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Center Point Blog

Medicare Billing Data a Drop in the Bucket

All the hype around the release of Medicare billing data clearly points out what little understanding there is when it comes to real problem regarding healthcare data. How many patients a doctor sees, and how many Medicare bills she racks up is not helpful when it comes to improving care. It may identify certain issues related to fraud and abuse for the very few doctors who are crooks; it does nothing to identify best practice and overall resource utilization.

Fortunately, a few legislators understand the real problem. That is why I am very excited about the bill being introduced by lead sponsors, Rep. Paul Ryan (R-WI) and Rep. Ron Kind (D-WI), both of whom are Ways & Means members. HR 4418, the Expanding the Availability of Medicare Data Act allows Qualified Entities to obtain a copy of the entire Medicare data file. It also allows for release of the file to providers of care for the purposes of understanding variation. Once doctors have this data, they will be looking for best practice. This will change the game from not knowing who is the best performer, to every doctor moving to best performance. By doing so we will finally start to see quality and cost improvement for Medicare patients.

Hats off to our legislators in Wisconsin who understand the real problem.

To access an article and more information on this topic Click Here.


Disappointment Again with SGR Fix

Congress kicked the can down the road for another year this week  in a disappointing end to a bipartisan bicameral bill that would have permanently fixed the flawed doctor payment legislation. More importantly the permanent fix bill had important provisions that could have saved billions of dollars, and improved care for Americans. Link to full article

For now, we will be fighting in D.C. to add the medicare data provisions back into next year’s SGR bill. It is a shame when the right thing to do for America does not get done by our elected officials.

Experimental Management Systems

In the spring of 2008, the leadership at ThedaCare recognized they were on the cusp of a necessary cultural shift.  Furthermore, the changes that were coming, based on a series of management experiments, required a deep understanding of how problems were being solved and how decisions were being made.  Like most health systems that were applying lean thinking, ThedaCare was seeing great results, but there wasn’t a system in place to sustain their gains.  As soon as the facilitators from the lean improvement office left an area, things would start sliding back to the more traditional work methods.

So, ThedaCare decided to experiment with creating a lean management system that fit the culture of their health system.  They started by developing a steering committee to guide the development of their lean management system.  They also reviewed books like, Creating a Lean Culture, by David Mann, and researched the management systems in place at lean companies like Autoliv. Continue reading →

When More Actually IS Better

By: Julie Bartels and Mike Stoecklein

At the ThedaCare Center for Healthcare Value, we see our mission as transformation of the healthcare system to assure the delivery of consistent, high quality care, and better outcomes for patients. Transformation We envision achieving this transformation in collaboration with patients and leaders in the provider, employer, insurer, and government communities.  Together, we can create a one-piece flow of value as depicted by the diagram on the right.  But it requires involvement on several different fronts. Continue reading →

How should congress pay for the SGR fix bill?

Harold Miller provides great insights as to how Congress should think about paying for the SGR fix.

“A bipartisan, bicameral bill was announced earlier this month as the result of a joint effort by the U.S. House Energy and Commerce Committee, House Ways and Means Committee, and Senate Finance Committee to repeal and replace the Sustainable Growth Rate formula in Medicare.  There is no other industry in America that tells its key professionals that their compensation will be cut by 25% at the end of each year regardless of whether they are doing a good job or not, but that’s what the Sustainable Growth Rate formula requires in the Medicare program.  Repeal is long overdue, and the members and staff of the Committees should be commended for advancing a solution in a collaborative way. Continue reading →

Accelerating Healthcare Value through Collaboration

We’ve heard it before…healthcare costs are rising faster than quality is improving.  Significant waste in healthcare delivery persists, harming patients, providers, payers, and purchasers.  Providers who do the right thing—improve quality, reduce waste—are penalized financially in a fee-for-service reimbursement environment.  Healthcare cost and quality data are largely unavailable to purchasers and consumers, so the market can’t reward the “good guys.”  And patients’ health conditions must be addressed not just inside a clinic or hospital, but also where the root causes of our most common and costly health conditions are found:  where people live, learn, work and play.

Continue reading →

What is the role of quality managers in the lean transformation?

Recently, Melissa Mannon, a former intern at the ThedaCare Center for Healthcare Value, authored this article regarding the role of a Quality Manager in a lean organization. What you will find is that the role changes from that of being a “checker” to that of being a team member in operations. When quality is built into a clinical care process it means the inspectors go away. This frees quality managers to do value added work which includes educating, designing and observing to standard. This is an exciting and energizing role compared to the past. Melissa does an excellent job of explaining the difference with real life examples from ThedaCare. Read the article published in the American Society for Quality Journal. Reprinted with permission from QMJ© 2014 ASQ,  No further distribution allowed without permission.

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Medicare data release to providers is part of bipartisan SGR “fix” bill.

On Thursday, three committees of Congress agreed on language that would permanently fix the flawed SGR bill. The bill has sweeping changes associated with it including moving physician payment away from fee-for-sevice to “alternative payment models” such as Accountable Care Organizations and Medical Homes. It also suggests a pay-for-value instead of volume program, although the value portion of payment is not clearly defined.

