Another Reason To Stop At CVS?….Or Is Merger Medicine A Tough Pill to Swallow?

As CVS and Aetna see it, the multi-billion dollar companies are getting together to tap into data and the “human touch” to transform and “redefine access” to health care.

How? By reducing costs,  help fight chronic conditions and lower readmission rates through an “effective integrated community-based health care delivery system,” the companies predict.

Today, CVS, the giant pharmacy,  announced it is buying Aetna, the giant insurer, for $69 billion — $77 billion including debt – that could have a significant impact on healthcare. The plan, if approved, would result in a company with an annual revenue of $240 billion – second only to Walmart in the U.S, according to news reports.

Ironically, as Congress seems confused about health care, the private sector is moving forward, with these major players aligning its futures into a growing force: personalized medicine. But the overall impact of the deal remains to be seen, and whether the proposed merger will even fly —  with regulators surely ready to raise questions about this huge health insurance deal

And there’s another question. Is this good for consumers?  The Coalition To Protect Patient Choice, said of the $200 per share offer: “This massive merger would greatly harm consumers, leading to less consumer choice and more exclusionary conduct, and (the) promised savings will not materialize.”

The move is considered by the companies as a “natural evolution as they seek to put the consumer at the of heath care delivery.” They said: “CVS Health has steadily become an integrated health care company, and Aetna has moved beyond being a traditional insurer to focus more on consumer well-being.”

CVS said the “transaction fills an unmet need in the current health system and presents a unique opportunity to redefine access to high-quality care in lower cost, local settings whether in the community, at home, or through digital tools.”

There are more than 9,700 CVS pharmacy locations and 1,100 walk-in clinics and other programs including 4,000 CVS Health nurses who provide  in-clinic and home-based care, the company says. By connecting with Aetna, which serves more than 44 million people and its  network of providers, CVS believes  “there will be a better opportunity to utilize local care solutions in a more integrated fashion with the goal of improving patient outcomes.”

“This combination brings together the expertise of two great companies to remake the consumer health care experience,” said CVS Health President and CEO Larry J. Merlo. “With the analytics of Aetna and CVS Health’s human touch, we will create a health care platform built around individuals.”

Said Mark T. Bertolini, the Aetna chairman and CEO: “Together with CVS Health, we will better understand our members’ health goals, guide them through the health care system and help them achieve their best health.”

As a “benefit to consumers,” CVS says its pharmacies will include “space for wellness, clinical and pharmacy services, vision, hearing, nutrition, beauty and medical equipment, in addition to the products and services our customers currently enjoy.”

“An entirely new health services offering available in many locations will function as a community-based health hub dedicated to connecting the pathways needed to improve health and prescription drugs and health coverage.”

No doubt, a hub of controversy, too.

— Joe Cantlupe





Healthcare, American style: Too many administrators? Too many regs? Doctors forced to look at their computers instead of having more time with patients? What’s the Rx?

Are there too many administrators in healthcare, compared to the number of clinicians? Have the technology and regulatory changes forced physicians to spend too much time at their computers, and not enough with patients, or undermined the relationship between physicians and administrators?

I explore some of these issues and more in a Q and A with top health officials in  athenaInsight that says:

“Here’s some food for thought: The number of physicians in the United States grew 150 percent between 1975 and 2010, roughly in keeping with population growth, while the number of healthcare administrators increased 3,200 percent for the same time period.”

“Yes, that’s 3,200 percent in 35 years, a statistic derived by Physicians for a National Health Program using data from the Bureau of Labor Statistics, the National Center for Health Statistics, and the United States Census Bureau’s Current Population Survey. Physicians for a National Health Program.

Healthcare Is So Much More Complex – More Administrators Needed?

Decades ago, “the hospital was seen as an open workshop where doctors brought their patients and worked largely independent of the hospital,” says Ben Bache-Wiig, MD, executive vice president and clinic clinical officer at Allina Health Group in Minneapolis, Minn. “Now, more than 50 percent of physicians are employed by hospitals and work in largely speciality groups. They’re being asked to follow protocols within a hospital system and report to administrators.”

