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May 2011 Ohio Healthcare Summit Presentation
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May 2011 Ohio Healthcare Summit Presentation



Kegler Brown Hill & Ritter's 2011 Ohio Healthcare Summit offered an in-depth look at National and Ohio Healthcare Reform, Legal Challenges, Regulation and Implications for Healthcare Providers, ...

Kegler Brown Hill & Ritter's 2011 Ohio Healthcare Summit offered an in-depth look at National and Ohio Healthcare Reform, Legal Challenges, Regulation and Implications for Healthcare Providers, Medical Malpractice, and the Health Information Exchange.



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  • This is not new, but it is always surprising – 5% of us consumes about half of total health care spendingIf you can improve the value of care for that complicated, high-cost group – both in terms of improving quality and controlling costs – then you can start to have a real impact on health system performance overallBoth of these ideas – integrated not fragmented care, and focusing first on high-risk populations – are themes in national reform
  • Here is one of two ideas I hope stick with you after today: a fragmented health care system is expensive and dangerousOur system today is very fragmented, very expensive, and very dangerousIt is organized around providers, not patients, and it rewards volume not valueBut you can imagine transforming the current system over time into something that is more integrated and focused on patient needs, where: providers work together, reimbursement rewards value, not volume information is available to improve care, and the focus is on getting the right care in the right place at the right timeBut where do we begin?Here is the second idea: we need to focus first on the complicated cases that have the most to gain from integrated care
  • Governor Kasich created this organizational structure through executive order.OHT reports to the Governor – I will be working closely with Governor Kasich and his Policy Director, Wayne Stuble.We have a core team to provide leadership across agencies: I will focus on policy Elise Spriggs is our Director of Government Affairs Eric Poklar is our Director of Communications and Monica Juenger is our Director of Stakeholder RelationsOur role is to support and align work in your departments. We do not want to disrupt the processes that are working well, or distract talent from the task at hand – but we do want to take issues that for whatever reason have been stuck in the mud and move them forward. We want to make decisions.It’s a challenge – but I have no fear, mainly because of the team of excellent directors Governor Kasich recruited into the health and human services cluster.I want to introduce you to them now: Tracy Plouck, ODMH, and John Martin, DODD, who you know Bonnie Kantor, ODA, Orman Hall, ODADAS, and Dr. Ted Wymyslo, DOH (2/15) and John McCarthy, Medicaid director, who I will ask to say a few words in a minute.
  • John McCarthy
  • Greg – overview of topics
  • John Martin – DODD success story
  • GREG
  • Aging-BKB - keep
  • Greg – overview of topics
  • Greg
  • Dr. Wymyslo
  • Dr. Wymyslo
  • Greg – Team Introduction
  • Enactment of two laws
  • External Context:
  • 38.4% of practices indicated that operating costs increased as a result of the EHR 25.9% of practices indicated that operating costs decreased as a result of the EHR
  • eHI approach to the ACO NPRM:Comments focused on areas where EHRs, HIT and HIE are specifically referencesAddition comments on areas where EHRs, HIT and HIE are not specifically referenced but we determine a nexus to our interest in driving improvement in the quality, safety and efficiency of healthcare through information and technology
  • Cleveland Clinic, the Mayo Clinic, Intermountain Healthcare or the Geisinger Health System—are the models for the Obama administration's accountable care organization (ACO) proposalinstitutions that were the inspiration for the program are reluctant to participate unless big changes

May 2011 Ohio Healthcare Summit Presentation May 2011 Ohio Healthcare Summit Presentation Presentation Transcript

  • Health Care Reform – An Overview
    presented by Kristy Britsch
    2011 Ohio Healthcare Summit
    May 12, 2011
  • GINA
    Title I of GINA Prohibits discrimination in health coverage based on genetic information as well as the collection of such information in certain circumstances
    Prohibits group health plans and group health insurance issuers from:
    Increasing premiums or contribution amounts based on genetic information
    Requiring an individual or family to undergo genetic testing
    Requesting or requiring genetic information prior to or in connection with enrollment for underwriting purposes
  • GINA
    Title II final regulations became effective January 10, 2011
    Prohibits an employer from using genetic information to make employment related decisions, from requesting or requiring genetic information, with limited exceptions, from retaliating against individuals based on genetic information and from disclosing genetic information
  • GINA
    Provided certain requirements are met, an employer will NOT be liable under Title II of GINA for acquiring genetic information if it is:
    Acquired inadvertently;
    Acquired as part of health or genetic services provided on a voluntary basis, including a voluntary wellness program;
    Family medical history acquired to comply with FMLA certification;
    Acquired through commercially or publicly available sources;
    Acquired by an employer that conducts DNA testing for law enforcement purposes (forensic lab, identification of human remains).
  • Extended Effective Dates Under PPACA
    Nondiscrimination Requirements
    Was effective for plan years on or after September 23, 2010
    Effective date has been delayed until regulations are issued
    Comments on new rules are due by March 11, 2011
    A non-grandfathered fully-insured plan is prohibited from discriminating as to eligibility or benefits in favor of highly compensated employees
    Penalties for Noncompliance
    $100 per individual per day for as long as violation continues
    Compare to self-insured penalty, which is the loss of tax benefits for the HCE who benefited from the discrimination
  • Extended Effective Dates Under PPACA
    Employer W-2 Reporting (Delayed until 2012)
    Employers must calculate and report the aggregate cost of applicable employer sponsored health insurance coverage on the employee’s W-2
  • Extended Effective Dates Under PPACA
    60-day Notice for Material Modifications effective for plan years on or after March 23, 2012
    Clarified by DOL; originally believed to have been March 23, 2010
    However, until federal agencies provide standards on benefits and coverage explanations, employers are not required to comply with this requirement
  • Extended Effective Dates Under PPACA
    Automatic Enrollment
    Effective January 1, 2014, employers with 200 or more full-time employees offering health coverage must enroll new full-time employees with the opportunity to opt-out
    In a FAQ in December 2010, DOL indicated that until EBSA issues regulations, employers will not be required to comply with this rule
  • PPACA Impact on ALL Health Plans:September 23, 2010
    No rescission of coverage except for fraud or intentional misrepresentation of a material fact
    Elimination of lifetime limits for “essential health benefits”
    Elimination of pre-existing conditions for children under age 19
    This prohibition will be extended to ALL individuals effective January 1, 2014
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Medicare Part D donut hole will be eliminated
    Retiree Reinsurance Program Effective June 1, 2010
    Only available to early retirees defined as individuals between the ages of 55 and 64 who are not eligible for Medicare and who are not active employees of the employer who maintains the plan
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Extend dependent coverage to age 26
    Coverage is required even if dependent is married
    Coverage must be provided even if dependent does not otherwise qualify as the employee’s dependent for tax purposes
    Children who were previously dropped because of age from dependent coverage will also be able to re-enroll
    Re-enrollment option only applies to plans that already offer dependent coverage
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Extend dependent coverage to age 26 (continued)
    For non-grandfathered plans, coverage must be offered to dependent even if eligible to enroll in another employer group health plan
    Grandfathered plans need not offer coverage to adult children who are eligible to enroll in another employer group health plan until January 1, 2014
    Cost of employer-provided health coverage with respect to an adult child is tax-free until end of calendar year in which the child turns age 27
    Ohio dependent coverage is extended to age 28
  • PPACA Impact on ALL Health Plans:September 23, 2010
    • Group health plans can only impose annual limits on the coverage for “essential health benefits” that exceed a restricted annual limit as determined by HHS
    • $750,000 limit per individual for plan year on or after September 23, 2010. Increases to $1,250,000 on or after September 23, 2011
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Effective June 23, 2010, establishment of high-risk pool for individuals to obtain coverage due to health status. Remains in effect until Exchanges are created in 2014
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Nursing Mothers: Affects employers with 50 or more full-time (at least 30 hours per week) employees
    New provision added to the Fair Labor Standards Act (the “FLSA”)
    Employers covered by FLSA must provide “reasonable” breaks to mothers to express milk for their infants up to one (1) year old
    Employers must provide a private location, other than a restroom
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Preventative Health Services and Cost-Sharing
    Effective for plan years on or after September 23, 2010, a non-grandfathered plan may not impose cost-sharing requirements (such as co-pays, co-insurance, or deductibles) for certain preventative services
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Preventative Health Services and Cost-Sharing (continued)
    Four types of preventative services will be covered at no charge to the individual, including:
    Screenings such as colon cancer tests, breast cancer screenings, screening of pregnant women for vitamin deficiencies, smoking cessation services, tests for diabetes, high cholesterol and high blood pressure tests
    Routine vaccines, including child immunizations and tetanus boosters
    Well-child visits, vision and hearing tests for children and weight counseling
    Preventative care for women (breast cancer screenings)
  • PPACA Impact on ALL Health Plans:September 23, 2010
    A non-grandfathered plan may not impose a pre-authorization requirement for a person seeking obstetrical or gynecological care
    A non-grandfathered plan that covers emergency department services:
    May not impose a pre-authorization requirement
    Must cover services regardless of whether the health care professional is a participating provider
    May not impose greater coverage restrictions for non-participating provider services than are imposed for participating providers
    May not impose greater cost-sharing requirements for out-of-network services than are imposed for in-network emergency room services
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Choice of Primary Care Provider
    A non-grandfathered plan that requires or provides for an individual’s designation of a health care provider as “primary,” must permit an individual to designate any participating primary care provider who is available to accept that individual
    Plan must permit the designation of a pediatric physician as the child’s primary care provider
  • PPACA Impact on ALL Health Plans:September 23, 2010
    • Internal Claims and Appeals:
    • Expanded definition of “adverse benefit determination”
    • Notice of benefit determinations for urgent care claims must be provided within 24 hours of receipt of claim
    • Avoid conflicts of interest
    • Upon review of a claim denial, claimants must be allowed to review their file and present evidence/testimony. Plans/insurers must provide, free of charge, any new or additional evidence considered, relied upon or generated by the plan or insurer in connection with the claim, and a reasonable opportunity for claimant to respond
  • PPACA Impact on ALL Health Plans:September 23, 2010
    • Internal Claims and Appeals (continued):
    • Notices regarding claims and appeals must be provided in a culturally and linguistically appropriate manner
    • Detailed notices of adverse benefit determinations and the availability of internal and external appeals
    • Coverage must be provided pending outcome of an internal appeal
    • Strict adherence to the internal claims and appeals process is required (claimant will be deemed to have exhausted the internal claims and appeals process if plan/insurer fails to comply)
  • PPACA Impact on ALL Health Plans:September 23, 2010
    External Review Process
    If an individual’s internal claim is denied, the individual will have the right to appeal to an independent reviewer pursuant to the standards established by the National Association of Insurance Commissioners (“NAIC”)
    States should adopt the NAIC standards before July 1, 2011
    Self-funded plans must comply with claims and appeals process consistent with the federal external review procedures
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Federal External Review Process: DOL Technical Release 2010-01 provides a safe-harbor and outlines the procedures for the federal external review process (standard and expedited external review)
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Standard External Review Process
    Requests for external review must be allowed under the plan and a claimant must file the request within 4 months after notice of an adverse determination of final internal adverse determination
    A preliminary review must be conducted by the plan within 5 days of receiving an external review request
    Within 1 day after completion of the preliminary review, the plan must issue notification in writing to the claimant
    Plan must assign an accredited Independent Review Organization (“IRO”) to conduct the external review. The IROs decision is binding except for other remedies available under state or federal law. IRO will review claim de novo (i.e., will not be bound by previous decision of plan sponsor). IRO will make final decision within 45 days.
    Upon receipt of notice of a final external review reversing an adverse benefit determination or final internal adverse benefit determination, the plan must immediately provide coverage or payment
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Transparency in Coverage Disclosures
    Effective for plan years on or after September 23, 2010, a non-grandfathered plan will be required to submit to the HHS information regarding the following:
    The plan’s claims payment policies and practices;
    Periodic financial disclosures;
    Data on enrollment;
    Data on disenrollment;
    Data on the number of claims that are denied;
    Data on rating practices;
    Information on cost-sharing and payments with respect to any out-of-network coverage;
    Information on enrollee and participant rights.
  • PPACA Impact on ALL Health Plans:September 23, 2010
    Uniform Explanation of Coverage (Mini-SPDs)
    Must be written in culturally and linguistically appropriate manner to explain health benefits under the plan
    Must include uniform set of definitions and medical terms and must describe cost-sharing requirements and plan term limits and exclusions
    Must be provided to participants at time of enrollment
    Uniform Explanation of Coverage is in addition to the SPD
    Distribution deadline of 24 months after the enactment of healthcare reform (i.e., March 23, 2012)
    HHS is to issue guidance addressing the Mini-SPDs by March 23, 2011
  • PPACA Impact on ALL Health Plans:January 1, 2011
    HSAs, FSAs, HRAs: Expenses for over-the-counter medications will no longer be eligible for reimbursement
    HSAs, FSAs, HRAs: Eligible medical expense = prescription or insulin
    Plans must be amended by June 30, 2011
    Simple Cafeteria Plans: Effective for tax years after December 31, 2010, small employers may adopt a new type of cafeteria plan
  • PPACA Impact on ALL Health Plans:January 1, 2013
    Medicare Payroll Tax Increase
    Increase in Medicare Part A tax from 1.45% to 2.35% applicable to single individuals earning more than $200,000 and married individuals earning more than $250,000
    Small Business Tax Credit
    Eligible employers (less than 25 full-time employees) will get a tax credit equal to a portion of its health insurance premiums
    Phase I: 2010 – 2013: May claim a credit of up to 35% of health insurance premiums for each tax year if employer contributes at least 50% of total premium cost
    Phase II: After 2013: May claim tax credit of up to 50% of employer’s contribution toward employees’ premiums if employer contributes at least 50% of total premium
  • PPACA Impact on ALL Health Plans:January 1, 2013
    FSAs: Salary reduction contributions to a health FSA are limited to $2,500 per year
    Contributions to dependent care FSAs remain at $5,000 per year
  • PPACA Impact on ALL Health Plans:January 1, 2014
    Elimination of pre-existing conditions for all individuals
    No annual limits on dollar value of coverage on essential health benefits
    Grandfathered plans that offer dependent coverage must offer coverage to adult children until age 26 regardless of whether or not the child is eligible to enroll in another employer health plan
  • PPACA Impact on ALL Health Plans:January 1, 2014
    Waiting Periods
    Cannot impose coverage waiting period that exceeds 90 days
    Out-of-Pocket Limits
    Effective January 1, 2014, a non-grandfathered group health plan cannot impose a total cost sharing for a year that exceeds the out-of-pocket limits that are applicable to high-deductible health plans
    Currently, these limits are $5,950 for individual coverage and $11,900 for family coverage
  • PPACA Impact on ALL Health Plans:January 1, 2014
    Mandate to Provide Health Insurance
    Employers with 50 or more full-time employees are required to offer health coverage or pay a penalty
    Penalty for failure to provide coverage is $2,000 per full-time employee (applicable if at least one full-time employee receives insurance on the Exchange)
    Penalty for failure to provide affordable coverage is $3,000 for each employee enrolled in Exchange coverage
    Part-time employees are included and calculated as full-time employees
  • PPACA Impact on ALL Health Plans:January 1, 2014
    • Health Insurance Exchanges
    • States must establish “Health Insurance Exchanges” to offer qualified health benefit plans
    • Exchanges are initially limited to individual markets and to employers with 100 employees or less
    • Effective January 1, 2017, States may allow employers with over 100 employees to access coverage through Exchanges
    • Individuals must purchase insurance for the minimum essential health coverage or pay penalty of the greater of $95, or up to 1% of income (penalty will increase each year)
  • PPACA Impact on ALL Health Plans:January 1, 2014
    Vouchers: Employers must provide free choice vouchers for lower income employees who qualify for an affordability exemption
    Employers who offer minimum essential coverage and who pay a portion of coverage must also provide “qualified employees” with a voucher that can be applied to the purchase of insurance through an Exchange
    Voucher must equal the amount the employer would have paid to provide coverage for the employee under its group health plan
  • PPACA Impact on ALL Health Plans:January 1, 2014
    Vouchers (continued):
    A “Qualified Employee” is an individual:
    who does not participate in the employer’s group health plan;
    whose required contribution for the employer sponsored minimum essential coverage exceeds 8% (but is less than 9.8%) of his/her household income;
    whose household income does not exceed 400% of the poverty level
  • PPACA Impact on ALL Health Plans:January 1, 2018
    Excise tax on Cadillac Plans
    Insurers (employer if self-insured) will pay 40% excise tax on high value Cadillac Plans with values exceeding $10,200 limit for individual coverage and $27,500 for family coverage
  • PPACA Impact on Non-Profit Hospitals
    If a non-profit hospital fails to meet any of the following requirements, its tax-exempt status under Code Section 501(c)(3) will be revoked
    Community health needs assessment requirements;
    Financial assistance policy requirements;
    Limitations on charges requirements;
    Billing and collection requirements.