The Medicare data policy is also covered. At the Center we have been working in D.C. for years on allowing Medicare data to be released to physicians for the purpose of improvement. (Read here.) In this bill Congress agrees with us. In the original ACA provision the Qualified Entities(QEs) were established to manage the use of Medicare data (as well as commercial and Medicaid data). The Wisconsin Health Information Organization (WHIO) and other All Payer Claims data bases, like CIVIC in Colorado, have been on the forefront of releasing meaningful data to providers for several years. Both organizations have become QEs recently and both have need for the Medicare data set. If passed by Congress this bill will:

  1. Allow QEs to provide or sell analyses to downstream “authorized users.” A QE could use combined data to conduct “additional non-public analyses,” as determined appropriate by the Secretary, and provide or sell those analyses to certain “authorized users” for non-public use. The list of authorized users includes: (1) a provider of services; (2) a supplier; (3) an employer who will use the analyses only for purposes of providing health insurance to its employees and retirees; (4) a health insurance issuer that is providing the QE with data; (5) a medical society or hospital association; and (6) any other entity that is approved by the Secretary. The analyses could not contain any information that individually identifies patients, except where the information relates to patients of the providers and suppliers who are receiving the analyses. Authorized users would be prohibited from using the analyses for marketing purposes.
  2. Allow QEs to provide or sell access to combined data to a subset of authorized users. A QE could provide or sell combined data to a subset of authorized users for non-public use, including for purposes of assisting providers and suppliers in developing and participating in quality and patient care improvement activities, including developing new models of care. Authorized recipients of the combined data include: (1) a provider of services; (2) a supplier; and (3) a medical society or hospital association. Employers and health insurance issuers would not be allowed to access the combined data from the QE. The data could not contain any information that individually identifies patients, except where the information relates to patients of the providers and suppliers who are receiving the data. QEs and authorized users must enter into a data use agreement (DUA), which must contain privacy and security requirements, as determined appropriate by the Secretary, and prohibitions on using data to link to other individually identifiable sources of information. Authorized users would be prohibited from using the data for marketing purposes.
  3. Allow QEs to provide, at no charge, Medicare-only claims data to a subset of authorized users. A QE could provide at no charge Medicare-only claims data to (1) providers; (2) suppliers; and (3) medical societies or hospital associations. The data could not contain any information that individually identifies patients, except where the information relates to patients of the providers and suppliers who are receiving the data. QEs and authorized users must enter into a DUA, which must contain privacy and security requirements, as determined appropriate by the Secretary, and prohibitions on using data to link to other individually identifiable sources of information. Authorized users would be prohibited from using the data for marketing purposes.
  4. Allow providers and suppliers who are authorized users to re-disclose analyses and data in certain limited circumstances. In general, authorized users would be prohibited from re-disclosing or making public any analyses or data provided to them (or any analyses the user generates from data provided to them). However, providers and suppliers who are authorized users may, as determined appropriate by the Secretary, redisclose analyses or data for purposes of performance improvement and care coordination activities, so long as the analyses or data is not made public.
  5. Require QEs to offer providers and suppliers an opportunity to review. Prior to providing or selling an analysis to an authorized user, where the analysis identifies a provider or supplier who is not being provided or sold the analysis, a QE must offer the provider or supplier an opportunity to appeal and correct errors.
  6. Assess penalties for breach of data use agreement. The Secretary would have the authority to assess a penalty on the QE in the event that the QE breaches its DUA with CMS or where the authorized user breaches its DUA with the QE. The assessment would be an amount up to $100 for each individual Medicare beneficiary whose data was disclosed pursuant to the DUA.
  7. Require annual reporting by QEs. QEs providing or selling non-public analyses or data would be required to submit annually to the Secretary a report that includes: (1) a summary of the analyses provided or sold and the total amount of fees received; (2) a description of the topics and purposes of such analyses; (3) information on the entities who receive actual data, including the uses of the data and the fees generated; and (4) other information as required by the Secretary.

This legislation (see attachment) has one disappointing feature from our perspective. It does not allow insurers to have direct access to the data set. They can request that analysis be done by the QE but won’t be able to run their own analysis. We did not advocate for this provision but it did end up in the final language. Despite this issue we are satisfied that this bill, if passed, will radically change the transparency environment in the U.S. Physicians will be able to benchmark against best practice for many health conditions. We believe cost and quality will rapidly improve as physicians see comparative data on their practices. In short, this a  triumph for patients and we urge Congress to act quickly to pass it.

Legislation: H R 4015

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Researchers Inappropriately Blast Innovation Center

An article in the New York Times recently criticized Medicare’s Innovation Center for not using placebo controlled double blind study design. According to the article:

“But now that the Center has gotten started, many researchers and economists are disturbed that it is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research. Such trials have long been required to prove the efficacy of medicines, and similarly designed studies have guided efforts to reform welfare-to-work, education and criminal justice programs.

But they have rarely been used to guide health care policy — and experts say the center is now squandering a crucial opportunity to develop the evidence needed to retool the nation’s troubled health care system in a period of rapid and fundamental change”. Continue reading →