The level of complexity has “grown exponentially and the degree of complexity has grown exponentially and the degree of external requirements has also skyrocketed,” says Marilu Bintz, MD, a senior vice president of population health and strategy at Gundersen Health System in La Crosse, Wis. “Since the early 1980s, there has been a consolidation and aggregation of larger and larger physician groups in our health system, some affiliated with one or more hospitals. Then there’s the trend of hospitals merging into larger networks. If we’re saying the sheer number of administrators is compromising relations between physicians and patients, I disagree. I don’t believe the number itself is a key factor. The key is for (physicians and administrators) to come together and deal with that complexity.”

“The challenge,” she adds, “is for physician leaders and non-physician administrators to find the common ground that, if approached with the best interests of patients and community in mind, leads to the success of the health system and physicians. That starts with an understanding of one another’s role.”

All those technological changes – impact on doctors. No time for patient care!

“When we talk about the practicing physician, the way the system is structured, there is a shorter and shorter window of time when a patient sees a doctor,” says Louis J. Goodman,PhD, executive vice president and CEO of the Texas Medical Association and board member of The Physicians Foundation, where he previously served as president. “Based on Physician Foundation surveys we have conducted over the past six years, that’s the No. 1 reason why doctors enjoy medicine and their practice, and that is the time with patients. Yet we see that time is diminished when they have to consider unnecessary box checking on electronic record forms to meet regulatory requirements.:

“Our 2016 Physicians Foundation survey shows that physicians spend 21 percent of their time on non-clinical paperwork. There is a significant increase in the number of administrators, at a much more rapid rate than we are producing physicians,” says Goodman. “With the growth of administrators, we naturally are going to see an increase in rules, regulations and management procedures to that ‘triple aim’ that hospitals like to talk about (improved patient experience, overall population health and reduced cost in healthcare).”

Physicians becoming administrators.

“More and more we’re seeing an enhanced push toward physician-administrators, with more physicians going into administration through MHA and other degrees. Doctors have a greater sense that an administrator understands their concerns and is focused on the clinical side of patient care than if that person is a physician-administrator rather than a lay administrator,” Goodman says.

“There’s been a conscious effort in our health system to encourage physicians to take a leading role in the organization,” says Bache-Wiig. “ I myself am a physician who had the opportunity to cross over and become successful as an administrator with excellent professional support throughout the system. That formula has been pretty successful for our four healthcare systems.”

“We have an open dialogue and have helped physicians maintain autonomy and innovative spirit,” Bache-Wiig says. “There is the challenge of standardization versus individualization, which can lead to physician burnout and disengagement, and we are not immune to that.” “

Hospitals Should Open-the-Door For Physicians To Become Administrators

“Health systems have to be more welcoming to physicians who want to be involved in administrative medicine,” says Bintz. “There needs to be a common understanding that the term physician-administrator does not require that a physician stop caring for patients. Physicians have to have the opportunity to be involved in caring for patients. Physicians (also) have to have the opportunity to be involved in administrative roles and continue to practice if that is their desire.”

Bintz adds: “Here at Gundersen Health System we have spent 125 years fostering a culture where we attract both administrators and physicians who believe the patient comes first, that we exist to serve our communities, and that it’s important for physicians and administrators to work together to demonstrate how we do those things.”

Training Physicians to Be Administrators

Goodman: The Physicians Foundation has sponsored the Physicians Leadership Academy since 2010 and what we’ve tried to play a role in helping physicians undertake leadership roles. We have partnered with different, highly seemed university and medical programs, such as Northwestern and Duke. And we use seminar and small group formats focused on areas such as leading organizational transformation, executive decision-making and negotiating productive agreements. Physicians can take back to their hospital or practice and give them the tools administrators need. Without understanding the technical or financials, that puts physicians at a disadvantage to being administrators. We are giving them the tools at the baseline for a practice so they can do the best they can, going forward for their patients.

