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Interoperability: A Love Battle

03/02/2020

It is in some ways flattering that in the great anonymous corners of the world there are known faction warring for our allegiance as consumers. We feel important, valued, both good feelings. This is perhaps one of the only upsides to a role otherwise troubled by a deluge of solicitations, misleading campaigns, trash beauty products, bad food, toothpaste, fad diets, false appeals to the heart.

Being vied for becomes a bit more muddled, however, in healthcare debates, an industry in which the consumer is even less surefooted due to the processes required in really getting a firm handle on that foreign organism that is the human body (I feel confident, for instance, making decisions about the right brand of cereal, yet I’d feel less good about applying that independence to heart medicine) and all the red tape that interferes with accessibility, not to mention the dire consequences of getting it wrong. But if you pay attention, bigwigs in the healthcare industry make appeals to us as consumers quite strongly too.

In February 2020, HHS announced that it’s adopting interoperability rules put out last year by the CMS and ONC aimed at addressing access, exchange and use of electronic information, and preventing healthcare organizations from using information blocking tactics. HHS director Alex Azar said the rules are “essential to building a healthcare system that pays for value rather than procedures, especially through empowering patients as consumers.” HHS, it appeared, made the decision with us at the fore of its mind.

Over the past few years much of the industry has begun shifting away from redundant fee-for-service models toward value-based ones. This has helped lower costs by pushing treatment courses on the merit of their effectiveness, not profitability. So when HHS announced it would be implementing measures for easier data sharing that push this evolution forward it was mostly seen as positive.

Yet shortly after the publication matters were complicated when healthcare software giant Epic, out of Madison, WI specializing in EMR and EHR software storage, sent a letter signed by an unavoidably lengthy list of hospitals citing concerns over patient privacy. Founded in 1970, Epic is one of the largest storage houses of EHRs so you would not be alone in seeing their defense as mere protection of a de facto stronghold using the guise of patient privacy to conceal this special interest. A more sympathetic view might see them as experts attuned to the complexities of software storage who worry that opening data sharing up for purchase and exploration by third-party IT groups might put at risk sensitive medical information.

The notable thing, though, is how both HHS and Epic cling to the noble position of being defenders of patient and consumer interest. But mark how differently, how interchangeably, the two employ the term consumer and patient, how malleable the term is, with HHS using the language of choice, empower, and Epic, defense and protection, and both reaching antithetical opinions over what is best for us. To be a consumer in this context is to be a very important abstraction, the most important empty chair in the room.

Regardless of who is closer to the truth both parties should take seriously their claims of devotion to the consumer by investing and not hamstringing innovations that might help solve some of the irrefutable headaches that plague this industry. As patients and doctors, as consumers endowed with the power of indifference and ire, it is high time for us to stop being seen as cynical pawns in this tumultuous debate over what is best for the consumer of healthcare while being largely excluded from the conversation. We should be courted as the formidable consumer base we are and looked at as discriminating entities more than willing to turn away from inferior practices, irrespective of which of our supposed protectors is claiming to hold us dearest.

Surprise Medical Billing (Balance Billing) Potential Federal Legislation

05/28/2019

Update: Surprise Medical Billing (Balance Billing) Potential Federal Legislation

Many emergency medicine groups are currently out-of-network with major private insurers, and therefore bill patients the difference between their charges and what the insurance company paid (referred to as “balance billing”).

This scenario may cause friction with patients and hospital administrators, especially where the hospital itself is in-network with the payer. However, many emergency medicine groups believe the in-network rates offered by some private insurers are inadequate and leave them no choice but to remain non-par with those payers.

Such bills are often included under the term “surprise medical bills” because patients were treated at an in-network facility, but the provider group itself was out-of-network and balance billed the patient. Some states have already addressed surprise medical bills and pressure has mounted on Congress to take action at the federal level.

This month a flurry of activity on Capitol Hill has produced legislative drafts, hearings, and announcements focused on surprise medical billing. The Senate, House, and Administration have all announced plans to address the situation, including a number of possible approaches. All agree that the patient should be taken out of the process and be responsible for only their in-network deductibles and co-insurance.

Final legislation is likely to contain recommendations from legislative and other stakeholders, which propose various solutions, such as:

  • Set Rates: pay out-of-network providers a median in-network rate
  • Network Matching: require all hospital-based providers be contracted with the same payers as the hospital
  • Bundled Billing: prevent hospital-based providers from submitting claims or billing patients (the facility would provide a single claim, including professional fees; physicians would be reimbursed by the facility)
  • Consent: Require patient notification and consent to balance bill for out-of-network services
  • Arbitration: create arbitration processes for providers and payers disputing the amount of out-of-network reimbursement
  • Databases: create state-based databases to collect claims and payment data for all payers
  • Price Transparency: healthcare providers to furnish expected costs for services to patients in advance of treatment
  • Network Adequacy: requirements that insurers provide adequate networks

Innovative is closely monitoring the situation and will be part of a group visiting with congressional and administration officials in Washington next month regarding healthcare reform in general, and surprise medical billing in particular.