  • Grandfathered Plans Under PPACA
    A “grandfathered plan” is any group health plan or health insurance coverage in effect as of March 23, 2010
    Grandfathered plans are not required to comply with all of the requirements under PPACA
    To maintain grandfathered status, a plan must include a statement in any plan materials to be provided to participants that describes plan benefits and must include a statement
  • Grandfathered Plans Under PPACA
    Plan sponsors must retain all plan documents in effect on March 23, 2010 to prove terms of plan at this time
    A grandfathered plan will lose its exemption from some of PPACA’s requirements if a plan significantly reduces benefits or increases employee premium contributions by more than 5% points
  • How to Lose Grandfathered Status
    Elimination of benefits (elimination of all or substantially all benefits to diagnose/treat a particular condition);
    Increase in co-insurance (i.e., increase in cost-sharing);
    Increase in co-payment (increase in a co-payment for any service by more than the greater of (a) $5.00 or (b) medical inflation plus 15%);
    Increase in deductible or out-of-pocket maximum;
    Decrease in employer contribution rate;
  • How to Lose Grandfathered Status
    Changes to annual limits;
    Issuance of new (not renewed) insurance policy;
    Transfer of employees (transfer of employees to another plan);
    Change of insurer (Effective Nov. 15, 2010, was removed as an event to lose grandfathered status);
    Merger, acquisition, restructuring anti-abuse rules (if principal purpose of merger, acquisition, or restructuring is to cover new individuals under a Grandfathered Plan, the plan will lose grandfathered status)
  • Grandfathered Plans
    The following WILLNOT cause a loss of grandfathered status:
    Change in plan premiums;
    Adjustments to employer contributions, premiums, co-payments and deductibles;
    Adding new benefits;
    Changes required to comply with state/federal law;
    Changes to comply voluntary with the Healthcare Reform law;
    Change in self-insured plans’ TPA;
    Renewal of a previous policy, certificate, or contract of insurance;
    Decrease in employee contribution rate.
    Change of insurer (Effective November 15, 2010)
  • Constitutional Challenges to PPACA
    26 States have challenged the constitutionality of PPACA
    Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Indiana, Idaho, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania, Virginia, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin and Wyoming
    2 Federal Judges have upheld law under Commerce Clause (Western District of Virginia and Michigan)
    2 Federal Judges have ruled PPACA unconstitutional (Florida and Virginia)
  • Constitutional Challenges to PPACA
    Principal Challenge to PPACA is the Commerce Clause
    States challenging PPACA argue that the Commerce Clause does not give Congress the authority to mandate that every American buy health insurance or pay a fee/penalty
    Other Challenges are Spending Clause and Taxing Power
    Related to Medicaid program; PPACA greatly expands eligibility rules under Medicaid and imposes unprecedented costs and burdens on states, and this exceeds Congress’s authority under the Spending Clause
    Tax Issues: Penalty imposed for noncompliance with PPACA’s individual mandate is unconstitutional as an improperly apportioned direct tax
  • Constitutional Challenges to PPACA
    Federal District Judge, Judge Vinson, in Florida ruled on February 1, 2010, that the individual mandate and the entirety of PPACA was unconstitutional
    Federal government cannot regulate inactivity through the Commerce Clause and refusing to buy health insurance is inactivity
    The individual mandate is so thoroughly interwoven into PPACA as a whole that the FL court could not sever that provision and rule only to its constitutionality
  • Constitutional Challenges to PPACA
    First time a federal court has ruled the entirety of PPACA to violate the Constitution
    Federal government has already filed its appeal from the Florida ruling by Judge Vinson with the Court of Appeals for the 11th Circuit
    Oral arguments begin in June
  • Constitutional Challenges to PPACA
    The matter will eventually reach the U.S. Supreme Court
    Not sure when, but before 2012 elections?
    There has been no injunction against the implementation of PPACA so nothing practical has changed for employers, insurers and individuals
    Remains to be seen whether states will put the brakes on the implementation of PPACA, particularly on states’ preparation for the creation of Exchanges
  • Thank You!
    Kristy N. Britsch
    Kegler Brown Associate
    (614) 462-5412
    65 East State St., Suite 1800, Columbus OH 43215
  • 2011 Ohio Healthcare Summit
    State of Healthcare Reform in Ohio
    Thursday, May 12, 2011
    Élise Spriggs
    Director of Government Affairs
  • Medicaid is Ohio’s Largest Health Payer
    • Provides health coverage for low-income children, parents, seniors, and people with disabilities
    • Covers 2.2 million Ohioans (1 in 5) including 2 in 5 births1
    • Spends $18+ billion annually all agencies, all funds (SFY 2011) 1
    • Accounts for 4.0% of Ohio’s total economy and is growing2
    • Funds are federal (63.69%) and state (36.31%)3
    SOURCES: (1) Ohio Department of Job and Family Services, (2) SFY 2011 estimate based on $18.0 billion in Medicaid spending per ODJFS and $498 billion Ohio gross domestic product per the State of Ohio Office of Budget and Management, and (3) Federal Register Vol. 76 No. 22 page 5811.
  • Ohioans Covered by Employer-Sponsored Health Insurance, Medicaid, or Uninsured
    Employer-Sponsored Insurance
    Source: Ohio Colleges of Medicine Government Resource Center, “Quantifying the Impact of the Recent Recession on Ohioans: preliminary findings from the 2010 Ohio Family Health Survey” (February 16, 2011)
  • Federal Health Care Reform:
    Government Coverage Expansions
    Private Insurance
    $89,400 for a family of 4
    Health Benefit Exchange
    Federal Poverty Level
    $30,843 for a family of 4
    Medicaid Expansion
    Medicaid Expansion
    Medicaid Expansion
    Source: X
  • Ohio’s Health System Performance
    Health Outcomes – 42nd overall1
    42nd in preventing infant mortality (only 8 states have higher mortality)
    37th in preventing childhood obesity
    44th in breast cancer deaths and 38th in colorectal cancer deaths
    Prevention, Primary Care, and Care Coordination1
    37th in preventing avoidable deaths before age 75
    44th in avoiding Medicare hospital admissions for preventable conditions
    40th in avoiding Medicare hospital readmissions
    Affordability of Health Services2
    37th most affordable (Ohio spends more per person than all but 13 states)
    38thmost affordable for hospital care and 45thfor nursing homes
    44thmost affordable Medicaid for seniors
    Sources: (1) Commonwealth Fund 2009 State Scorecard on Health System Performance, (2) Kaiser Family Foundation State Health Facts (updated March 2011)
  • A few high-cost cases account for most Medicaid spending
    1% of the Medicaid population consumes 23% of total Medicaid spending
    4% of the Medicaid population consumes 51% of total spending
    Source: Ohio Department of Job and Family Services; SFY 2010 for all Medicaid populations and all medical (not administrative) costs
  • SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009)
  • “The critical flaw in our health care system … is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the emergency room visit. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.”