Nick A. Fabrizio, PHD, FACMPE, FACHE, a principal consultant with the MGMA Health Care Consulting Group in Washington DC, observes:

“There are definitely gaps with lack of business training (for physicians). That’s where the MGMA and other groups, graduate programs and trade associations provide needed additional training. Working in a health system is difficult and very different from a physician group practice. There are multiple stakeholders. And behind every physician leader, there is always a great non-physician administrator, whether a CFO or a CEO, someone with the knowledge of running a hospital for 20 years or more, having that knowledge especially being able to survive politically in this climate, is invaluable.

Docs: Don’t Be Loners — Be Part of a Team

The need for teamwork: “If we’re saying the sheer number of administrators is compromising relations between physicians and patients, I disagree. I don’t believe the number itself is a key factor. The key is for (physicians and administrators) to come together and deal with that complexity.” Says Bintz: “Beyond that, the best way to improve the quality of care that patients receive is to have a strong partnership between physicians and administrators so that both understand the complexity of how ‘quality is defined and reported, and both understand the real-life details of high-quality care at the bedside. The relationship is far more important than the numbers.”

Bache-Wiig: “In many ways we across the country have trained physicians to come out and think of themselves as individual businesses. There will be an increasing need for physicians to function within complex systems, and understanding that role in complex systems.”

What’s the shouting about?

“I don’t’ see what the data sees – big discrepancies in the numbers of administrators to physicians,” Fabrizio says. “ In fact I have seen hospitals taking away administrative operations people through mergers and combined joint ventures. I see that happening as positions are absorbed into the larger structures.” – Joe Cantlupe, HealthDataBuzz

Trump Does Health Care ‘End Run’ Around Congress – Critics Call Executive Order ‘Callous Sabotage’

Interestingly in a country where many debate the psychological state of this president, the American Psychological Association says Donald Trump is taking us backward in healthcare. Other critics are much, much harsher.

For much of the year, Trump has been upset that one of his signature campaign themes was not realized, the overturning of Obamacare. After all, for his base, his hard-core supporters, what had he done, beyond the mood swings? Every once in a while, in between tweets denouncing “false media” or criticizing the NFL, he took stabs at Congress for not passing a bill to rid the Affordable Care Act.

He wanted the wrecking ball and the GOP leadership didn’t come through.

Yesterday, he went off the legislative track and stayed on the executive: Trump signed an executive order to take steps that he says were designed to expand choices and alternatives to Obamacare, while increasing competition to reduce costs. Not so fast, critics say.  Trump also is moving to end billions of dollars of key so-called “cost-sharing” payments by insurers that help lower-income people pay for insurance, opponents say. The actions could undermine the entire Obamacare marketplace, and result in insurance policies with reduced benefits.

Many groups are concerned that the Trump action targets the most vulnerable: those people who need services the most may be left out in the cold. Some say that they are concerned that health plans ultimately would not provide the essential health services such as maternity care and services for children, and cheap and narrow plans would be structured outside of the Affordable Care Act  that might draw healthy people, but leave sicker people or those with pre-existing conditions facing what some term as “impossibly higher premiums.”

In a tweet this morning, Trump suggested he wants to work with Democrats on Obamacare. “The Democrats ObamaCare is imploding,” he wrote. “Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!.”

“The time has come to give Americans the freedom to purchase health insurance across state lines, which will create a truly competitive national marketplace that will bring costs way down and provide for better care,” Trump said in an earlier statement.

Trump poked at the flaws of Obamacare: the percentage of workers at small firms receiving coverage through their employer had declined from nearly half in 2010 to about one-third in 2017, according to the White House.

The subsidies that Trump seeks to get rid of impact about 6 million people, the Department of Health and Human Services says, costing about $7 billion in 2017, according to CNN.

Once again, instead of trying to rebuild flaws in the current system, Trump seems intent on undoing it. He’s an interesting kind of developer. He destroys and then….His critics say with the executive action and others, healthcare in the country is becoming Trumpcare and the problems are his, at least politically.

