline-recommended procedures varied significantly by condition.

Though the study did not assert whether virtual visits were superior to or inferior to in-person visits, the researchers indicated that the rates of incorrectly ordering tests may be lower in virtual care than in in-person settings. The researchers said that variation among virtual providers can be reduced by creating industry standards and encouraging greater collaboration among telehealth companies.

(Source: Changes in Health Care Financing & Organization, “Variation in Quality of Care among Virtual Urgent Care Providers,” September 2016)

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Study: Higher premiums in employer-sponsored insurance than in exchanges

Premiums for plans sold in the public health insurance exchanges are 10 percent lower than premiums for employer-sponsored plans, according to a report by the Urban Institute. In 38 states and the District of Columbia, the average premium for the second-lowest-cost silver-level plan in the exchanges (individual coverage) was lower than the average employer-sponsored plan premium.

The researchers also looked at data for 32 metropolitan areas: 

  • The places where average premiums in the exchanges exceeded average employer premiums tended to have high costs of medical care or fewer health plans participating in the exchanges. 
  • Only four metropolitan areas – San Francisco, Atlanta, New Orleans, and Charlotte – had exchange premiums higher than the average employer premium.

Researchers used the second-lowest-cost silver exchange plan for their analysis and adjusted for differences in utilization, age distribution, and actuarial values. The second-lowest-cost silver exchange plan is the “benchmark” for the premium tax credits and the most commonly purchased in the exchanges. The researchers looked at unsubsidized exchange premiums to compare against average employer premiums in the same geographic area.

Analysis: The report challenges the idea that premiums in the exchanges are too high. The US Department of Health and Human Services (HHS) cited the report in countering recent criticism of the rising costs of premiums on the exchanges. Groups such as the Cato Institute have faulted the methodology in the report, saying that spending on exchange enrollees is much higher than on individuals in employer coverage. Cato says that the Urban Institute’s analysis does not account for reinsurance payments or losses that health plans are taking on those enrollees, both of which would show larger differences in premiums if they were factored in.

(Source: Urban Institute, “Are Nongroup Marketplace Premiums Really High? Not in Comparison with Employer Insurance,” September 2016)

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Report: Premiums for employer coverage remain stable as deductibles grow

Kaiser Family Foundation released its annual survey on employer health benefits, which finds that average annual premiums for employer-sponsored insurance – including employer and worker contributions – are $6,435 for individual plans and $18,142 for family plans. This is up 3 percent from 2015. On average, employees contribute 18 percent of the premium for individual health plans and 30 percent of the premium for family health plans.

Premiums remained relatively stable, but deductibles continued to grow. Preferred provider organization (PPO) plans make up the highest share of enrollment (48 percent of covered employees), but enrollment in high-deductible health plans with savings options (HDHP/SOs) plans is increasing (8 percentage points over the past two years). Among employees with coverage that has a deductible, the average deductible increased from $1,318 in 2015 to $1,478 in 2016. This is partly due to the higher enrollment in HDHP/SOs. However, HDHP/SOs enrollees often receive contributions from their employers, which can offset the high cost-sharing of these plans. For example, some employers report making contributions to health reimbursement arrangements (HRA) or health savings accounts (HSA) that are equal to employees’ deductibles.

(Source: Kaiser Family Foundation, “2016 Employer Health Benefits Survey,” September 2016)

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Few Medicare Advantage enrollees switch plans

One in ten Medicare Advantage (MA) enrollees switched to another health plan in 2014, a rate which has remained relatively unchanged from 2007 to 2013. This is according to a recent Kaiser Family Foundation study, which looks at MA enrollees’ decisions during open enrollment.

MA enrollees switched less than enrollees in the exchanges (43 percent), perhaps because exchange enrollees can save more from switching plans than MA enrollees. Switching was most common for MA enrollees who faced a premium increase of $20 or more. Most MA enrollees faced premium increases of less than $10, which may be a reason switching is rare.

Eleven percent of MA enrollees voluntarily switched plans between 2013 and 2014. Only 5 percent of MA enrollees had to switch because their health plan exited the market. MA enrollees in health maintenance organization plans were the least likely to switch to another plan.

Related: CMS announced last week that MA premiums have dropped by 13 percent since 2010, and enrollment is at an all-time high of 32 percent of Medicare enrollment (18.5 million enrollees). CMS says that initiatives like the Star Rating system, which assesses the performance of plans, and a new risk adjustment model to improve payments have helped improve the MA program as enrollment continues to grow.

(Source: Kaiser Family Foundation, “Medicare Advantage Plan Switching: Exception or Norm?” September 2016)

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On the Hill & In the Courts

HHS, NIH expand reporting requirements for clinical trial data

Earlier this month, HHS and the National Institutes of Health (NIH) finalized rules that require researchers to publish the results of even more clinical trials. Researchers will also have to publish more information about the trials themselves and the participants. The data will be made publically available on the database.