    Source: The New Yorker (Jan 24, 2011).
  • Medical Hot Spot:Emergency Department Utilization: Ohio vs. US
    Hospital Emergency Room Visits per 1,000 Population
    Source: American Hospital Association Annual Survey (March 2010) and population data from Annual Population Estimates, US Census Bureau: http://www.census.gov/popest/states/NST-ann-est.html.
  • Medicaid Hot Spot:Medicaid Enrollees Who Get Care Primarily from Hospitals*
    * Indicating a lack of primary care and/or care coordination
    Source: Ohio Department of Job and Family Services for SFY 2010. Note that medical costs include those incurred by MCPs and paid by FFS, excluding institutionalized consumers and their costs. Consumers may have been in both FFS and MC delivery systems within SFY 2010. This analysis includes consumers costs in both systems.
  • Medicaid Hot Spot:Hospital Admissions for People with Severe Mental Illness
    Avoidable hospitalizations per 1000 persons for ambulatory care sensitive conditions (avoidable with proper treatment)
    Source: Ohio Colleges of Medicine Government Resource Center and Health Management Associates, Ohio Medicaid Claims Analysis (February 2011)
  • Ohio Medicaid Spending Trend9 percent average annual growth, 2008-2011
    + 42.8%
    Source: Office of Health Transformation Consolidated Medicaid Budget, All Funds, All Agencies; actual SFY 2008-2010 and estimated SFY 2011-2013; “All Other” includes Federal Funds and Non-General Revenue Funds (non-GRF)
  • The current Ohio HHS Medicaid organization
    Medicaid Single State Agency
    56 Combined
    County Boards
    130 County Offices
    88 County Boards
    12 Area Agencies on Aging
    130 Local Health Departments
    Source: Legislative Service Commission, “Total Medicaid Spending by Agency” (State Fiscal Year 2010).
  • John R. Kasich, Governor
    Leadership Team
    • Elise Spriggs, Government Affairs
    • Eric Poklar, Communications
    • Monica Juenger, Stakeholder Relations
    Greg Moody, Director
    Policy Teams
    “All Cabinet Agencies, Boards and Commissions shall comply with requests or directives issued by OHT, subject to supervision of their respective directors.”
    Consultant Team
    “OHT shall contract with state and/or private agencies for services in order to facilitate the implementation and operation of the OHT’s responsibilities.”
    Stakeholder Partners
    Prioritize stakeholder communication
    Dr. Ted Wymyslo(Health)
    Bonnie Kantor (Aging)
    Tracy Plouck(ODMH)
    John Martin (DODD)
    Michael Colbert
    John McCarthy (Medicaid)
    Source: Ohio Governor John R. Kasich, Executive Order 2011-02K (January 13, 2011)
  • Executive Order
    Plan for the long-term efficient administration of the Ohio Medicaid Program and act to improve overall health system performance. In the next six months:
    Advance the Administration’s Medicaid modernization and cost-containment priorities in the operating budget;
    Initiate and guide insurance market exchange planning;
    Engage private sector partners to set clear expectations for overall health system performance; and
    Recommend a permanent Ohio health and human services organizational structure and oversee transition.
    Source: Ohio Governor John R. Kasich, Executive Order 2011-02K (January 13, 2011)
  • The Vision for Better Care Coordination
    • Create a person-centered care management approach – not a provider, program, or payer approach
    • Services are integrated for all physical, behavioral, long-term care, and social needs
    • Services are provided in the setting of choice
    • Easy to navigate for consumers and providers
    • Transition seamlessly among settings as needs change
    • Link payment to person-centered performance outcomes
  • Medicaid Hot Spot:Enrollment Spending by Top Managed Chronic Conditions
    Consumers with TWO OR MORE of the top managed chronic conditions
    Consumers with ONE of the top managed chronic conditions
    Consumers without one of the top managed chronic conditions
    Source: Ohio Department of Job and Family Services. Institutionalized consumers excluded. Based on SFY 2010 total medical cost either by ODJFS or Medicaid managed care plans. Top managed conditions = Diabetes, CAD, CHF, Hypertension, COPD, Asthma, Obesity, Migraine, HIV, BH, & Sub. Abuse.
  • Ohio Health Transformation Priorities
    Improve Care Coordination
    Integrate Behavioral and Physical Health
    Rebalance Long-Term Care
    Modernize Reimbursement
  • A Case Study in Transformation:
    Ohio Department of Developmental Disabilities
  • Ohio Medicaid Spending per Member per Month by Setting
    People with developmental disabilities
    People with other disabilities or over age 65
    Other children and parents
    Source: Ohio Department of Job and Family Services. Includes claims incurred from July 2009 through June 2010 and paid through October 2010; cost differences between institutional and waiver/community alternatives do not necessarily represent program savings because population groups being compared may differ in health care needs.
  • Ohio Medicaid Residents of Institutions Compared to Recipients of Home and Community Based Waivers
    Home and Community Based (Aging, JFS, and DD waiver recipients)
    (NF, ICF/DD, Developmental Center residents)
    Source: Ohio Department of Job and Family Services; based on average monthly recipients for SFYs 2006-2010.
  • Medical Hot Spot:Per Capita Health Spending: Ohio vs. US
    Source: 2004 Health Expenditure Data, Health Expenditures by State of Residence, Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, released September 2007; available at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/res-us.pdf
  • Medicaid Hot Spot:Per Enrollee Medicaid Spending: Ohio vs. US
    Source: 2007 The Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on data from Medicaid Statistical Information System (MSIS) and CMS-64 reports from the Centers for Medicare and Medicaid Services (CMS), 2010.
  • Unused Nursing Home Capacity
    In 70 counties more than 10% of beds are empty
    Van Wert
    Nursing Facility Surplus
    Percentage of total bed days vacant
    6.6% - 10.4%
    10.5% - 12.5%
    12.6% - 16.3%
    16.4% - 23.0%
    23.1% - 35.1%
  • Rebalance Long Term Care
    Enable seniors and people with disabilities to live with dignity in the settings they prefer
    • Create a Single Point of Care Coordination
    • Consolidate and Streamline Waiver Programs
    • Reward Person-Centered Outcomes in Nursing Homes
    • Expect Greater Efficiency from NF and Waiver Providers
    • Decrease payments to “hold” empty beds
    • Reduce the nursing home franchise fee
    • Saves $427 million all funds over the biennium
  • Research suggests that person-centered care is associated with improved organizational performance including higher resident and staff satisfaction, better workforce performance and higher occupancy rates.
    Source: 2010 Annual Quality Report, Alliance for Quality Nursing Home Care and American Health Care Association
  • Ohio Health Transformation Priorities
    Improve Care Coordination
    Integrate Behavioral and Physical Health
    Rebalance Long-Term Care
    Modernize Reimbursement
  • Balance the Budget
    Contain Medicaid program costs in the short term and ensure financial stability over time
    • A sustainable system
    • $1.4 billion in net savings over the biennium
    • Align priorities for consumers (better health outcomes) and taxpayers (better value)
    • Challenge the system to improve performance (better care and cost savings through improvement)
  • Total Ohio Medicaid Expenditures, SFY 2010
    Source: Ohio Department of Job and Family Services and the Governors Office of Health Transformation. Managed care expenditures are distributed to providers according to information from Milliman. Hospitals include inpatient and outpatient expenditures as well as HCAP Home and community services include waivers as well as home health and private duty nursing.