“The executive order begins by reciting perceived failures of the Affordable Care Act; rising premiums for ACA coverage, reduced insurer participation in exchanges and reduced exchange enrollment,” Timothy Jost, a contributing editor at Health Affairs and emeritus professor at the Washington and Lee University School of Law, wrote in a Health Affairs blog. “However, many of the problems the individual market is experiencing are certainly due to actions the Trump administration has taken to undermine ACA coverage, and there is good evidence that the ACA market could have stabilized absent those actions,” Jost added.

The order essentially encourages health plans “to pick and choose” services they cover and won’t help those who desperately need mental health, substance use, and other critical services,” Antonio Punte, PhD, president of the American Psychological Association said in a statement. “Before the Affordable Care Act, more than one-third of individual market plan plans chose not to cover mental health services and nearly half chose not to cover substance abuse.”

Punte noted these are especially tough times: 91 Americans a day, for instance, are dying from opioid overdoses.

“Today health plans are competing on how efficiently and effectively they provide care, but the president’s executive order, if carried out, would take us backward by letting plans once again compete on how fewer services they cover and ignore state health insurance protections,” Punte said. “We are deeply disappointed that the administration continues to try to dismantle our health care system, instead of trying to increase enrollment and stabilize insurance markets.”

“Now that President Trump and the Republican Congress failed to end the Affordable Care Act by legislation, the president is sabotaging the law by executive action,” said Vanita Gupta, president and CEO of The Leadership Conference on Civil & Human Rights. “Today’s move is their effort to put another nail in the coffin. This order will only drive up costs for the sick and put the health of millions at risk.”

Trump’s executive order “will result in fewer protections for the most vulnerable Americans, such as those with pre-existing conditions, and will encourage sham, loosely regulated health insurance plans that won’t provide adequate benefits,” said Randi Weingarten, head of the American Federation of Teachers in a statement. “Ultimately, this could lead to the collapse of individual health insurance markets through which millions of Americans obtain coverage.”

“Donald Trump owns the unwinding of the Affordable Care Act,” Weingarten said. “He is ignoring the rule of law, refusing to compromise, and doing an end-run around Congress in order to strip people of their healthcare. Millions of Americans will be worse off because of his actions. There is an ongoing pattern of the Trump administration’s callous sabotage of Obamacare, and it will cause real harm to American families.” – Joe Cantlupe

To Err In An Electronic Medical Record

After spending a lot of my time recently visiting my mom in a hospital, I couldn’t help but think every time the nurse came by, with pills and a small plastic cup of water, about what physicians, nurses and patients must confront: what is the right medication, when is it too much, what isn’t enough? What if they make a mistake about those medications?

Yes, despite electronic medical records, which have enabled sweeping changes in healthcare over the last few years to improve coordination efficiency, and quality of care, there are still wide gaps in the information that exists and not used properly.

That’s one of the reasons some numbers, like those of medication errors, are not where we want them to be.

According to the FDA, medication errors increased from 16,689 in 2010, to over 93,930 in 2016 – showing a whopping 463 percent jump. Those errors contributed to at least 230,000 deaths annually, some studies show, making them responsible for being the third largest cause of fatalities.

As in any error, there are many variables and reasons for each of them. Ironically, the increasing errors come at a time when hospital officials say there have been many data significant improvements in medical data systems. They include “alerts” in electronic medical records when the computers identify something that procedurally may be wrong, such as the kind of – or amount of – medications being given to a patient.

The latest statistics on medication errors show that more safeguards and tools are needed to help physicians, nurses and other staff overcome human flaws in assessing these alerts, such as “alert fatigue” when too many red lights go off, and the staff believe they know better than what machines are telling them, as if the computers are crying wolf once too often, and the physicians or nurses just walk on by to the next patient.

Shobha Phansalkar, MD

Shobha Phansalkar, RPh, PhD, director of informatics and clinical innovation at Wolters Kluwer, has spent years evaluating these so-called clinical information systems, especially the ins-and-outs of how healthcare handles medications and how they are given to patients. Also an assistant professor in the division of general medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, Phansalkar has worked diligently on analytical tools and yes, has examined the human factor in medication errors. In extensive studies she has carried out with colleagues over the years, and in an interview with HealthDataBuzz earlier this year, Phansalkar says the push toward adopting electronic medical records have been key initiatives for hospital quality and safety, but they are deeply flawed and their potential benefits have not been reached, not by any stretch.

