Just yesterday, we had an update from the AAP about how healthcare reform items are taking shape in Washington.  Now, we have a new one, a little more fresh.  The most important part is the "ACADEMY PERSPECTIVE" I think.

MEMORANDUM

July 31, 2009

To:       AAP Chapter Presidents
            AAP Chapter Vice Presidents
            AAP Chapter Executive Directors

Fr:       AAP Department of Federal Affairs

Re:       Federal Health Care Reform Update

FEDERAL UPDATE:

After another weekend of meetings with the conservative Blue Dog Democrats, at the outset of this week the House Energy and Commerce Committee seemed to be in deadlock over issues regarding the cost of health care reform, the public plan option and employer mandates. Even though the Energy and Commerce Committee was tentatively scheduled to continue debate earlier this week, the Blue Dogs succeeded in postponing the Committee's action, confirming Majority Leader Hoyer’s statement at the end of last week that it was unlikely that the House of Representatives would vote on legislation before the August recess.

Despite the delay, the House did take a step forward Wednesday afternoon when House leaders announced they had come to an agreement with the Blue Dogs. Chairman Waxman’s deal with four of the Energy and Commerce Committee Blue Dogs cuts more than $100 billion from the bill, prevents a new public option from using Medicare rates to reimburse providers and exempts small businesses with payrolls of less than $500,000 from a new employer mandate, among other changes. Following the announcement, progressive Democrats in the House expressed their concern and disappointment over the House leadership’s willingness to surrender several key provisions in the legislation, particularly the weakening of the public option. Moreover, the Blue Dogs received an assurance that the full of House of Representatives would not vote on health care reform before the August recess, insisting that they needed to review the full legislation and discuss it with constituents during the district work period.

We expect the Energy and Commerce to pass their legislation later today.

The Energy and Commerce Committee assembled Thursday morning to debate amendments to the America’s Affordable Health Choices Act (HR 3200). During the morning session, they considered seven amendments. Two of the amendments agreed to will strengthen the current legislation by improving the health and well-being of children.

These two amendments include:

· An amendment introduced by Jerry McNerney (D-CA) and Tim Murphy (R-PA) to improve access to health care for children by preventing enrollment waiting periods for children who lose insurance due to parents’ job loss; preventing waivers to enroll children who are uninsured due a reduction or elimination of parent’s work hours; and expediting enrollment for children in families whose health costs exceed 10% of income.

· An amendment introduced by Tammy Baldwin (D-WI) to improve Medicaid coverage for children and young adults through the expansion of therapeutic foster care.

The Committee also rejected two amendments that could have threatened children currently enrolled in CHIP and Medicaid and limited children’s ability to access quality health care:

· An amendment offered by Rep. Nathan Deal (R-GA) to expand the citizenship documentation requirement established under the Deficit Reduction Act to apply to all newly enrolled Medicaid beneficiaries. The amendment was defeated by a vote of 28-29.

· An amendment proposed by Reps. Joe Barton (R-TX) and Nathan Deal (R-GA) to provide families and children eligible for Medicaid and CHIP with premium assistance to purchase private insurance. The amendment was defeated by a vote of  21-33.

Recognizing the concerns of many child advocates and pediatricians over the potential elimination of the CHIP program, Energy and Commerce Committee Vice-Chair Diana DeGette (D-CO) , plans to introduce an amendment which would require the HHS Secretary to submit a report to Congress by December 31, 2011, comparing the coverage that would be offered in an Exchange plan (new plans that would be available under the insurance Exchange structure established in the legislation) to the coverage offered by an average CHIP plan. The Secretary would examine the benefit package, cost-sharing, and the adequacy of provider networks to ensure that the coverage offered under the Exchange is at least comparable to the coverage offered by an average CHIP plan. The current legislation would transfer children currently enrolled in CHIP into the Exchange when the CHIP program expires in 2013; under this amendment, no child would be enrolled in an Exchange plan unless the Secretary certifies that the Exchange plans will provide comparable coverage.

Due to ongoing negotiations in the Senate Finance Committee, Senator Durbin (D-IL), Majority Whip, stated last week that the Senate would postpone any vote on health care reform until after the August recess. Finance Committee Chairman Max Baucus (D-MT) continues to meet with three Republicans (Finance Committee Ranking Member Charles Grassley and Senators Olympia Snowe, and Mike Enzi) and two Democrats (Senators Kent Conrad and Jeff Bingaman) to craft a bipartisan bill. Senator Enzi, meanwhile, emphasized that no deal was imminent, and legislative language had not been crafted for many provisions. While many Senators, including Democrats, are frustrated with the process in the Finance Committee, the six Senators in negotiations have assured their colleagues that they have made significant progress, but also that they want to make sure they come out of negotiations with a strong, cost effective and bipartisan compromise. Despite pressure from their colleagues, Chairman Baucus stated late Thursday that the bipartisan coalition has yet to reach a deal and as a result the full Finance Committee will not consider legislation next week. The Committee will reconvene after the four week summer recess