  • Medicaid Budget:Savings and Investments
    in millions
    Source: Office of Health Transformation (March 15, 2011)
  • Medicaid Budget:Impact on Rates by Provider
    Estimated change in rate
    Source: Office of Health Transformation (March 15, 2011)
  • What this budget does NOT do
    Does not cut eligibility
    Does not cut optional services, including dental
    Does not make arbitrary across-the-board cuts
    Does not resort to smoke and mirrors
    Does not count hypothetical savings
  • Thank you.
    Élise Spriggs, Director of Government Affairs
    Governor's Office of Health Transformation 77 South High Street, 30th Floor Columbus, Ohio 43215 Phone: 614-752-2784
    Email: elise.spriggs@governor.ohio.gov
  • The View From DC
    Presented by
    Jennifer Covich, Chief Executive Officer, eHealth Initiative
  • eHealth Initiative
    Since 2001, only national, non-partisan group that represents all the stakeholders in health care
    eHI counts over 200 of the most influential organizations amongst its members
    In 2005, eHI launched Connecting Communities, coalition representing more than 250 HIE initiatives
    eHI advocates for the use of health IT that is practical, sustainable and addresses stakeholder needs, particularly those of patients.
  • EHRs, HIES, and ACOs…Oh my!
  • Agenda Today
    Current State of the Field
    Electronic Health Records
    Health Information Exchange
    What does the advent of Accountable Care Organizations (ACOs) mean?
    The Government’s Big Plan
  • Enactment of Two Laws
    Stimulus Package-The American Recovery and Reinvestment Act (ARRA- 2009): $20B to support adoption of health IT.
    Health Care Reform-The Patient Protection and Affordable Care Act (PACCA) creates a national, voluntary shared savings program for accountable care organizations (ACOs), strengthens primary care (Medical Homes) and incentivizes care coordination
  • Trends in Health Care Reform
    Transfer risk to delivery system and consumers
    Pay for performance & outcomes, not volume
    Provides array of health services (information, DM, Case Management)
    “We are a health services company that happens to sell health insurance”
    Medical Homes  ACOs
    HIT enabled
    Workforce shortages, especially in primary care and ancillaries
    Greater financial stake and purchasing discretion
    Self-reliance: new consumer models emerging. Role of social networks
  • EHR Adoption
  • Meaningful Use
    Use of certified EHR technology:
    In a meaningful manner
    For electronic exchange of health information to improve the quality of care
    To submit clinical quality measures to CMS
  • Meaningful Use
    Shift From Process Reporting to Outcomes Reporting
    Improved Outcomes
    Functional Process Objectives
    • Outcomes, clinically based measures
    • More patient-generated data
    • Dynamic quality reports
    • Patient access to data, rather than access to copies of data
    • Real-time syndromic surveillance
    • Claims and clinically based measures
    • Streamlined enrollment, eligibility and claims
    • CPOE for all order types
    • Use Clinical Decision Support to achieve specific outcome
    • Increased clinical documentation in EHR
    • Health summaries for continuity of care
    • Registry reporting and reporting to public health
    • Process, claims based measures
    • Transmit prescriptions
    • Generation of patient list
    • Capability to exchange clinical data
    • Patient e-copies of their discharge and visit summaries
    • Quality and immunization reporting
  • Status of EHR Adoption
    80% medical practices already adopted an EHR
    72% said they are satisfied with the EHR system
    13.6% of medical practices indicated that they are currently able to meet all 15 core MU criteria
    26.5% of practices indicated that productivity increased as a result of the EHR
    30.6% of practices indicated that productivity decreased as a result of the EHR
    Of the practices still using paper records, 28.8% were in the process of selecting an EHR system
    Electronic Health Records: Status, Needs, and Lessons 2011, (The Medical Group Management Association).
  • CIOs and EHR adoption
    More CIOs say they are accelerating plans to implement EHRs, with 40.5 percent reporting such plans in March vs. 35.6 percent in November 2010 (CHIME Survey, April 2011)
    Capturing and submitting data for quality measures has become the most frequently cited concern of CIOs
    Nearly 75 percent of responding CIOs say they are concerned about legislative proposals to repeal incentive funding, including the EHR Medicare and Medicaid Incentive Program.
  • Kübler-Ross Model of EHR Adoption
    Denial – This is a joke. These people don’t understand medicine and this Obamacarething will soon go away and we’ll return to normalcy.
    Anger – This is a cruel joke. This EHR thing is just a government ploy to punish doctors and enslave them. There’s nothing in this for me and you want me to pay for it?? We are all going to stop taking Medicare, Medicaid and all your government plans, which don’t even pay for my receptionist, see what you do then.
    The Kübler-Ross Model of EHR AdoptionBy MARGALIT GUR-ARIE http://thehealthcareblog.com/blog/2011/04/25/the-kubler-ross-model-of-ehr-adoption/
  • Kübler-Ross Model of EHR Adoption
    Bargaining – This is not happening to me. I am a doctor. If I stop playing their game, they’ll have no way to touch me. I will only take cash, at least for a while, until this thing blows over. I’ll practice good medicine, and in time everybody will come to their senses and see that this is the right way to care for people.
    Depression – What’s the point? Why did I have to sacrifice my entire life and work like a dog for these ungrateful people? There’s no respect any more. There is no gratitude. There’s no money in this either. I should have gone to law school
  • Finally….
    Acceptance – This EHR is really primitive. Costs a fortune, but the hospital kicked in for most of it. They want to measure my performance; fine with me. I’m a good doctor and I take good care of my patients. I don’t like using the computer in the exam room. My nurse does though, but you should see her texting, and my receptionist says it’s better than the old system. I wish I could get the hospital labs, but they’re still faxing them over.
    The Kübler-Ross Model of EHR AdoptionBy MARGALIT GUR-ARIE http://thehealthcareblog.com/blog/2011/04/25/the-kubler-ross-model-of-ehr-adoption/
  • A Real Issue: Staffing Shortages
    More than 60 percent of responding CIOs reported that IT staffing deficiencies will possibly (51 percent) or definitely (10 percent) affect their chances to implement EHR and receive funding.
    More than 70 percent of respondents reported that their organizations lack staff to implement clinical applications.
    Respondents from smaller hospitals reported the lowest percentage of open positions.
    IT Staffing Shortages, October 2011
  • The National Landscape on HIE
  • eHI on HIE
    • Since 2004, eHealth Initiative (eHI) has tracked the progress of organizations and initiatives across the country working in this area.
    • Health information exchange is the act of transferring health information electronically between two or more entities.
    • eHI has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country.
    • eHI and its membership support HIEs through research, education and advocacy for HIEs.
  • 100
    Why It Won’t Work
    “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”
  • 101
    “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”
    from The London Times in 1834
    Commenting on ...
    the “stethoscope”
  • 102
    Obligatory Confusing Diagram
    Payer 1
    Payer 2
    Payer 6
    Specialist 1
    Specialist 2
    Specialist 6
    Specialist 3
    Specialist 5
    Specialist 4
    Payer 3
    Payer 5
    Payer 4
    = Patients
  • 103
    National Landscape on HIE
  • What Are Communities Doing?
  • eHI Stages of Development
  • 106
    2010 Stages of Development
  • 107
    Operational InitiativesActually Transmitting Data
  • 108
    Who Is Engaged?
  • 2009
  • 110
  • Why is this so hard?
    Public Good
    Demonstrating Value and ROI
    Continuing to Offer Valuable Services
  • 112
    Challenges Faced by All
  • Privacy
    • Initiatives are creating methods to address the complexities of security and privacy. More organizations are creating systems which allow patients to control the level of access to their information.
    36 have an opt-in policy where patients must give consent to have their data included.
    81 have an opt-out policy, where patients’ data is automatically included but they can choose to withdraw.
    27 unsure
  • Sustainable Initiatives: How Do They Do It?
  • 115
    Revenue Sources for Ongoing Operations-
  • 116
    Stakeholders Paying Participation Fees
  • What Service Are They Paying For?