In fact, Phansalkar’s studies on medication errors, particularly related to alerts related to drug-interaction, have exposed significant weaknesses in healthcare electronic medical systems and the so-called alerts. One of the major problems, she says, is that there are unclear messages in these alerts, and physicians decide to ignore or “override” them because they are not presented in a clear manner, or give context to what the doctors are doing. Studies by Phansalkar and her colleagues show that as many as 49 to 96 percent of all alerts are ignored, depending on the setting. Or as she and her colleagues have written: Alerts have “lagged behind expectations.”

As such, Phansalkar and her colleagues have been working to develop alert systems that have tools to overcome these limitations, with the “human element” very much a key focus. Wolters Kluwer Clinical Drug Information technology has developed programs to revise the alerting “logic” in electronic medical records to improve patient safety, she says.

“Errors are continuing to take place in every aspect of healthcare,” she says. “And they are taking place especially at the point of care such as when the right medications are chosen or supposed to be chosen. One of the problems is that providers are inundated with these alerts and are overriding a large number of them.”

Electronic medical records are limited in their ability to evaluate drug interactions, which could have sharp negative impacts on patients. This is becoming of greater importance as patients take more prescription medications than ever and often physicians still don’t have access to the entire patient history – despite the electronic medical records, Phansalkar says.

“It’s an age where we can exchange information easily, but somehow healthcare has lagged behind,” she says. “We’ve become more aware of the problem and we have better mechanisms in place, but with a fragmented system, and patients seeking care from multiple numbers of providers, whether it’s by choice or driven by health insurance, providers don’t have access to the entire patient profile. The physician doesn’t have access to all the medications and relies on a piece of the pie and that results in errors.

When a physician gets these “alerts” there are some built-in problems that Phansalkar and others are trying to fix. The lack of context about the medications being prescribed, such as the dose-toxicity or potential dependency of the patient, Phansalkar says.  Also, alerts should be identified as to whether they should be a priority or not, or the impact to the patient when a doctor decides to override them, she adds.  In addition, physicians have to evaluate similarities in different medications to ensure there is a “right bar code,” for instance, that is coordinated with pharmacies, according to Phansalkar.

Another problem in how these alerts are put together, she and colleagues say in a study. That relates to how “designers and vendors sharply limit the ability to modify alert systems because they fear being exposed to liability,” they wrote. That can be overcome through “finely tailored or parsimonious warnings that could ease alert fatigue without imparting a high risk of litigation for vendors, purchasers, and users,” the authors added in the study.  In addition, they said, more government regulation and development of international practice guidelines should highlight the warnings.

As Phansalkar wrote in Health System Management last year, “Alert fatigue remains one of the greatest hindrances to optimal use of clinical decision support at the point of care. Finding the right balance of the volume of alerts to display has been an elusive pursuit for EMR and CDS vendors.”

Phansalkar and her colleagues are working to change the alert system through various new models to improve patient care.

“Warnings could be tailored to a particular clinical environment, taking into account the individual care setting, such as adjusting the type or state of a medication interaction alert if a particular community of physicians is found to respond inappropriately to it,” they said in one study. “A tailored system might advise adjusting a patients medication dosage only when other patient data, such as age, or specific comorbidities, such as a rental function, raise concern, as opposed to alerting indiscriminately for all patients.”

Some healthcare organizations have taken steps to do just that – tinkering with their alert systems, such as the Group Health Cooperative of South Central Wisconsin, which used “filtering mechanisms” to address potential alert fatigue. Using guidelines developed by Wolters Kluwer, the healthcare system reduced the number of alerts from 87 percent to 27 percent, Phansalkar wrote.

MetroHealth in Ohio reduced and streamlined drug dose alerts by some 80 percent to avoid physician fatigue, she added.

Phansalkar is examining the impact of medication errors through and beyond the hospital stay or at a physician’s office.

