The Trump Effect on Mega-Mergers


In the latest issue of Verden ViewPoint we discussed the likely impact of proposed health insurance company mega mergers. It remains to be seen how the election of Donald Trump could affect the deals between Anthem & Cigna, and Aetna & Humana but it’s entirely possible that a Trump administration would be pro merger.

With the Anthem/Cigna deal already before the courts and the Aetna/Humana trial scheduled for December, it’s fairly safe to assume that decisions in both cases will be made before Trump is set to take office in January but that likely won’t be the end of it.

Conservative Republican Senator Jeff Sessions was recently nominated by Trump to be Attorney General, and while we can’t know how Sessions would deal with antitrust cases, we do know that Trump has said he wants less government regulation of business.

It’s not clear how Mr. Sessions would have the department handle antitrust cases, but Mr. Trump has previously said that he wants “deep cuts” to government regulation of business. It’s doubtful that the DOJ would drop the cases but it’s also entirely possible that the losing party will appeal and that’s where Trump’s influence may come into play. Where a Trump administration will stand on antitrust issues can’t really be known until key positions in Federal Trade Commission and Justice Department are made but it’s not far fetched to think a Trump administration will be more lenient in terms of a settlement favoring a big insurer.

 

 

 

Many State Medicaid Meaningful Use Attestations Delayed


For Medicare providers, the deadline to attest for the 2015 reporting period with CMS was March 11, 2016. However, due to recent revised requirements, many states have not yet established a 2016 deadline for providers to attest for the 2015 reporting period with their Medicaid EHR Incentive Program. If fact, many states are only accepting 2015 reporting period attestations for adopt, implement, or upgrade (AIU), and Meaningful use Modified Stage 2 attestations are not yet available.

If you are a Medicaid provider, visit your State Medicaid EHR Incentive web site and subscribe to their Listservs to be kept informed if attestations or deadlines have been or will be set.

Terminating the Physician-Patient Relationship


By Sumita Saxena, Senior Consultant, The Verden Group

It unfortunately can happen to anyone: You go above and beyond to provide your patients excellent care with uncompromising accessibility, and yet something somewhere goes wrong and the relationship quickly deteriorates. After trying your best to mend the problem it becomes clear – the relationship has broken down beyond repair and for whatever reason you reach the tough decision to terminate the patient from the practice.

Before you act and send notice, please take a look at some helpful steps we have compiled for you to consider as you navigate this difficult subject.

Step One:  Try to Work It Out With Your Patient.  Practically speaking, when faced with a difficult patient situation, the best course of action is to avoid a unilateral termination of the physician/patient relationship by addressing the problem quickly. Communication is the key. The patient should be advised of the situation and given a reasonable opportunity to correct the problem. You should make it clear that failure to correct the problem may result in the dismissal of the patient from the practice.

Step Two:  Review the Applicable State Medical Licensing Rules. State licensing boards govern the practice of medicine and the relationship between a physician licensed in that state and his or her patients. Accordingly, it is essential to review the medical board rules carefully before you terminate a patient from your practice.

Step Three:  Consider AMA Guidance. The American Medical Association (the “AMA”) has provided guidance on terminating the physician/patient relationship. According to the AMA’s Code of Medical Ethics, physicians have the option of terminating the physician/patient relationship, but they must give sufficient notice of withdrawal to the patient, relatives, or responsible friends and guardians to allow another physician to be secured.

The AMA recognizes that there are times when a physician may no longer be able to provide care to a certain patient, including when the patient refuses to comply, is unreasonably demanding, threatens the physician or staff, or otherwise is contributing to a breakdown of the physician/patient relationship. According to the AMA, terminating a physician/patient relationship is ethical as long as the proper procedures are followed.