    Connectivity to EHRs (15)
    Alerts to providers (12)
    Consultation/referral (12)
    Results Delivery (12)
    Alerts to providers Drug-to-drug (11)
    Health summaries for continuity of care (11)
    Clinical documentation (10)
    Electronic prescribing (10)
  • Characteristics of Sustainable Groups
    Established organizations
    Involvement of multiple stakeholders- the more the merrier is true - in this case
    Paying participants
    Focus on limited number of data and functionalities
    Active physician engagement
    A business, not a project
    Money does not erase need for time
    Page 118
  • Value from HIE
  • 120
    Measures of Financial Success
  • Patient Engagement With HIE
    More consumers involved in governance
    71 in 2010, up from 22 in 2009
    More patients viewing data
    44 operational initiatives allowed review access in 2010, up from 3 in 2009
    More patients adding information to health status
    31 operational initiatives allowed patients to add information on their health status, up from 7 operational initiatives in 2010
    Provide electronic communication between patients and care providers
    33 operational initiatives provide in 2010
    More patients provided access to health education information
    30 operational initiatives in 2010
  • Accountable Care Organizations
  • Creation of ACOs
    Networks of providers within Medicare system includes physicians, hospitals and health systems.
    Aim is to improve the quality of care, save money, with any savings to be shared by the government and the ACOs
    Centers for Medicare and Medicaid Services (CMS) released a proposed rule at the end of March, how the program will work, how much financial risk medical providers will face, and what type of data the organization need to collect.
  • General Thoughts on ACO Rule
    HIEs are essential for the success of ACOs
    Example: The underlying assumption is that ACO will access patient records from providers not participating in the ACO via HIE
    CMS is increasing the demands for exchange of information among providers and individuals
    This will support the demand for robust HIE
    CMS is offering flexibility the ACOs to determine the strategy for information exchange that best meets their needs
  • ACO NPRM Specific Comments
    Quality measure reporting in the ACO NPRM should align with meaningful use quality measure reporting yet recognize that all measures in MU are not applicable to all providers participating in the ACO
    Retrospective Assignment of Beneficiaries
    Beneficiary assignment in ACOs that relies on retroactive claims data will require interoperable EHRs and standards that may not currently exist
  • Comments
    Meaningful Use Requirement for PCPs:
    The 50 percent threshold requirement for certified EHR use among PCPs is high and could hinder participation in the ACO.
    The certified EHR use requirement is not extended beyond PCPs.
    Is this a challenge to care coordination with non-PCPs participating in the ACO, and providers offering care to the beneficiary outside of the ACO?
  • Concerns About ACO Program
    Some key groups reluctant to participate unless changes made
    College of Healthcare Information Management Executives argues that allowing patients to limit access to their medical data could impede efforts to provide accountable care
  • The Government’s Plan
  • Federal Health IT Strategic Plan
    5 Goals, 15 Objectives, 50 Strategies for 2011 - 2015
    Achieve adoption and information exchange through meaningful use of Health IT
    Improve care and population health, and reduce health care costs through use of Health IT
    Inspire confidence and trust in Health IT
    Empower individuals with Health IT to improve their health and the health care system
    Achieve rapid learning and technological achievement
  • eHI Comments on Federal HIT Plan
    The Strategic Plan must be inclusive of healthcare settings and providers
    The objectives and strategies should clearly articulate the expectation that HIT and HIE will support empowerment of individuals as participants in the healthcare system
    Think expansively about the ability of HIE to support the Strategic Plan goals
    The Strategic Plan should support connectivity and exchange between the healthcare delivery system and the public health system
  • Federal HIT Strategic Plan
    ONC, in its coordinating role, must be aware of and plan for the concurrent federal healthcare activities across federal departments
    Recommended the establishment of a Coordinating Committee that defines alignment and coordination of federal activities, and with opportunities for public participation
    It is important to add an evaluation component and modifications based on experience
    Plan HIT that supports the greater use of personalized medicine
    Foster HIT adoption without requirements that mandate uniform use of HIT across medical specialties
  • Big discrepancy in EHR adoption in small practices, rural communities, etc.
    Web-based solutions
    Defining and sharing sustainable business models continues to be focus
    Focus is not on the Government funded SDEs, RECs, etc. for the experience factor
    Significant gap with staffing and expertise in HIE—organizations with experience
    Final Thoughts
  • Where to Find More Info
  • 135
    Contact Information
  • Legal Challenges to PPACA and the Current Regulatory Environment Surrounding HIT and Meaningful Use
    presented by Jeff Porter2011 Ohio Healthcare Summit
    May 12, 2011
  • Meaningful Use
  • Update on Meaningful Use
  • In July of 2010, the Department of Health and Human Services released the proposed final rule for Stage 1 meaningful use of EHR.
  • Since that time, the HIT Policy Committee has been engaged in public hearings and soliciting testimony regarding the future stages of meaningful use.
  • Stage 2 recommendations are likely to be issued in the summer of 2011.
  • The HIT Policy Committee released proposed meaningful use objectives and measures for stages 2 and 3. The Committee received comments until February 25, 2011.
  • During the comment period, 422 organizations submitted comments regarding the proposed objectives and measures
  • Among the comments there was support for several new objectives:
    Electronic prescribing for discharge prescriptions
    Electronic clinical progress notes
    Patient-provider secured messaging
  • There was less support for objectives such as:
    List of care team members
    Advanced directives for EPs
  • Many hospitals, Physicians and EHR vendors generally supported slowing down timeline for meaningful use.
  • You can find a copy of the HIT Policy Committee’s Proposed Objectives and Measures here:
    Or contact me at jporter@keglerbrown.com
  • Shared Savings Program or Accountable Care Organizations
  • Medicare Shared Savings Program or Accountable Care Organizations
    Medicare Shared Savings Program proposed regulations were released March 31, 2011 by:
    CMS, Centers for Medicare and Medicaid Services
    Office of Inspector General
    Official proposed regulations were in April 7 Federal Register
  • Comment Period on Regulations
    Comments due by May 31st (FTC/IRS) and June 6th (CMS/OIG) to various organizations involved.
    Program set to begin January 1, 2012 (maybe).
    Regulations were over 400 pages long.
  • General Facts Regarding Medicare Shared Savings Program
    Providers who are eligible to form ACOs:
    ACO professionals in group practice arrangements
    Hospitals employing ACO professionals
    Networks of individual practices of ACO professionals
    Critical Access Hospitals
    Partnerships or joint venture arrangements between hospitals and ACO professionals
    Other providers and suppliers may participate in ACOs.
  • General Facts Regarding ACO’s
    Must create a legal entity (e.g., corporation, partnership, LLC) that is recognized by the state, has a Tax Identification Number (TIN) for purposes of:
    Receiving and distributing funds;
    Repaying shared losses;
    Establishing, reporting, and ensuring ACO participant and ACO provider/supplier compliance with program requirements, including quality performance standards; and
    Performing other functions as identified in statute.
    Must provide for a shared governance model that provides all participants with appropriate proportionate control over decision-making process.
  • Some Basic Considerations
    ACO must have 5k Medicare fee for service lives attributed in base period.
    If ACO’s lives drop below 5k, CMS will establish Corrective Action Plan and ACO must exceed 5k in next year of agreement or will be ineligible.
  • Some Basic Considerations
    ACO governing body should consist of:
    Representatives from each provider/supplier participant
    Medicare beneficiary representatives
    At least 75% of body must be participants in ACO
    May include non-providers (e.g. health plan management companies)
    May include community representatives
  • Contract with CMS
    Three year contract
    CMS considering new possible start date of July 1, 2012 in addition to January 1, 2013 (but then would be 3.5 year agreement).
    60-day Termination (will result in forfeit of shared savings.)
    CMS will approve/deny applications prior to the end of the calendar year in which the applications are submitted.