THE ACADEMY’S PERSPECTIVE

The Academy's goals for health reform are to achieve coverage for all children; age-appropriate benefits in a medical home; and appropriate payment.  We strongly believe that no child should be worse off after reform, and if all of these things can be achieved, many children and pediatricians stand to benefit from the reform effort. While the Academy has not endorsed any specific piece of legislation, AAP has provided direct feedback to the specific House and Senate committees on the bills and is supportive of the overall process.

 
As an example, when the three House Committees issued a first draft of legislation, AAP responded with a letter commenting on the positive and negative provisions included.  The following list includes several positive aspects that come from the AAP comment letter (many of which are included in updated version of the legislation, HR 3200):

    * Prohibiting Pre-Existing Condition Exclusions (Sec. 111 in the draft bill).
    * Payments to Primary Care Practitioners (Sec.1821. in the draft bill).
    * Medicaid Medical Home Pilot Program - $1.235 billion over 5 years (Sec. 1822. in the draft bill).
    * Recognition that outreach to special populations, including children, is essential to improve enrollment (Sec. 205(a)(1) in the draft bill).
    * Recognition that a child's medical home should not change due to a process of automatic enrollment (Sec. 205(b)(3)(A) in the draft bill).
    * Recognition that some families will need culturally and linguistically appropriate assistance in signing up for Exchange plans (Sec. 205(c)(3) in the draft bill).
    * Recognition that services such as well-child services may not be listed in Medicare fee schedules, and should be included in new insurance products (Sec. 223(a)(3) in the draft bill).
    * Recognition that primary care pediatricians would not be eligible for increased payment rates stemming from Medicare changes but for Sec. 223 (b)(1)(C) in the draft bill.
    * The inclusion of dependent coverage in the employer mandate (Sec. 312 in the draft bill).
    * Allowance for ERISA plans to elect to be subject to health coverage participation requirements (Sec. 321 in the draft bill). Pediatricians report that they currently have difficulty obtaining immunization payments from ERISA plans, and this should alleviate that situation to some degree.
    * Inclusion of family coverage in the individual mandate (Sec. 401 in the draft bill).
    * Streamlining of enrollment procedures and other steps to make it easier for children and families to obtain insurance. (Sec. 501 in the draft bill).
    * Inclusion of different age groups in research priorities as designated by the Center for Comparative Effectiveness Research (Sec. 1401(c)(4) in the draft bill).
    * Inclusion of tobacco cessation drugs in Medicaid coverage for enrollees and particularly for pregnant women (Sec. 1812 in the draft bill).
    * Inclusion of grants and an option for states to fund nurse home visitation services as well as family planning services (Secs. 1704, 1813 and 1814 in the draft bill).
    * Increased funding for electronic eligibility systems (Sec. 1833 in the draft bill).
    * Workforce solutions for primary care pediatricians (Secs. 2212-2215 in the draft bill).
    * Enhancement of cultural and linguistic competence through training grants (Sec. 2251 in the draft bill).
    * Funding for the prevention and wellness trust, and the inclusion of a child and adolescent health professional on the Task Force on Clinical Preventive Services (Sec. 2301 in the draft bill).
    * Expansion of the 340B program to allow discounted drugs to be purchased by children's hospitals and Title V grantees (Sec. 2501 in the draft bill).

While there are clearly many positive provisions within H.R. 3200, there is a reason AAP has not endorsed the bill. For example, H.R. 3200 includes new federal funding to increase Medicaid payments for primary care services to be, at a minimum, 100% of Medicare rates.  This provision was originally drafted to apply to all primary care providers, which would have included nurse practitioners.  The Academy was successful at urging Congress to change this section to apply only to the provision of services by physicians paid for by primary care codes.  Thus, pediatric specialty surgeons and subspecialty physicians could also receive the increased payment from the primary care codes while nurse practitioners would not be eligible.  Even with this win, the Academy does not believe that this provision goes far enough, since the provision should apply to all Medicaid payments to physicians.  The Academy is working to improve many components of this and other health reform legislation.