Innovative executives are actively involved in national organizations that help inform and guide policymakers on healthcare issues, including: Healthcare Business Management Association (HBMA), American College of Emergency Physicians (ACEP), Emergency Department Practice Management Association (EDPMA), American College of Osteopathic Emergency Physicians (ACOEP), Workgroup for Electronic Data Interchange (WEDI), and others.

 

The Way of All Flesh

03/25/2019

The topic of artificial intelligence (AI) is a vast and complicated one. It’s alluring to the wacky and visionary, a source of terrifying possibility to the unhinged uncle standing before the half-closed blinds and looking into the grey empty street. The experts say it’s the way of the future and when the entrepreneurial technocrats start making prophesy, it’s best, as the last twenty years have indicated, not to drag your heals too much in opposition. It’s more favorable to look into what it’s all about.

AI is, simply put, a branch of computer science that develops machine learning. This makes it seem like something you can shake hands with, be friendly. Though it’s become a hot-button topic in recent years, it’s not necessarily that new a concept. In the early 1940s Alan Turing predicted that digital computers would ultimately be sophisticated enough to engage in logical reasoning. MIT, circa 1950, dedicated a program of study to it. That was three decades before the first digital wristwatch, twenty-four years before the first pair of Nike shoes swooshed into the market, and forty-four years before Mr. Zuckerberg’s birthday.

In the chaotic world of healthcare, AI offers far-reaching possibilities geared toward addressing problems that have materialized out of our reliance on unsustainable processes and procedures. In “Patient, Heal Thyself,” Roy Smythe puts these clumsy holdovers succinctly, writing, “[w]hile modern medicine has made amazing contributions to acute care, reducing mortality and mass epidemics, the organized structure of it is not effectively serving the general medical needs of the world’s population, and those chiefly responsible for patient care—physicians, nurses, and other caregivers—are being pushed to the point of physical and psychological burnout.”

This is where experts say AI can play a vital role in protecting doctors and other medical professionals from oversaturation in inefficient practices—repetitive tests, monitoring, reliance on limited databases, workflow and administrative tasks, clinical judgments and diagnosis, image analysis—leaving them more opportunity for engagements that require keen human supervision. And of course someone will need to keep an eye on the technologies.

AI also empowers patients to play a more active part in their own care through the utilization of apps, virtual consultations, remote monitoring, and other technologies that prevent avoidable hospital visits and excessive expenses. For remote populations lacking accessible medical care, the technologies will be, in many ways, a salvation.

This all makes AI seem jolly good and warm saline sea breezes and something to anticipate, something to look forward to watching mature, like the neighbor’s five-year-old who seems to be fascinatingly competent with a tennis racket. You look forward to its adulthood. And to a large extent this promise is appropriate.

But, on the other hand, maybe we shouldn’t altogether forget that paranoid uncle tracking a residual unease, surveying the boulevards. A lot of AI’s future rests in cost-saving practices and financial incentives, not altruism. Maybe we should ask questions if the physician shows up for the pre-op consultation and explains a machine will be wielding the scalpel. Maybe we should feel somewhat unsettled when our EHRs are abstracted to some cloud-based data center to live an eternal life alongside electronic reports on other people’s bodies. Maybe we should feel dubious when we can’t get into our GP and, as recourse, a series of codified multiple-choice answers prescribes us antibiotics for our kid’s sore throat.

Subdued paranoia and articulate skepticism have always played important roles in improving revolutions in their infancies. A new form of healthcare is moving inevitably in the direction of AI technologies. The current system is unsustainable—there’s unanimity on this. But that doesn’t mean a dose of slack-jawed skepticism isn’t a boon in our approach to these new, mesmerizing technologies.

A BRIEF, UNHAPPY HISTORY OF HEALTHCARE CO-OPS: WHERE ARE THEY GOING, WHERE HAVE THEY BEEN?

One of the Internet’s gifts—and occasional annoyances!— is its space for people to self-publish their alleged expertise on a subject. Surely this must be some form of purging. I feel an odd mixture of depression and excitement toward these online message boards. The writers on healthcare forums vary from doctors, hospital executives, and private insurers, to young families whose finances have been wrecked by medical expenses.