  • Further Thoughts on Medicare Shared Savings or ACO Program
    Highly intensive regulation
    Overall rules on participation in NPRM could dampen participation
    Broad waivers of Stark and Anti-kickback laws do apply, but caution is still required
    Rules tend to favor hospitals creating ACO, if only for the 5,000 live requirement
  • Further Thoughts on Medicare Shared Savings or ACO Program
    Two-sided savings/loss model poses some risks, especially considering that quality measures must be met to obtain shared savings
    Additional costs in running ACO need to be considered
    Need to have a compliance office on staff who reports to the board and is not legal counsel to ACO
    CMS expects that at least 50% of physicians in an ACO to achieve Stage 1 meaningful use
  • Thank You!
    Jeff Porter
    Kegler Brown Director, Health Care Regulation & HIT Practice co-chair
    (614) 462-5418
    65 East State St., Suite 1800, Columbus OH 43215
  • Healthcare Regulation and the Implications for Healthcare Providers
    presented by Ralph Breitfeller2011 Ohio Healthcare Summit
    May 12, 2011
  • Stark: Self Reporting
    Different from reporting non-Stark issues to OIG.
    Voluntary Self-Referral Disclosure Protocol (SRDP) posted 9/23/10.
    Reduced penalties for self reporting of overpayment.
    Statute requires reporting by the later of: (1) within 60 days after overpayment identified; OR, (2) the date the cost report is due.
    SRPD allows additional time to investigate complicated issues.
  • Stark: Self Reporting Protocol
    Must provide all relevant information, including corrective action.
    If already under government investigation, must disclose this fact to CMS.
    Must provide all supporting documents without assertion of privilege.
    Submit detailed financial analysis.
    Statement of why disclosing party believes there is a violation, including legal analysis.
    Circumstances by which violation was discovered and measures taken.
    History of similar conduct and other violations.
    Certification by CEO or CFO.
  • Stark: Self Reporting Mitigation Factors
    Nature and extent of violation
    Timeliness of Disclosure.
    Litigation risk.
    Financial condition of disclosing party.
  • HIPAA: Civil Monetary Penalty
    First HIPAA penalty issued by the HHS Office of Civil Rights (OCR).
    Issued against Cignet Health of Prince George’s County.
    $4.3 million.
    Proposed determination states that Cignet failed to provide 41 individuals with timely access to medical records. Each day was a separate violation (45 CFR 164.524), resulting in $1.3 million.
  • HIPAA (cont.)
    Cignet failed to cooperate:
    Refused to produce documents.
    Complied with subpoena only after Court enforced.
    Made no effort to resolve complaints.
    Failure to cooperate resulted in finding of willful neglect of Privacy Rule. An additional $3 million, 16 CFR 160.401.
  • Signature on Lab Requisition
    Final Physician Fee Schedule Rule for 2011 requires physician or qualified NPP sign a requisition for clinical diagnostic Lab test.
    On 12/10/10, CMS announced it would not enforce during Q1-2011.
    On 3/31/11, CMS announced it would rescind the rule; HOWEVER, it now appears that they will have to comply with APA.
    Meanwhile, CMS will not enforce the rule and has so instructed contractors.
  • 340B Drugs
    Discharge Prescription:
    From HRSA website 2/7/2011:
    Can 340B drugs be used for discharge prescriptions?
    The Office of Pharmacy Affairs continues to stand by its long held position that the 340B program is an outpatient drug program.
    Eligible entities have the responsibility to ensure that drugs purchased under 340B be limited to outpatient use and provided to patients who meet the requirements of the current patient definition.  
    340B drugs can be used for discharge prescriptions to the extent that the drugs are for outpatient use. Whether a drug qualifies as outpatient and the individual meets the definition of patient depends upon the factual circumstances surrounding the care of that particular individual.
    If an entity uses 340B drugs, it should be able to explain why the entity is responsible for the use of the drugs on outpatient basis and have auditable records that demonstrate compliance with 340B requirements.
  • 340B (cont.)
    Definition of a Patient
    the covered entity has established a relationship with the individual, such that the covered entity maintains records of the individual's health care; and 
    the individual receives health care services from a health care professional who is either employed by the covered entity or provides health care under contractual or other arrangements (e.g. referral for consultation) such that responsibility for the care provided remains with the covered entity; and
    the individual receives a health care service or range of services from the covered entity which is consistent with the service or range of services for which grant funding or Federally-qualified health center look-alike status has been provided to the entity. Disproportionate share hospitals are exempt from this requirement.
    An individual will not be considered a "patient" of the entity for purposes of 340B if the only health care service received by the individual from the covered entity is the dispensing of a drug or drugs for subsequent self- administration or administration in the home setting. An individual registered in a State operated AIDS drug purchasing assistance program receiving financial assistance under title XXVI of the PHS Act will be considered a "patient" of the covered entity for purposes of this definition if so registered as eligible by the State program. 
  • Primary Care Incentive Program
    ACA authorizes 10% incentive payments to primary care physicians and NPP:
    (1) who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants; and
    (2) For whom primary care services accounted for at least 60 percent of the practitioner’s allowed charges under Part B for a prior period as determined by HHS.
  • Hospital Surgical Incentive Program
    In Health Professional Shortage Areas (HPSA):
    must be enrolled in Medicare as a general surgeon.
    the amount of the incentive payment is equal to 10 percent of the payment for the surgical services furnished by the general surgeon occurring in a ZIP code that is located in an area designated as a primary care HPSA.
  • Reprocessing of Claims
    ACA made corrections and changes to fee schedule, retroactive to 1/1/2010.
    Large volume of claims will be reprocessed.
    CMS instructed contractors to begin reprocessing the first week of March 2011.
    Claim submitted at charge lower than the revised 2010 schedule will not be automatically reprocessed. Will need to request manual reopening.
    CMS considers these circumstances to be “good cause” for extending the 1 year period for reopening.
  • Waiving beneficiary’s cost-sharing portion of increase
    OIG has issued a policy that it will not sanction a provider who waives the beneficiary’s cost-sharing increase:
    This policy statement applies only to waivers of Retroactive Beneficiary Liability owed by beneficiaries for items and services furnished during the Retroactive Period. Once new, increased payment rates are implemented, Providers are expected to calculate and collect cost-sharing amounts for items and services furnished after the Retroactive Period based on the new, increased payment rates.
    This policy statement applies only to waivers of Retroactive Beneficiary Liability, which is the increase in the beneficiary's cost-sharing amount attributable to the commensurate increase in payment rates by operation of new Federal statutes or regulations. This policy does not apply to waivers of beneficiary cost-sharing amounts that were calculated using the prior, lower payment rates.
    This policy statement applies only to waivers of Retroactive Beneficiary Liability if:
    Providers uniformly offer the waivers to all of their affected beneficiaries (~, without regard to the types of items and services furnished to a beneficiary or a beneficiary's diagnosis); and
    Providers do not offer the waivers as part of any advertisement or solicitation.
    This policy statement does not apply to waivers of Retroactive Beneficiary Liability if the waivers are conditioned in any manner on the provision of items, supplies, or servIces.
  • Thank You!
    Ralph Breitfeller
    Kegler Brown Of Counsel, Health Care Regulation & HIT Practice co-chair
    (614) 462-5427
    65 East State St., Suite 1800, Columbus OH 43215
  • Medical Malpractice:What To Do If You Get Sued
    presented by Traci McGuire2011 Ohio Healthcare Summit
    May 12, 2011
  • Discussion
    Litigation process
    If you have been sued:
    what you should and should not do
    How to help yourself
  • Nuts and Bolts: Medical Malpractice
    What is it?
    Any act or failure to act by a health care professional which deviates from the acceptable standard of care and causes injury to a patient.
  • Nuts and Bolts: Medical Malpractice
    Standard of Care
    The standard of care is that of a reasonable physician in the light of present day scientific knowledge in that field of specialty.