There have also been some misleading press reports on the issue of the ability of physicians to privately contract with those they care for. H.R. 3200 does not make private insurance illegal.  Rather, one main thrust of the legislation is the regulation of health insurance coverage in the individual and micro-group markets.  It is true that except for some "grandfathered" existing policies, individual coverage could only be offered through the Health Insurance Exchange established by the House bill.  (The Health Insurance Exchange is a regulated market place for people to purchase private coverage that meets minimum criteria. It is called the "Gateway" in the Senate HELP committee legislation). This provision responds to the fact that there have been many problems with the individual market, and there is a strong consensus that these plans do not work to the benefit of enrollees or physicians. (See http://www.eurekalert.org/pub_releases/2009-07/cf-nri072009.php). It is likely that the provisions regarding a reformed individual and micro-group market in the legislation would make great strides in regulating insurers so that they treat patients and providers more fairly.

The Academy will continue to work in the hopes that the best provisions for children and pediatricians from the three bills are included in the final product and improved along the way. But we can not do it alone! That is why we need your help to keep the momentum up and our message heard!

WHAT CAN YOU DO?

The upcoming August recess will be critical. Significant behind-the-scenes work will continue with Congressional members, but it also provides AAP an opportunity to turn up the heat in their districts. We must continue to act on behalf of our nation's children, and continue to remind our Congressional members of the importance of providing children with the services they need and deserve in health reform.

ACTION STEPS:

   1. Call your local district offices to schedule a meeting during the August recess. The time members spend in their districts in August is critical—it is imperative they hear from as many pediatricians as possible in the coming weeks!

   2. Call or email your member of Congress and tell them that children need comprehensive health care reform, and we must get this done!

   3. Submit an Op-Ed to Your Local Newspaper. You can find suggested talking points and suggested tips on submitting an Op-Ed by logging into the AAP Members Center and clicking the Health Care Reform.

   4. Forward this memo to other AAP Members!

Learn more about the issues in health care reform! Log on to the AAP Members Center Federal Advocacy Page to get the latest background information and tools you need to make a difference!

    * AAP Health Care Reform backgrounder
    * AAP Access Principles
    * AAP Priorities on Health Care Reform
    * Talking Points
    * Chapter sign-on letter
    * Specific Senate and House legislation and official AAP responses
    * Kaiser Family Foundation side-by-side of the Senate and House legislation

Become a Key Contact! Unlike regular FAAN emails, Key Contacts receive regular, more specific emails from the Department of Federal Affairs, keeping them informed about the latest developments and ways to get involved.

Key Contacts are AAP members who have agreed to take their advocacy to the next level. By becoming a Key Contact, you will receive important assignments and can provide critical information to AAP based on your results. In the coming months, we will be calling on Key Contacts with specific requests to make an impact on the health care reform debate. Being a Key Contact requires a very small time commitment but can yield big results! Join today by logging into the AAP Members Center and going to the Federal Advocacy page.

The Department of Federal Affairs is here to support you, and we are more than willing to answer any questions you may have. Please contact Claire Bornstein (hidden@email-address) or Erin Howard (hidden@email-address) if you have any questions.
 

OK, I admit that I missed the original headline.  I was busy in FL at the Users' Conference.  But here it is:

UnitedHealthcare Buys Some Health Net subsidiaries

Bottom line is that UHC picks up Healthnet's business in the northeast.  So, New Jerseyites and New Yorkers, remember that awesome UHC-Oxford merger?  How'd that work out for you?

Susanne Madden, who actually clued me into this, said the following:

If you par with UHC, expect to see HealthNet business roll under the same policies and reimbursement as UHC (unless the fee are less and the policies more restrictive), increasing the amount of your business done with UHC (e.g. if you have 20% UHC and 20% HealthNet, UHC will now own 40% of your business); and if you par with HealthNet but not UHC, you might likely have to (though according to them, that's only 5% of HealthNet's providers).

Fortunately, UHC assures everyone that all will go just fine.  Just like all their other mergers.

How this isn't restraining trade in the form of delivering healthcare in the north east is beyond me.  Boy, two docs get together and compare prices and they can go to jail.  These folks can own a 20-50+% of dozens of practices in northern NJ and no one cares.

Today, I share a memo from the Federal Affairs desk of the AAP that pediatricians and their staff should consider.   Normally, I gloss over stuff like this (admit it, you do, too), but the comments Obama has made about child health are important and I think this is the time to make your voices heard.  We saw CMS make some changes as the result of private pediatric feedback promoted on this blog, so we know that input is valuable.

Questions?   Contact info is at the bottom.