Currently, researchers are only required to report data from clinical trials that include approved drugs or devices. The new HHS rule requires researchers to report clinical results to, regardless of whether the drug, compound, or device has been approved by the US Food and Drug Administration (FDA). HHS is excluding Phase I research trials and small feasibility studies from the reporting requirements. Investigational drugs under expanded access protocols, which provide access to not-yet approved drugs for patients with no therapeutic alternatives, will be exempt as well. The final rules extend the HHS rule to all NIH-funded clinical trials, regardless of research phase, trial size, or designation.

Key provisions of the new rule:

The rule will take effect January 18, 2017, and research organizations will have 90 days to comply with it. HHS and the NIH said that providing access to more data will spur innovation, increase transparency, and fulfill ethical obligations to clinical trial participants.

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PTAC releases format, timeline for APM application review, requests input on technical assistance

The Physician-Focused Payment Model Technical Advisory Commission (PTAC) recently held a meeting to gather input and testimony from health care stakeholders. MACRA established PTAC to review payment models and consider whether or not to accept them as advanced APMs. At the meeting, the commission shared their proposed timeline for reviewing APM applications, the format in which they will accept applications, and the required content.

The PTAC board of reviewers can either approve payment models for final review and implementation by HHS, or ask the applicant to revise the model according to MACRA’s requirements.

PTAC outlined the criteria it will use to review payment models. There are nine basic criteria, three of which are “high priority”:

The commission also discussed the proposed timeline for review. The timeline should be no longer than 16 weeks per application, after which the applicant will receive either a referral to HHS or recommendations for improvement. The commission also requested input on several key issues in implementation, including the role of non-physician providers and the inclusion of bundled payment models.

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BPCI improves outcomes and costs for orthopedic surgery

CMS released the Year 2 Evaluation and Monitoring Annual Report for the Bundled Payments for Care Improvement (BPCI) initiative, the second in a series of five annual reports. This report analyzed the first year performance of Phase II participants in BPCI Models 2-4.

Orthopedic surgery bundling had the biggest effects on cost and quality:

  • Costs decreased by $864 (3 percent) per episode
  • Patients reported fewer functional limitations, better mobility, and faster recuperation rates
  • Average length of stay in a skilled nursing facility following orthopedic surgery dropped 1.3 days
  • The percent of patients who received institutional post-acute care services dropped from 64 percent to 57 percent

Even though the impact was largest for orthopedic surgery, 11 out of 15 clinical episode groups showed indicators for potential savings. According the report, the reduced costs across the models stemmed mainly from lower use of institutional post-acute care settings following hospital stays.

Background: BPCI aims to reduce spending for Medicare beneficiaries who are hospitalized for heart attacks, heart bypass surgery, and hip fracture surgeries.

BPCI awardees in Phase I did not face any downside financial risk, but Phase II requires providers to take both upside and downside financial risk. In other words, if total payments are below the target price, awardees can share in the savings, but if they are above the target price, awardees must pay a portion back to CMS.

More than half (61 awardees out of 94) of BPCI providers are participating in Model 2, which accounts for 43,000 out of the 59,000 episodes in the initiative. Model 2 is also the most comprehensive model:

(Source: CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 2 Evaluation & Monitoring Annual Report, August, 2016)

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CMS and OIG propose updates to Medicaid Fraud Control Units

A new proposed rule, published last week by CMS and the Office of the Inspector General (OIG), would update the funding procedures, scope, and authority of Medicaid Fraud Control Units (MFCUs). The proposal is the first major update to these regulations since 1977.

The proposed changes include:

  • Expanding MFCU authority to investigate patient abuse and neglect complaints in cases where Medicaid is not the primary payer
  • Expanding the definition of provider to include other types of clinicians and referring physicians
  • Requiring states to maintain an MFCU as part of their Medicaid state plan
  • Giving CMS authority to assess whether a state MFCU complies with regulatory requirements
  • Requiring fraud teams to meet regularly and communicate with OIG 
  • Updating the federal match for MFCU operating costs from 50 percent to 75 percent

Background: The proposed rule comes shortly after OIG published its annual report on MFCUs. In 2015, MFCUs had 1,553 convictions totaling $744 million in criminal and civil recoveries, the highest conviction rate since 2011. But, OIG says that civil settlements and judgements are declining. Cases involving pharmaceutical manufacturers made up over a third of the 731 civil settlements, 33 percent involved personal care or home health aides, and 11 percent involved nurse aides.

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HHS final rule sets national emergency preparedness standards that include cybersecurity measures

Earlier this month, HHS finalized rules that establish emergency preparedness requirements for providers and suppliers of Medicare and Medicaid services. The rule sets national standards for emergency response plans to natural or man-made disasters. It also outlines what assistance (state, federal, tribal, regional, or local) would be available for providers and suppliers in an emergency situation.