  • Nuts and Bolts: Medical Malpractice
    Patient must prove, by a preponderance of the evidence:
    a physician had a duty to provide medical treatment
    a physician breached the duty to provide treatment in accordance with the applicable standard of care
    the patient suffered an injury that was proximately caused by the physician’s failure to provide treatment in accordance with the standard of care
  • Anatomy of a Lawsuit
    What you should know about the litigation process
    Lawsuits take a long time
    Discovery – information sharing
    Medical records, office charts, xrays, monitoring strips – any information, hard copy or electronic, that is part of the patient’s medical chart
    Information about your malpractice carrier, medical training, credentials and history as a physician
  • Anatomy of a Lawsuit
    What you should know about the litigation process
    Expert testimony
    Lost wages
    Present and future medical care
    Pain and suffering
    Large percentage of medical malpractice cases settle or are otherwise dismissed before trial
  • Top 10 things you SHOULD and SHOULD NOT do if you are sued!
    Immediately notify your professional malpractice insurance carrier and your lawyer.
    2. Set up a separate correspondence file for all communication with your malpractice liability carrier and your lawyer.
    Do not keep it with the patient’s medical record.
    Be wary of quick communications – emails
    3. Honest and candid communication is key.
    Do not hide any information.
    Do not destroy any information – do not throw it away or delete it.
  • Top 10 things you SHOULD and SHOULD NOT do if you are sued!
    Do not alter, clarify or supplement the medical record for any reason.
    Do not discuss the facts or details about the lawsuit with anyone other than your attorney.
    Do not talk to the patient or the patient’s attorney or the patient’s family members.
    Do not talk to the media.
  • Top 10 things you SHOULD and SHOULD NOT do if you are sued!
    6.If asked by your lawyer, prepare a narrative of the events and the treatment provided.
    Give it to your lawyer – do not put it in the patient’s chart.
    Carefully and fully honor any request for documents – including medical records.
    8.Do not do extra medical research.
  • Top 10 things you SHOULD and SHOULD NOT do if you are sued!
    9.Help your attorneys.
    Learn the medicine
    Identify and select your experts
    Make contacts with the other medial professionals involved in the care and treatment
    10. Set aside enough time to meaningfully participate in the case.
    Do not try to fit patients in during meetings with your attorney, the trial or your deposition
    Be prepared for the unpredictable nature of the legal process and the lengthy timetable
  • How Can You Help Yourself?
    Good bedside manner
    Positive experience influences a patient’s decision to sue or not to sue
    Appreciate the importance of documentation
    If something is not documented in the record, we can not prove it happened
    Pay attention to documentation details – common errors
    Failure to indicate the time
    Failure to sign
    Failure to date
    Illegible writing
    Lack of information
  • How Can You Help Yourself?
    Communicate clearly and thoroughly
    With patients
    With other doctors and medical professionals – including residents
    Be a good listener
    Take communications from others seriously
    Other medical professionals, including nurses, respiratory therapists, residents, etc. – they are the eyes and ears of the patient
    Family members
  • Thank You
    Traci McGuire
    Kegler Brown Hill & Ritter
    65 E. State Street, Suite 1800
    Columbus, Ohio 43215
    Direct: 614/462-5408
  • Fred Richards, COO/CIO
    Ohio Health Information Partnership
  • Who is the Ohio Health Information Partnership?
  • The Ohio Health Information Partnership
    • Nonprofit partnership
    • State-designated Regional Extension Center and Health Information Exchange
    • Federal funding through Office of National Coordinator of HIT, Department of Health & Human Services
    • Board members have vested interest in its success
  • OHIP’s Founders
  • How can we help achieve the State’s health transformation objectives?
  • Medicaid Hot Spots
    Overall health care fragmentation
    Emergency department dependency
    Avoidable admissions
    Lack of primary care coordination
    Behavioral health
    Nursing home care
    Patients with other chronic conditions
    Medicare and Medicaid coordination
  • Addressing the Hot Spots
    Regional Extension Center Services
    Helps providers adopt EHRs and achieve meaningful use
    Health Information Exchange
    Connects providers so they can electronically exchange data to better coordinate care
  • Regional Extension Center Services
    You may be one of the 6,000 priority primary care physicians or health professionals who can take advantage of federal funding for free REC services.
    Assess your practice to prepare for electronic health records
    Select, adopt and implement an EHR system
    Help you reach “meaningful use” under federal provisions
    Assist in getting federal incentives -- $44,000 from Medicare or $64,750 from Medicaid for each physician or eligible professional within your practice
    Care Summaries
  • HIT Training Program
    1,500 Graduates in June in Midwest
    80% have College Degree
    Job Board Coordination
  • Health Information Exchange
  • Assessing HIE Benefits
    Which benefits align with your strategic goals?
  • Priorities for Meaningful Use
    Structured Lab Results
    Care Summaries
  • FQHCs
    and CMHCs
    3 Major Labs
    200 Touch Points to 80% EMR
    750 Providers
    6,000-10,000 Physicians
    8,000 Physicians
    50-80 EHR
    174 Hospitals
    80 IntegratedDelivery Systems
    5 OHIP Preferred EHR Vendors
    Health Information Exchange
    Public Health
    5 Major Payers
    5 Major MCOs
  • HIE Planning and Preparation
    ONC Planning
    HIE State Plan
    Privacy White Paper
    Sustainability Plan
    HIE Procurement
    RFP Process
    Medicity Selected as Vendor
  • Experienced Vendor
    Ohio joins Delaware, Colorado, Vermont and Michigan
  • Phasing of HIE Services
    • 20 Hospitals
    • 200 Offices
    • 20 Hospitals
    • 200 Offices
    • 10 Hospitals
    • 100 Offices
    Confidential, For Internal Discussion Only
  • HIE Financing
    • Hospital Integration Costs
    • To be covered by grant funds
    • Ongoing Subscription Fees
    • Hospital fee based on annual discharge volumes
    • Physician fee will be minimal to encourage adoption
    • Optional fees for additional services such as ePrescribing or EMR Lite
  • Stakeholder engagement
  • Supporting Hospitals
    Adams County Regional Medical Center
    Aultman Health Foundation
    Barnesville Hospital
    Berger Health System
    Brown County Regional Healthcare
    Bucyrus Community Hospital
    Catholic Health Partners
    Cleveland Clinic
    Dunlap Community Hospital
    Fairfield Medical
    Genesis Healthcare System
    Health Alliance of Greater Cincinnati
    Humility of Mary Health Partners (CHP)
    Kettering Health Network
    Madison County Hospital
    Marietta Memorial Hospital
    Mary Rutan Hospital
    MedCentral Health System
    Mercer County Health System
    O’Bleness Memorial Hospital
    Ohio State University Medical Center
    Pomerene Hospital
    Promedica Health System
    Salem Community Hospital
    Southeastern Medical
    Southwest General Health Center
    St. Rita's Hospital (CHP)
    Summa Health System
    University Hospitals
    Wood County Hospital
    Wooster Community Hospital
  • Supporting Associations
    Academy of Medicine of Toledo and Lucas County
    Academy of Medicine of Cleveland and Northern Ohio
    American College of Obstetricians +and Gynecologists
    Butler County Medical Society
    Columbus Medical Association
    Ohio Academy of Family Physicians
    Ohio Chapter of American College of Pediatrics
    Ohio Council of Behavioral Health and Family Providers
    Ohio Hematology
    Oncology Society
    Ohio Hospital Association
    Ohio Osteopathic Association Ohio State Medical Association
    Ohio Ophthalmological Society
    Scioto County Medical Society
    Society of the American College of Osteopathic Family Physicians
  • Supporting Organizations
    Anthem Blue Cross and Blue Shield
    Medical Mutual of Ohio
    Unison Health Plan
    United Healthcare
    Ohio Board of Regents
    State of Ohio
    Americare Community Care
    Center for Healthy Communities
    Ohio Association of Community Health Centers
    One Community
    Ohio KePRO
  • For More Information
    Visit www.ohiponline.org
    Contact Doug Green
    Contact your OHIP regional partners