MEMORANDUM

July 24, 2009

To:       AAP Chapter Presidents
            AAP Chapter Vice Presidents
            AAP Chapter Executive Directors

Fr:        AAP Department of Federal Affairs

Re:       Federal Health Care Reform Update

FEDERAL UPDATE:

After a weekend of meetings with the conservative Blue Dog Democrats, the House Energy and Commerce Committee reconvened late Monday to debate and vote on amendments to the America's Affordable Health Choices Act (HR 3200). Even though Energy and Commerce was scheduled to continue debate through Tuesday and Wednesday of this week, the Blue Dogs succeeded in postponing the Committee's action to negotiate with Democratic leaders on cost savings, mandates on small businesses and the proposed public option. President Obama invited the Energy and Commerce Blue Dogs to the White House Tuesday afternoon to listen to their concerns and forge agreement on how to move forward.

Late Tuesday, Chairman Waxman (D-CA) announced that negotiations among Democrats may have reached a "turning point" with the agreement to create an independent board to evaluate and influence payment rates in Medicare similar to the existing Medicare Payment Advisory Commission (MedPAC). President Obama has endorsed a proposal by Senator John D. Rockefeller IV (D-WV) to strengthen MedPAC and make its recommendations law unless rejected by Congress. Despite support from members of the Energy and Commerce Committee, those committees with jurisdiction over Medicare (Senate Finance Committee and House Ways and Means Committee) have opposed to the idea for fear that the board could impose cuts that result in reduced services.

Republicans and Democrats in both chambers have expressed concerns regarding provisions in the bill as well as the speed with which President Obama and Democratic leadership are moving forward. On Friday six senators sent a letter to Senate leadership voicing their concerns over the timetable for floor action in the Senate. The six senators, Senators Snowe (R-ME), Collins (R-ME), Lieberman (I-CT), Ben Nelson (D-NE), Landrieu (D-LA) and Wyden (D-OR), represent some of the centrist/moderate Democrats and Republicans in the Senate. If health reform is to succeed it is imperative that these moderate members, especially the four Democrats that signed the letter, support the final health reform package.

The contention amongst Democrats in both chambers is causing party leaders to soften timelines for the legislation. Speaker Pelosi announced Wednesday that while she has no doubt that she has the votes in the House to pass legislation, whether or not they vote before they adjourn for the summer recess on July 31st remains to be seen. Due to ongoing negotiations in the Senate Finance Committee, Senator Durbin (D-IL), Majority Whip, stated late Wednesday that the Senate would postpone the vote until after the August recess. Chairman Baucus continues to meet with three Republicans, Senators Snowe, Ranking Member Grassley and Enzi to craft a bipartisan bill. Senator Hatch (D-UT) was a regular participant in the negotiations, but announced Wednesday that he has stopped attending the sessions.

 

On Monday, President Obama addressed a small group of pediatricians, nurses and a physician's assistant at Children's National Medical Center in Washington, DC. One of the points he raised during his remarks was the steady increase in the volume of visits to emergency departments (ED), specifically the impact these increases have on pediatric emergency visits, shrinking access and under-insurance, and the added burden and expense that unnecessary pediatric ED visits represent. Additionally President Obama spoke to the strains our health care system places on parents with sick children. Many families, even those with health insurance, can't afford routine visits for their children. Mr. Obama also mentioned that poor payment rates for pediatricians and primary care doctors contribute to barriers to care.

On Wednesday, to rally public support for overhauling the nation's health care system, President Obama convened a primetime press conference at the White House. Following days of reports regarding the divisiveness in Congress, Mr. Obama used the news conference to take his message out of Congress and straight to the public. He said for the first time that he would be willing to help pay for the plan by raising income taxes on families earning more than $1 million a year, and is opposed to taxing middle-class families. Additionally he signaled that he was also receptive to another idea under consideration in the Senate: taxing employer-provided health benefits, as long as the tax did not fall on the middle class. During his speech Mr. Obama reaffirmed several key points:

·       Overhauling the nation's health care system would benefit Americans and strengthen the economy.
·       A new health care system would be a necessary improvement, and will implement reforms that work for the American people.
·       American's that have insurance that they like will be able to keep it.

WHAT CAN YOU DO?

We must continue to act on behalf of our nation's children. Even though your members are working hard in Washington, they need to hear from you. Over the next weeks members of Congress and advocates in DC will be working to hammer out legislation and as a result we need to regularly reaffirm the importance of providing children with the services they need and deserve in health reform.

ACTION STEPS:
   1. Call you local district offices to schedule a meeting during the August recess. Even though the recess is still a month away, schedules fill up quickly.
   2. Call your member of Congress and tell them that children need comprehensive health care reform, and the time to pass health care reform is NOW!
   3. Submit an Op-Ed to Your Local Newspaper. You can find suggested talking points and suggested tips on submitting an Op-Ed by logging into the AAP Members Center and clicking the Health Care Reform.
   4. Forward this memo to other AAP Members!

Learn more about the issues in health care reform! Log on to the AAP Members Center Federal Advocacy Page to get the latest background information and tools you need to make a difference!

