COMING: Standard Quality Measures

The Obama administration, acting in concert with the health insurance trade group America's Health Insurance Plans (AHIP), announced today an agreement to develop a standardized set of healthcare quality measures for physicians. In particular, the new quality measurement system will track care given by accountable care organizations, patient-centered medical homes, primary care physicians, cardiologists, gastroenterologists, HIV and hepatitis C care providers, medical oncologists, orthopedists, obstetricians and gynecologists.

As physician's pay from insurance plans is more and more tied to quality outcomes - did the patient get well, or will there be additional claims down the road? - a system for measuring outcomes has become necessary. In recent years, government and private health plans have been working separately, and a confusing array of different measures for different companies has been growing. The CMS/AHIP agreement will seek to create a single standard system of measurement, relieving much of the burden caused by separate systems. In their news release, acting CMS administrator Andy Slavitt stated that "this agreement today will reduce unnecessary burdens for physicians and accelerate the country's movement to better quality." Representatives of the American Medical Association and the Americal Academy of Family Physicians praised the effort.

Healthcare Reform Brews Startup Gold

As state and federal insurance exchanges struggle to open their portals to millions of new insureds, the Affordable Care Act is spawning myriad opportunities for startup entrepreneurs in the healthcare IT space.

The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 handed physicians generous incentives to invest in healthcare information technology. Unprecedented investment has been finding its way to to electronic medical record (EMR) vendors. Use of these systems has exploded, roughly doubling since 2012.

That other familiar new legislation, the Affordable Care Act, affectionately dubbed "Obamacare," seems to be awakening the sleeping giant of American capital investment, as the largest growth in the history of healthcare insurance is being launched this month. Private exchanges have offered one such opportunity, but many more are on the horizon, as healthcare providers turn to technology to cope with increases in patient services, and as new providers hang out their shingles to capture the burgeoning patient market. Coupled with the aging of the Baby Boom generation, healthcare industry fortunes have never looked so good.

Remote patient monitoring tools, including wearable sensor/transmitters, represents one of the early forays for startups. Mobile devices will monitor patients and report bio data to patients' healthcare provider teams. As the ACA changes the game from the existing volume-based model to a value-based revenue system, physicians will no longer have an incentive to order a flurry of expensive tests, but to maintain a 360-degree view of patients' health, catching threats while intervention is relatively less costly, and to prevent hospital re-admissions by remote monitoring of biometrics during at-home recovery and on an ongoing basis. Federal incentives to treat patients under outpatient conditions will be an initial major driver. A recent estimate by Rock Health pegs recent investment in this technology at $102 million.

MedTronic, a manufacturer of mobile insulin delivery technologies, recently announced FDA approval of its new "artificial pancreas," a mobile device that combines automated constant glucose testing with insulin delivery. The device, already in use in Europe, collects and can report patient blood glucose levels and insulin pump interventions on a minute-to-minute basis, and will be rolling out in the U.S. over the next year. The device does not yet transmit data, but must be downloaded.

Fitness-tracking devices are among the new direct-to-consumer devices finding acceptance in the market. Some see this development as helping to bring down the cost of mobile biometrics, and providing the data stream needed to feed the emerging preventive care and early intervention movement. The presence of such technology in the consumer market could ease consumer acceptance of more clinically-oriented mobile technologies related to population health management, a potentially enormous new segment in the industry.

Population health management encompasses tools and expertise to capture and analyze vast streams of biometric data and broader patient health information in order to identify trends that threaten particular populations. Hospitals are the current market for these tools, but new markets can be imagined among outpatient services providers of many types, in supply chain management, pharmaceuticals and medical devices, as well as government-based public health entities.

New ways of delivering primary and specialty care represent another area of growth. Concierge clinics, and clinics that cater to niche patient populations make heavy use of technology in acquiring and keeping patients, frequently commanding higher fees than broader-based clinics.