“We’re are studying the downstream impact, what happens when a patient leaves the hospital, or the provider. Are they being counseled appropriately about medications or drug interactions?” she says. “There is a big opportunity to counsel these patients at that time.”

Indeed, health officials must ensure proper medication adherence from the beginning of a patient’s journey through the healthcare system, from the moment at “the gateway of patient interaction,” Phansalkar says . – Joe Cantlupe.




Let’s Come Together And Have An ‘Apolitical” Approach to End Gun Violence, Johns Hopkins Researcher Says: Multi-Year Health Affairs Study Shows Extensive Gun-Related Injuries

As America reels over the horrendous and heart-breaking mass shooting in Las Vegas, researchers from the Johns Hopkins University School of Medicine coincidentally released a disturbing report about firearm-related injuries in the U.S. that showed more than 700,000 patient visits to hospital emergency departments that resulted from shootings (25 per 100,000 people) between 2006 and 2014.

While shooting deaths are the third leading cause of injury-related mortalities in the U.S., the researchers said they performed the extensive study on firearm injuries because they said there was a lack of information about that aspect of gun violence and the economic impact on EDs.

“I think that the major surprise and interesting finding of our study was the immense number of individuals affected by the issue,” Faiz Gani, postdoctoral research fellow at the Johns Hopkins University School of Medicine’s Department of Surgery and lead author.

In the study published in Health Affairs, the researchers cited the “overall incidence” of ED visits for firearm-related injuries for the period 2006-2014, noting it was 25.3 per 100,000 people. That number was “disproportionately higher” in the U.S. than in other higher high-income countries, such as Germany, Japan and the United Kingdom. Gun-related deaths also are higher in the U.S., with about 36,000 reported in 2015, the researchers said.

The victims’ also were studied, with some possibly startling conclusions. Patients injured in suicide attempts, for instance, were more likely to be from highest income groups, people who were assault victims in shootings had low income, the researchers said.

Suicide attempts involving guns were linked more often – twice as high – among Medicare enrollees, compared to patients enrolled in other insurance, they said.

The results showed that the number of “non-fatal” firearm injuries at EDs was 2.4 times of fatal injuries. Such injuries were about nine times more common among men, ages 20 to 24, then women. Since the study did not include people who died before reaching the hospital or did not seek emergency treatment, the researchers acknowledged the increased burden for hospital EDs.

Not surprisingly, the researchers called for greater gun control laws, noting the immense political debate. Adding to the argument over gun control, the researchers said policymakers should consider universal background checks for gun purchases and limiting access for people with histories of violence or previous convictions, which now isn’t always the case.

“I think it’s extremely tragic that we continue to encounter mass shootings today, particularly given that they are potentially preventable to a degree,” Gani told HealthData Buzz following Sunday’s shooting that resulted in the deaths of 58 concert-goers, the gunman himself, and left more than 500 wounded. “I really hope that moving forward we can all come together and adopt a scientific and apolitical approach to gun violence,” he said.

Gani and his colleagues wrote that policymakers – perhaps in an understatement – “might consider implementing universal background checks” for firearm purchases. In addition, gun access should be limited to “people with a history of violence or previous convictions to reduce the clinical and financial burden associated with these injuries,” they wrote.

They acknowledged that “efforts to reduce firearm-related injuries have been limited as a result of the politicized environment surrounding gun violence and a lack of will to consistently implement proposed policies.”

In their study of gun-related injuries, the cost for each injured person treated at an ED was more than $5,000, and $95,000 for inpatient charges; the total was about $2.8 billion annually or $24.9 billion over the study period.

“It was very interesting to note that over 50 percent of our study population was either uninsured or self-pay,” Gani said. “This finding has broad policy implications. While these patients represent the most financially vulnerable patients, they also often do not have any insurance company negotiating on their behalf and therefore often incur the entire financial charge in the form of high pocket expenses.