    * AAP Health Care Reform backgrounder
    * AAP Access Principles
    * AAP Priorities on Health Care Reform
    * Talking Points
    * Chapter sign-on letter
    * Specific Senate and House legislation and official AAP responses
    * Kaiser Family Foundation side-by-side of the Senate and House legislation

Become a Key Contact! Unlike regular FAAN emails, Key Contacts receive regular, more specific emails from the Department of Federal Affairs, keeping them informed about the latest developments and ways to get involved.

Key Contacts are AAP members who have agreed to take their advocacy to the next level. By becoming a Key Contact, you will receive important assignments and can provide critical information to AAP based on your results. In the coming months, we will be calling on Key Contacts with specific requests to make an impact on the health care reform debate. Being a Key Contact requires a very small time commitment but can yield big results! Join today by logging into the AAP Members Center and going to the Federal Advocacy page.

The Department of Federal Affairs is here to support you, and we are more than willing to answer any questions you may have. Please contact Claire Bornstein (cbornstein@aap.org) or Erin Howard (ehoward@aap.org) if you have any questions.

This is the blog that was never meant to be.  Two times, now, I have lost the entire thing just before posting due to a quick trigger finger.  Ay yi yi.  I will fight the WWW Gods, though, and make it happen.

CCHIT Update #1: After my comments from the CCHIT meeting recently, one of our co-Chairs, Dr. Jeannie Marcus, sent me an interesting response correcting or updating some of my comments.  Although we disagree on one or two issues, her insight was helpful and interesting.

I asked if I could post her message here, and she graciously agreed.  She was worried that it might look like she's attacking me and I assured her she's not (not even close...I appreciate the feedback).

At this point, I promptly deleted her email message.  See how this blog entry is cursed?

With her help, we have reconstructed PART of the message here.  Some of the good points are missing (particularly ones I agree with), but it's better than nothing.  Her original message is indented.

From: Chip Hart [mailto:chip@pcc.com]

Sent: July 20, 2009 1:06 AM
To: Eugenia Marcus
Subject: Re: CCHIT clarification

> The CCHIT data as I know it. This year they went from 9 workgroups to 16

> which accounts for so many more people involved. The increase in the

> workgroups reflect the increase in the scope of work.

That certainly makes sense.

> I personally recruited a whole bunch of people to apply the way I recruited

> you last year. Most of the people I recruited made it on to a workgroup.

From a pediatric perspective, I think it paid off. 
[Dr. Marcus was instrumental in getting me on the committee last year.]

> Bonnie told me that one third of each

> workgroup is experienced CCHIT people and 2/3 are new to CCHIT except

> Child Health where we have 2/3 returning.

I find that interesting!  I understand it's a tough entry this year - 
I heard some interesting stories from people within CCHIT about 
the political issues...no more than 3 from a vendor, etc

> I don't know that the stimulus money created an

> increased interest.

Without asking, we'll never know...but *everyone* I know (except you)
told me they feel that way.  Sure - folks like BillZ and John Sutter
aren't there for the money, but all of the intense competition I heard
from other CCHIT folks sure seemed driven by it.  I even heard it from
the CCHIT folks themselves!

I hope you took note of my anti-anti-vendor comments.  I'm no fan of
NextGen (how can I be? :-)), but I think they belong at the table and
are no more self-protective than those other companies who aren't
software vendors.  Most of the organizations at CCHIT who aren't
software companies are SO MUCH BIGGER than all but 6-7 of the software
companies.  That drives me crazy.

> I just think there were more opportunities and

> people were beginning to appreciate the work being done.

I think the increased opportunities is an interesting point that I
hadn't considered...but I don't know how you can consider the stimulus
package anything but the primary motivator!

> I, for one, think that I am contributing to the health of all children

> (not just the patients I see one at a time) by helping define the

> functionality of EMRs that will guide the care of children.

Well, I'm with you on that.  There's no money in this for me or PCC,
that's for sure...but I want it done RIGHT.

Thank you for the candor, Dr. Marcus.

CCHIT Update #2, the folks over at histalkpractice.com have a fun interview with Dr. Christoph Diasio, PCC-client extraordinaire, where he addresses EHR (f)utility, certification, and more. It's been making the rounds among AAP members.

I might be at an all-time backup on blog entries, but wanted to share this article quickly.  After doing two classes about this very example here at the UC in the last 24 hours, Lynn sent me this piece about the very example I use!  Way to go, Lynn.

From the Central Pennsylvania Business Journal:

Pay for performance: Health insurers seek money's worth

Two years ago, nearly one out of every 10 patients at Eden Park Pediatric Associates
was overweight. About 1 percent of patients at the Lancaster County practice had hypertension and 28 percent had high cholesterol.