The emerging "maker community" also represents a new force in the healthcare technology and medical device development markets. New technologies that democratize the prototyping of new technologies, utilizing $35 computers, smart phones and inexpensive 3D printing, are attracting record numbers of individual inventors to the once-stodgy healthcare industry dominated by huge conglomerates like GE and 3M. What healthcare will look like after the coming boom is anyone's guess, but it will almost certainly involve more people applying more intelligence and effort to our health, and, as their achievements emerge, so may vast new wealth.

CarePrecise provides data products to the healthcare IT market, and marketing tools to vendors of health IT, medical devices, pharmaceuticals, including numerous startups.

Doctors: Will Patients Misread Sunshine Info?

The Centers for Medicare and Medicaid Services (CMS) is reassuring physicians about Physician Payment Sunshine Act reporting, saying that reporting efforts involving connections between physicians and vendors will fall largely on the shoulders of the vendors, rather than on physicians. But that's not the only issue that worries docs. Once the Sunshine data becomes public, they are concerned that it may be incorrectly interpreted by consumers and the media, leading to unwarranted witch hunts. At the AMA's House of Delegates meeting in Chicago, pediatrician Lynda Young said "The media can really sensationalize this," worrying that when information goes public, "the media jumps on it."

The Sunshine Act (Section 6002 of the Patient Protection and Affordable Care Act) is being rebranded by CMS as the "Open Payment Program," according to a June 20 article in Modern Healthcare. Quoting Dr. Shantanu Agrawal, director of the CMS data-sharing and partnership group, the agency wants to create a national transparency program for payments to physicians and teaching hospitals by drug and medical-device manufacturers and group purchasing organizations. According to Agrawal, pharmaceutical companies spent $15.7 billion in 2011 on face-to-face sales and promotional activities. But companies like Pfizer and GlaxoSmithKline have reported reductions in spending to attract doctors.

The law kicks in August 1, requiring drug and device companies to start tracking transfers of anything valued at more than $10. Physicians will be able to see what has been reported about them in the second quarter of 2014, and reports will become public on Septenver 30 of that year.

CarePrecise.com supplies accurate physician databases used by drug and device manufacturers in their Sunshine Act tracking programs.

Healthcare IT Spending Optimism

As federal support for EHR implementation ebbs, other HIT projects are crowding in to keep spending strong. Aging financial management systems will need to be replaced as pay-for-performance ramps up as a result of the Patient Protection and Affordable Care Act. The mandated switch to the ICD-10 diagnostic and procedural code set, requiring updates in IT systems, as well as more advanced coding systems to handle the vastly increased code granularity, not to mention the new technical complexities felt by state Medicaids and CMS itself, is already making good business for firms like Cognosante, a brain trust of some of the most talented healthcare IT people in the country.

BCC Research recently predicted that total spending on clinical health IT would soar to $26.1 billion a year in five years, up from $9.5 billion in 2011 and $11.2 billion in 2012. CarePrecise builds provider databases targeting various applications within the healthcare industry, including EHR, HIE, HIX and Sunshine Law (Open Payments) applications.

Joseph Conn has an excellent article in Modern Healthcare will more details.

Exchange and Medicaid IT Contract Tracker

State Refor(u)m has created a chart that tracks states' choices of firms to build health insurance exchanges and Medicaid systems, with details on technical roles performed by vendors and on some of the software components vendors will use. The chart was produced by the Office of Health Policy and Technology at the University of Massachusetts Medical School. States can help State Refor(u)m keep the tool updated by using the page's comments section to post information about similar contracts awarded in their states.

CarePrecise provides healthcare provider information to state insurance exchanges, health information exchanges, Sunshine Act programs, healthcare fraud investigations and other state and federal healthcare projects.

Visit the Exchange and Medicaid Systems Contracts Chart to see who's doing what on whose project, and to add your own.

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CarePrecise is a sponsor of Big Data for Healthcare Forum, April 29 - May 1, 2013. Join us there!

Population Healthcare Is Health Reform

Michael Christopher
Chief Chigger, CarePrecise Technology

We have heard many people say that the Affordable Care Act is not health reform, but an attempt at health insurance reform. But a broad shift in the focus and delivery of healthcare has begun, shaped in part by the ACA, and poised to bring significant change to American healthcare. At the heart of that change is population-based healthcare.