HHS is mandating that providers and suppliers perform regular risk assessments. Risk assessments must use the “all hazard” approach. This protocol, used by other federal agencies, is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for many emergencies or disasters. Disasters could include earthquakes, acts of terrorism, cyber-attacks, or pandemics. The final rule does not require a plan of action for cybersecurity, but urges providers to assess whether their facility could benefit from a cybersecurity plan.

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Around the Country

Administration encourages opioid information sharing across state lines

President Obama made the week of September 16, 2016 Prescription Opioid and Heroin Epidemic Awareness Week. This symbolic gesture has been accompanied by a series of speeches, initiatives, and policy directives to combat the opioid abuse crisis.

The administration is taking action on opioid abuse:

  • US Department of Justice Secretary Loretta Lynch directed states and prosecutors at the US Attorney's Office to share information on opioid use across state lines to help identify distribution networks and coordinate with public health officials.
  • Secretary Lynch also announced increased funding through the Harold Rogers Prescription Drug Monitoring Program (PDMP) and new resources and efforts to assist state and local efforts to expand the use of PDMPs that will be available for 20 organizations across the country. 
  • The FDA will award $40,000 to the highest scoring entrant to the Naloxone App Competition. The competition challenges developers to make a mobile app that allows opioid users, their friends and families, and first responders better identify and react to an overdose.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) is permitting 1,275 medical practitioners to treat as many as 275 patients each with buprenorphine, a synthetic drug used to treat opioid addiction. The previous limit was 100. 
  • Veterans Affairs will give additional funding to Veterans Drug Courts to encourage treatment for veterans with substance abuse problems.

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Researchers to investigate how to use value-based pricing for drugs in Medicaid

Oregon Health & Science University (OHSU) is planning a large-scale research project to assess if paying drug manufacturers based on how well their medicines control, contain, or cure disease can reduce costs for state Medicaid programs. Many health insurance companies and Medicare have already begun experimenting with tying drug payments to results or “pay-for-performance pricing” and “value-based pricing.”

States want to contain Medicaid costs. On average, roughly a quarter of any state’s budget goes to Medicaid and expenses are expected to grow. Though increases in Medicaid coverage can explain some the recent spending growth, Medicaid spending on prescription drugs increased 24.3 percent between 2013 and 2014. Last year specialty drugs accounted for nearly a third of Medicaid spending, or about $16.9 billion.

The OHSU research project, called State Medicaid Alternative Reimbursement and Purchasing Test for High-cost Drugs (SMART-D), aims to support states’ use of alternative purchasing models for high-cost drugs in Medicaid. It will provide legal and regulatory guidance and technical assistance and help develop relationships between states and stakeholders.

SMART-D includes a readiness assessment for states. It gauges preparedness for developing and implementing alternative purchasing models for high-cost drugs by leveraging insights from pharmacy, data analytics, finance and budget, information technology, managed care contracting, and executive leadership at state Medicaid agencies. A broad value-based system for drug pricing in Medicaid would require changes to Medicaid law.

(Source: Michael Ollove, “'Pay-for-performance' aims to save money on high drug prices” Pew Charitable Trusts, September 2016)

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Breaking Boundaries

Are micro-hospitals the next big trend in health care?

Micro-hospitals – small-scale inpatient facilities that are open 24 hours a day all year long and typically have between eight and 10 beds for observation and short-stay use –
are a growing trend in health care. Many health systems are using micro-hospitals to fill service gaps in markets where demand would not be able to support a traditional hospital. While micro-hospitals vary in what services they offer and how they are designed, core services typically include emergency care, lab services, imaging, and pharmacy. Supplemental services may include outpatient surgery and primary care.

Micro-hospitals differ from standalone emergency departments (EDs), which have also been growing in urban areas over the last several years. While both micro-hospitals and standalone EDs are equipped to treat many emergencies and have laboratory, imaging, and some diagnostic capabilities, micro-hospitals differ from standalone EDs in that they are fully licensed with inpatient beds. Some offer primary and specialty care services.

To date, micro-hospitals are launching in just a few states: The SCL Health Community Hospital-Southwest facility opened in Denver earlier this year. Dignity Health opened a micro-hospital in Phoenix last year and plans to open more in the coming years. St. Elizabeth Hospital in Wisconsin has also launched micro-hospitals centered around a Clinical Nurse Leader who works to coordinate services.

Analysis: The move from volume to value in health care and the increased attention to consumer demands for convenient, accessible care may be shifting the landscape. The growing interest in micro-hospitals is likely in part connected to the shift toward providing more care in outpatient settings. Micro-hospitals may provide more care options for patients and reduce travel time. While patients facing serious emergencies such as a possible heart attack or major medical trauma are still advised to call 911 and let their locally trained medical professionals decide what is the best option for them, micro-hospitals may reduce reliance and wait times in EDs in certain areas.

(Source: Michelle Andrews, “Sometimes tiny is just the right size: Microhospitals filling some ER needs,” Kaiser Health News, July 19, 2016)

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