Those
are alarming numbers, especially in light of what they could lead to in 30 or 40 years. So Eden Park decided to do something about it.

The practice used Pittsburgh-based insurer Highmark Inc.’s pay-for-performance program, called QualityBlue, as a springboard to improve care.

“The
physicians are amazed,” said Lynn Cramer, the practice administrator and a board-certified pediatric nurse. “They never thought we would be able to impact (patients) positively to the degree that the program has allowed us to.”

Pay-for-performance programs, in which providers’ reimbursement is tied to patient care, have grown nationwide over the past decade and have been proposed as part of federal health
care reforms.

Capital BlueCross spokesman Joseph Butera said the Susquehanna Township, Dauphin County-based insurer plans to roll out its own pay-for-performance initiative this month.

“Capital BlueCross recognizes that pay-for-performance initiatives are increasingly becoming an important part of the business relationship between a health insurer and its providers,” Butera wrote in an e-mail.

He declined to elaborate on details of the program before its official launch.

The term “pay for performance” encompasses several types of initiatives,
said Lynn Leighton, vice president of health services for the Hospital & Healthcare Association of Pennsylvania (HAP).

For the past five years, Medicare has paid hospitals for reporting certain quality measures, she said. A few years after that, Medicare added a second piece to its pay-for-performance program by imposing reimbursement penalties for certain undesirable outcomes, such as high rates of hospital-acquired infections.

A third piece of the pay-for-performance puzzle, which has been proposed for Medicare but hasn’t been passed, is using increased reimbursements as incentives for achieving certain measures or for showing improvement.

Commercial insurers have taken similar approaches to pay for performance. Some pay
— and penalize — based on performance, others provide additional payment for improvements, and a third group mixes the two, Leighton said.

Pay for performance is growing among commercial providers, Leighton said, though she said she didn’t have exact numbers. She predicted other segments of the health care field, such as home health care agencies and nursing homes, increasingly will adopt these models as well.

The advantage of pay-for-performance programs is they ensure all parties are working toward the same goals, she said.

For
Highmark’s QualityBlue, providers get points based on how close to — or far above — they are compared to the local rate for a certain set of procedures, such as proscribing generic drugs, providing breast-cancer screenings or installing electronic medical records.

Providers also can earn points by using best practices to develop processes that target a practice’s trouble spots, such as childhood obesity at Eden Park Pediatric Associates. Points are then distributed based on progress made toward program goals.

The points translate to varying amounts of reimbursement above the set rate. Data is compiled and compared quarterly.

The program began in Western Pennsylvania in 2002 and reached Central Pennsylvania in 2006, said Dr. Carey Vinson, Highmark’s vice president of quality and medical performance management. Enrollment among physicians and hospitals is voluntary.

About 1,400 physicians in Central Pennsylvania — more than half of the region’s primary-care providers — are using QualityBlue, according to Highmark.

“We believe this does two things. Number one, it helps clinical care in all-round delivery of service. We want the standard of care to be promoted,” Vinson said. “It also helps primary-care providers who do a superior job to be recognized and get rewarded.”

Vinson said Highmark has seen encouraging results. For example, before QualityBlue, the generic prescription rate among Highmark’s Central Pennsylvania providers was 48 percent. By the last quarter of 2008, that rate had increased to 68 percent.

Highmark is seeking to improve the program, Vinson said. A few areas it aims to remedy are the facts that QualityBlue doesn’t take into account improved patient outcomes, doesn’t include specialists and, because it’s based on claims filed, in
some cases depends on whether patients take advice from providers.

At Eden Park, staff members used best practices to develop a formal protocol for combating childhood obesity, including measures such as scheduling regular appointments, charting patient information at every visit and using lab screening results.

At the end of the first year, 3 percent of patients with obesity had “problem resolved” written on their charts, Cramer said. None of the patients with hypertension
had their condition progress, she said. The practice is compiling more data on results next month, she said.

“Before, we thought we were addressing pediatric obesity, but it did not involve every person from the one who answers the phone to the pediatrician. It was not done in a coordinated manner where all problem issues were captured,” Cramer said. “Everyone thought we were doing it, but no one was doing it well.

The key is that Highmark’s program gives providers extra dollars to improve care, Cramer said.

“There has to be money there to establish good, preventative programs,” she said.

Some live-blogging from CCHIT.

My comments below are my off-the-cuff notes about what I saw and heard today and yesterday at the CCHIT meeting.  I certainly expect that some of what I report here is wrong or misinterpreted and I welcome any feedback either way.  I don't intend offense to anyone and have no interest in somehow undermining my effort.  That said...