Other findings:

  • Among patients who were shooting victims but treated at EDs, handguns were the most commonly used weapons, 27 percent. Then shotguns, 5.9 percent, or hunting rifles, 2 percent.
  • Emergency Care. While there was data that showed reduced shooting related injuries and ED visits for several years, there was an uptick in the most recent year studied, 2014. The incidence of ED admissions for firearm-related injuries decreased from 27.9 ED visits per 100,000 people in 2006 to 21.5 visits in 2013. But there was a “significant increase” in 2014 with 26.6 ED visits per 100,000 people.
  • Mental Health Issues. There was an increase in the number of patients “presenting with a diagnosis of a mental health disorder” at EDs stemming from shootings, from 5.3 percent in 2006-2008, to 7.5 percent in 2012-2014. “Of note, the incidence of mental health disorders was highest among patients injured in an attempted suicide, 40.8 percent patients.” the researchers said. While there have been political debate about gun violence and impacts related to people with mental health issues, the discussion might not be so straightforward, they said. “While policy makers have proposed mental health facilities to curtail gun violence, they would likely reduce the number of deaths associated with mental health disorders, but would have a limited impact on the overall burden of firearm-related injuries, given the small share of patients with such injuries,” the researchers said.

Despite all the debate over guns, research in the field is not funded where it should be – and that’s because of politics, they said.

“Research has been limited due to the politicized nature of this and the lack of appropriate funding despite the high clinical and financial burden associated with this issue,” they added.

As their study was published in in a week of turmoil for the country on gun-related violence, Gani observed: “I hope that our study coupled with work from other gun violence researchers furthers the conversation of gun violence through the use of robust evidence.”

“Only after we understand the complex factors at play can we develop appropriate and effective policies that ensure that we aren’t’ having the same conversation again in a few months,” he said.  — Joe Cantlupe



Helping Doctors Through the Coding and Billing Maze

When they bill a procedure, physicians match their work with a special code for reimbursement. Sometimes – all too often – there is a mismatch, and the numbers don’t add up.

It is becoming so confusing that many docs don’t want to deal with it, but that causes problems up the road, as physicians and health systems evaluate procedures, the kind of diseases being treated, and reimbursement. Lots of money is being lost all around.

Incorrect coding is to blame for nearly half of improper claims submitted to Medicare, and the monetary losses increased from $57.8 billion in Medicare and Medicaid payments in 2015, and $68 billion in 2016. When the government is unsure what’s going on, it carries out what doctors dread: audits.

The audits themselves are causing disarray among physicians and hospital systems. Having conflict with the government is one thing, and that draws big headlines. But there is often the unspoken side to this: doctors and hospital systems are also hurting themselves, by improperly filing codes that cheat themselves out of millions of dollars and undermine their quality of care, says Adrian Velasquez, CEO and founder of predictive analytics provider Fi-Med, based in Brookfield, Wi.

Fi-Med touts its proprietary technology that has helped major hospital systems increase revenues and eliminate compliance risk through their software technology that identifies potential billing errors that can lead to overpayments. His clients include major hospital systems such as Mt. Sinai in New York, the Catholic Health Initiative and University of Alabama health systems.

“More hospitals are ripping themselves off; they aren’t compliant and they don’t have the right protocols, or are doing an effective review of documentation,” Velasquez says. At the same time, “insurance companies have many coders looking at what is submitted by doctors. For doctors, it’s difficult to match the codes for work they are doing,” he says. “It’s humanly impossible to keep track of a specialty.”

Velasquez says studies show a whopping 80 percent of all medical bills contain errors, which he blames on lack of industry staffing and wide-ranging standards, suggesting that it is too low of a priority among doctors and hospitals until it is too late.

One of the problems is the complication of the codes themselves, which must be measured to actual procedures. The health system’s ICD-9 and ICD-10 added thousands of new codes, or revised them, which physicians must match to get proper reimbursement, he says.

As Velasquez said in a statement, compliance is one of the most important areas of any hospital system, or even in physician groups, but the most are “under-resourced when it comes to personnel and budget.”

“It’s viewed as a cost center, not a profit center,” he says. “When cuts are made they are often made in compliance.”