"With the Supreme Court upholding the ACA, we all now understand that population healthcare is what we're all going to be doing going forward," says Dr. Steven Davidson, senior vice president and chief medical informatics officer for New York's Maimonides Medical Center in a June 28 Modern Healthcare article. What is "population healthcare," what does it have to do with the Affordable Care Act, and what does it mean to industry vendors?

The term refers to "the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for individual patients in the context of the culture, health status, and health needs of the populations" according to the Association of American Medical Colleges. Population healthcare is a broadening of focus to see beyond the individual patient to the broad context of that patient's health issues, and to understand the issues of the patient's population to better serve both the individual patient and broader communities of patients.

This perspective becomes ever more critical when cost efficiencies are taken seriously into account, as they must be in an "affordable care" paradigm. In a Tufts Managed Care Institute's white paper on population health, we find

"Population-based care involves a new way of seeing the masses of individuals seeking health care. It is a way of looking at patients not just as individuals but as members of groups with shared health care needs. This approach does not detract from individuality but rather adds another dimension, as individuals benefit from the guidelines developed for the populations to which they belong.* Members with a particular disease must be prioritized so that disease management interventions are targeted toward those members most likely to  cost-effectively benefit.**"

The Affordable Care Act package as it now stands places the emphasis on results, rather than on specific means to obtain results. Despite what has been said by opponents, providers are given wide freedom in achieving improved quality and reach of care, and are provided with new resources, such as advanced electronic health records, paid for in part by the taxpayer. Population healthcare is a strategy for deploying these resources and creative latitudes, in a package of practical tactics and achievable objectives, and at scale.

When viewed through the lens of health reform's quality focus, public health data collection and bringing the technologies that enable collection to every point of care, population healthcare is seen as a key - if not the key - strategy for both implementing the provider side of health reform, and rewiring its financial backbone of health insurance.

* Boland P., editor. Redesigning Heath Care
Delivery. Boland Health Care, Berkeley,
1996. pp. 159-163.
** Zeich R. Patient identification as a key to
population health management. New
Medicine. 1998;2:109-116.

Now We Know: Time to implement the Affordable Care Act

As the Tennessee Medical Association puts it, there is now a "certain finality" to the Affordable Care Act following the Supreme Court decision upholding the law. A huge win for the Obama administration, the decision yesterday was like kicking a hornet's nest among conservatives. The Christian Medical Association said the decision "sounds an alarm across the country to people with faith-based and pro-life convictions" and called on Congress to repeal the law.

An article in Modern Physician characterizes the response among physicians as "mixed," but the vast majority of our MD, DO, PA and RN contacts have come down strongly in favor of the law, in one case saying "The government did something right... 50 million healthier Americans is going to look pretty good here in a few years."

Whichever political side one is on, it is now clear that work can move forward on implementing the law. The Tennessee Medical Association's statement concluded "Today's decision allows us to make more definitive plans regarding reforms to our healthcare system in Tennessee." The sentiment seems to be fairly widespread through the provider side of the industry.

Some states - among them our own Oklahoma - elected to refuse federal funding ($54 million in Oklahoma's case) to establish health insurance exchanges. The decision, taken on the part of Governor Mary Fallin, appears to have been politically motivated, but Oklahoma is, in fact, developing an exchange, without the federal dollars. An agency head, speaking with an Oklahoma radio station, said "It would have been good to have the money, so we could have a more user friendly and effective system, but we'll have something, anyway."

The justices struck down provisions in the law that would empower the federal government to force states to comply with the planned Medicaid expansion or lose all of their Medicaid funding. Now states will be eligible for basic Medicare funding even if they choose not to accept the additional dollars to provide expanded care. Numerous states have sworn to refuse expanded Medicaid funding, but it remains to be seen whether any will ultimately deny this added coverage for hundreds of thousands of their citizens. The federal dollars are being offered with no required match for three years. Medicaid is often one of the biggest lines in states' budgets, and that share is growing as healthcare costs continue to rise.