- CCHIT membership has changed quite a bit this year.  I may have the numbers wrong, but only 2/3 of last years' members are back, the impression is that most of them re-applied, but weren't invited.  There are ~80 members from last year and 150 new members.  Nearly 630 people submitted ~1120 applications.

On a related manner, the audience (thanks, Sue) figured out that CCHIT just signed us up to a 2 year committment, not the one year we expected.  I think that's actually a good thing, given how much institutional knowledge they may have just lost this year - were 1/3 of
the members really not functional?

- The table I was at, Child Health, was by far the most talkative again this year.  Not only did we do the most whispering, nearly everyone at the table addressed the room a few times. There were nearly 50 tables in the room, perhaps 40 of them said nothing.  Peds DOMINATED. According to Dr. Marcus, there are 29 pediatricians - more than 10% of the entire group - in CCHIT and Dr. Zurhellen said nearly 70 treat children directly. Crazy!

- Mark Leavitt (my sneak photo of him during the opening is over there on the left) mentioned that the massive increase in applications this year means "they must be doing something right" which is, unfortunately, demonstrably bogus. I don't think the increase in applications is an endorsement of CCHIT by the volunteer public, but a direct reflection of the stimulus package.  Does anyone think that the applications would have gone up 2.5x without it? Not at my table, they didn't.

- I find it interesting that 60% of the CCHIT certified vendors are < $10m and 25% are under $1m.  Which leads me to this rant:

The bashing of vendors both within and outside of CCHIT is bogus.  Vendors aren't only the software companies.  Every one of those hospitals, IPAs, health systems, etc. at the table - Taconic IPA, Parkview Health Systems, and so forth - DWARF most of the vendors getting certified.  Does anyone think an IPA or health system is there simply for the greater good?  No way - they are there to protect their turf, their members, their money.  And you'll have a hard time convincing me that most hospitals/IPAs/health systems are any less immoral/corrupt/etc. than the majority of HIT vendors (bad as they are).  Let's be real about it - yes, there is some big vendor control at CCHIT, and that's not entirely a bad thing.  They're key stakeholders.  But the other interests in the room are even bigger - non-profit doesn't mean "good guy."

    Lest anyone get the wrong impression, I'm not even sure I count as a vendor, so I'm not being defensive.

- I don't have the time to do this, but if you want to check for influence, someone do a body count of who the chairs of each committee are.  They have a LOT of control over what happens, priorities, etc.  Are the chairs only 30% vendor-driven?  Can't tell, but if you want to look for sneaky influence, look there.

- I was glad to have ML be direct on the matter of EHR-S.  It's fraud protection.  I'm sure it's spelled out in their materials somewhere, but I've had to simply follow that implication all along.  Nice to have someone say it.

In fact, his description of the EHR-C, EHR-M, and EHR-S models is exactly what I think I'd suggest if I were forced to follow this certification model.  In fact, it's a clever and sophisticated methodology and I applaud CCHIT for the effort.

That said, I am acutely aware of both the criticisms of the models (Dr.  Borges' piece on-line is a good one) and the potential impossibility of, in particular, the EHR-S model.  How are they going to review the 10K sites that might want it?

- I also approve CCHIT's recent maturity and recognition of their weaknesses.  For the first time, I heard ML say (though I'm sure he's said it elsewhere, often) that the "one size fits all" model they put together in 2005 simply wouldn't work.  We brought this issue up at the meeting last year and it didn't get much traction.  He also implied that some of the newer paths to certification, namely the -M and -S, would have more than the binary gradiation of Certified/Not-certified...long overdue, in my book.  He ALSO added that they are going to make the scripts more generic so that the different specialties can provide input and focus.  His example was pediatric, which was nice.

- They are also getting rid of "version lockdown."  In other words, if someone gets certified, they can continue to improve the product and re-number it and NOT have to go through re-certification.  As he said, "If a product stops providing meaningful use, the users will let the vendor know and the problem will be fixed."  Another new one for me - the first time I've heard the use of market forces trusted by CCHIT.  Good news.

- Bobbie Byrne is a great addition to the CCHIT team.  Sure, I'm biased (I think she helped keep me on the committee), but she's a naturally funny and engaging speaker...who doesn't waste time.  More than that, she's about the only speaker from CCHIT who doesn't seem defensive.

- In the middle of the meeting, there was an uncomfortable back-and-forth with the behavioral health folks.  It culminated with ML saying into the microphone something like, "...there's a reason why you were the only group who worked for an entire year on the project and couldn't hand something in."  I thought it was incredibly thoughtless, myself - even if it's true, is that how you want to talk to them publically?  Especially when CCHIT might be part of the problem?  He apologized a minute or two later for any "misunderstanding," but he'd already showed more than a flash of his infamous style.  I'm sure this will get me in trouble, but I find that behavior scary and a bad sign of leadership.