As a result, lots of physicians are caught in the maelstrom, putting inaccurate information into coding systems, either by “undercoding” – that can result in underpayment for the conditions they are treating, or “overcoding” – billing too much for the procedure. While the percentages vary, at least 25 percent occurrence rate for each incident, which Velasquez decries as undermining docs and the system.

“Physicians didn’t become physicians to become compliant,” he says. “They became physicians to heal people and make people well. That’s the real problem.”

In the meantime, there have been many cases in which a host of hospitals and physician groups have been shelling out big money to settle cases in which they have either flouted the law, or having problems dealing with billing. Some are involved in fraud, trying to re-invent their coding to get bigger payments, while others are making big mistakes. Government regulators also are having trouble keeping tabs on all this.

Each week, the government enters into corporate integrity agreements (CIAs) or simply integrity agreements with health care providers as part of federal health care program investigations stemming from a variety of false claim statutes.

In such an analytical world, physicians and hospitals can use data to substantially help themselves with coding issues, and that’s the business Velasquez is in.

Essentially, technology to locate coding issues can prevent incorrect billing, saving hospital networks millions of dollars, he says. “Healthcare providers who use analytics to improve internal processes and identify red flags dramatically improve their compliance risk and bottom line,” Velasquez said in a statement.

He points to one particular case where technology assistance potentially could have played a key role in overcoming significant billing and coding problems.

Earlier this year, the Carolinas Healthcare system settled a Justice Department lawsuit alleging that it “upcoded” lab results to get bigger payments from federal healthcare programs, Healthcare Finance News reported.

The government said the hospital system conducted urine tests coded as “high complexity” for federal reimbursement, which resulted in more than $80 per test than if coded properly as a “moderate complexity.” The event occurred from 2011 to 2015. It resulted in Carolinas Healthcare System paying out $6.6 million.

With great technology, the issue could have been prevented, or as Velasquez says, “proactive technology.” It’s about the interpretation and application of complex and constantly changing billing guidelines, Velasquez says.

Since 1993, Fi-Med has been working alongside healthcare providers to “maximize revenue and reduce risk,” from catching billing errors to providing high-level safeguards. The company  touts a subscription service that analyzes hospital or network billing data that quickly shows if providers are at risk. Its technology tracks “coding behavior, audit risk evaluation, management revenues and over/under charges,” according to the company website.

Its REVEAL/md can identify “in minutes” unusual coding behavior and patterns that fall outside of what would be considered normal numbers based on comparisons to what was submitted to the Centers for Medicare and Medicaid Services (CMS).  Once identified in REVEAL, the hospital or auditor would have to investigate further to determine if an error occurred leading to the overpayments, the company says.

“REVEAL/md cannot determine if fraud has occurred, but this step is essentially the first step that a government auditor/investigator would take to determine if they need to dig deeper,” says Velasquez.

When he created the program, “there wasn’t a lot of interest,” Velasquez says, but he knew it would become a significant issue as there were growing headlines about federal recovery and audit charges.

“Now it’s getting a lot of traction, and a lot of interest,” he says.

The reason? More hospitals are finding they are lost in the maze, even before they start their billing journey.  — Joe Cantlupe

Another Bad CBO Report Card for Latest GOP Healthcare Bill

While Republican Senators try to put together their latest, flailing plan to overhaul Obamacare, the Congressional Budget Office today released some quick calculating of its own:

Not good.

The CBO says the result of the Graham-Cassidy bill would be that insurance coverage for “high-cost medical events would be reduced by millions” of people.  (The deficit would be reduced by $133 billion under the bill with in a 10-year period, the agency says).


The reason, says the CBO:

  • Enrollment in Medicaid “would be substantially lower because of large reductions in federal funding.”
  • Enrollment in nongroup coverage “would be lower because of reductions in subsidies for it.”
  • Enrollment in  “all types of health insurance would be lower because penalties for not having insurance would be repealed.” Those losses would be “partly offset by enrollment in new programs established by states using the block grants and by somewhat higher enrollment in employment-based insurance,” the CBO says.

Because of the quick turnaround, the CBO said it didn’t have time yet to estimate the exact numbers. — Joe Cantlupe