- During the presentation, I learned, the Child Health segment will cover inpatient visits in 2011 or 2013, which was news to me and, I think, everyone else on the committee.

- Bill Zurhellen got up and said something which drew a round of applause.  "If our goal is to certify to get ARRA payments, we're doing the wrong thing.  We should be focusing on improving health care."  ML replied, "We should consider changing the mission statement to reflect healthcare outcomes and improvement..." because, right now, the mission statement is focused solely on improving HIT use.  It doesn't actually reflect the greater intent to improve healthcare.  Balanced against his reaction to the behavioral health folks, this was a sign of GOOD leadership - not just because I agree with him, but because he handled this critique very differently.

Day Two:

- CCHIT changed its name a few months ago?  The acronym is the same, but the name is different.  I missed what the old one...

- We watched this hysterical and clever video:

  http://www.rossmartinmd.com/2009/05/hitech-interoperetta-in-three-acts.htm

  Worth it to get to the end.

- We got the C-C-H-I-T pronounciation talk again.  Ha ha ha.

- I didn't realize, but should have, that CCHIT also owns ehrdecisions.com and phrdecisions.com.  And a twitter account.

- Their communication policy is a LOT MORE CLEAR this year and I can't argue with it.  If you're speaking for yourself or your company, do what you need to do.  If you're speaking for CCHIT, then you need to clear it with them.  No early disclosure of information, even to your employer (yeah, right...like that's happening).  No "cheating."  I'm OK with that.

They also encourage us to respond to or alert them of "misinformation" that we read on other blogs, tweets, etc.

Hence, my blog today.

- The "set up" data for testing is going to get more fluid with the ability for the specialist groups to provide more input.

- The first test pass rate is over 90%.  No surprise, it's an open book test with the teacher helping.

Spent a lot of time arguing about the Meaningful Use information that got cleared today.  I think our Child Health crew suffers the most in this regard, because it's completely adult-health skewed and trying to figure out what to do with it.

My apologies for the long absence.  I've been ridiculously busy getting ready for next week and have been on the road too much. 

The real reason I haven't written is that I've had a bizarre attack of self-conciousness...normally, this blog is a purely solipsistic exercise and I do not think much about people actually reading it.  However, three times in the past two weeks I have had people on the phone or in person suddenly say, "Wait a second!  You're that guy who posts on the coding lists/MGMA lists/PedTalk/your blog!"  Fortunately, they've warmed up considerably once they realize they "know" me, which is quite flattering...or, they're awfully polite.  Probably the latter.

My lack of input isn't due to a lack of content.  For example, let's explore everyone's favorite topic, hospital discharge coding.  OK, 1/2 of my readers just left.  For those of you who stayed, Q asked me the following back in June:

The June 2009 AAP Coding Newsletter brings up a good question about
whether practices are billing for hospital discharge services properly. 
They're losing money if they report Subsequent Hospital Care of a Normal
NB (99462) when they should bill Discharge Day Management (99238 or 99239).

How're our clients doing?  Total Hospital Visits vs total number of
99238's and 9's combined should be a fair gauge,  yeah?

Yeah, I think so.  If I follow the logic properly, there should be at least one Discharge Day Management for each kid who goes into the hospital.  You might rack up a couple Subsequent Days, of course, for a multi-day stay, but it's nice to know what the ratio is. 

Why is this important?  A 99462 is worth ~.83 RVUs in 2009 while the 99238/9 are worth 1.83 and 2.65 respectively.  In other words, somewhere between 2-3x as much.

Igor went to work (I love it when everyone else does the shoveling) and came back with some interesting preliminary info. We took a big sample of PCC clients and counted up their hospital visits (9943X and 9946X) and counted up their discharges (99238/9) and sorted them.  I subjectively grouped the clients into thirds based on hospital volume and discovered this:

So...those who do fewer hospital visits are better at coding discharges?  No so fast, I suspect.  I'll bet that many of those smaller groups, by virtue of doing far fewer hospital visits, are less likely to have those kids with long stays?  I don't know, I have to work with Igor some more.  

What was REALLY interesting, though, was the variance in discharge use.  We clearly have some clients whose coding we need to go fix (a job for Q!)...one practice, for example, had over 650 hospital visits and only 19 discharge codes.  Another practice had 21 hospital visits (solo doc)...and one discharge.  Meanwhile, more than 10% of our clients had more discharges than total visits!  How does that happen?  Anyone?

I can look at revenue effects if anyone is interested.  Q: let's make some client phone calls and get these practices some well earned money!

Off to CCHIT on Wednesday.