The AMA has given the following advice for the termination process:

  1. Giving the patient written notice, preferably by certified mail, return receipt requested;
  2. Providing the patient with a brief explanation for terminating the relationship (this should be a valid reason, for instance non-compliance, failure to keep appointments);
  3. Agreeing to continue to provide treatment and access to services for a reasonable period of time, such as 30 days, to allow a patient to secure care from another person (a physician may want to extend the period for emergency services);
  4. Providing resources and/or recommendations to help a patient locate another physician of like specialty; and
  5. Offering to transfer records to a newly designated physician upon signed patient authorization to do so. American Medical Association (AMA), “Ending the Patient-Physician Relationship,” http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/ending-patient-physician-relationship.page

Step Four:  Check Your Payer Contracts and Policies.   A physician who is a participating provider (under contract) with the patient’s insurer (commercial or government payer) may be obligated to notify the payer and comply with additional requirements. You should review your provider contract(s) and policies in order to determine if the payer has a policy on patient termination. For example, some insurance carriers require 60 or 90 days notice before dismissal (as compared to the 30 days notice required pursuant to certain state laws) and some require prior written notice to the carrier to enable the carrier to contact the patient.  There also may be specific requirements concerning pregnant or mental health patients. Medicare, Medicaid, and other government payers have strict policies on terminating a patient that should be reviewed before terminating a governmental plan beneficiary.

Step Five:  Review Your Malpractice Carrier Requirements.  Some medical malpractice insurance carriers have adopted rules or recommendations for terminating the physician/patient relationship. Accordingly, you should review your malpractice policy or contact the malpractice carrier when establishing the procedure for terminating the physician/patient relationship.

Step Six:  Send Written Notification to Your Patient.  You should send written notification advising the patient that he or she is terminating the patient relationship. The notification should comply with the licensing board’s rules and the requirements of the applicable payer and the your malpractice carrier. Ideally the patient notification should be prepared or reviewed by experienced counsel before sending to the patient.

Step Seven:  Provide Continuity of Care.  You should ensure that you provide the proper continuity of care when dismissing a patient from your practice, including any requirements under state licensing rules, their payer contracts and their malpractice policy. The AMA guidance recommends that the physician provide the patient with resources and referrals for other sources of care.

Step Eight:  Do not Charge for Patient Records.  A physician who terminates his or her relationship with a patient should not charge the patient for copying the patient’s medical records.

Step Nine:  Consider Risk Management.  Additionally, you should perform a risk management analysis before terminating the physician/patient relationship. You should consider the possibility (even if the patient’s position is without merit and you will ultimately be successful) of patient complaints, disciplinary investigations, litigation, or other action initiated by disgruntled patients.

Step Ten:  Establish a Set Policy on Patient Terminations and Train Staff on the Policy.  In order to avoid any potential issues with former patients, the practice should have a set policy in place for the termination of the physician/patient relationship, including a sample termination letter.  The policy should be applied to patients consistently and without discrimination.  The staff should be trained on the policy and should document compliance with the policy.

By following the above steps you can be proactive and diligent in mitigating your risk if such a situation ever arises with a patient.

Looking Ahead: Meaningful Use Stage 3 Requirements


By Jose Lopez, Senior Consultant, The Verden Group

In my recent blog on the proposed changes to Meaningful Use 2 requirements CMS recognized the barriers providers were facing in meeting the Meaningful Use Stage 2 requirements, and proposed a rule to simplify the Measures and Objectives for 2015 and beyond. CMS clearly heard the complaints from providers that meeting the measures were creating workflow issues. The Verden Group applauds these changes and hope they are approved in their entirety.

Let’s look forward now to what lies beyond meeting the revised Stage 2 requirements in 2015 and 2016, to Stage 3. Following a proposed “optional” year in 2017, all providers will report on the same streamlined definition of Meaningful Use at the Stage 3 level in 2018, regardless of prior participation.

CMS has come out with 8 tentative advanced use objectives for Stage 3 designed to align with national healthcare quality improvement efforts, and to promote interoperability and health information exchange which will focus on the triple aim of reducing costs, improving access and improving quality:

  1. Protect electronic health information
  2. e-Prescribing
  3. Clinical decision support
  4. Computerized provider order entry
  5. Patient electronic access to their data
  6. Coordination of care through patient engagement
  7. Health information exchange
  8. Public health reporting

The specific measures for each objective have yet to be defined but if you think the objectives look like Stage 2, then you would be correct. And as with Stage 2, the most challenging objectives appear to be those where the provider does not have direct control over their outcomes: patient engagement (patient use of portals and e-messaging), health information exchange (by states or other entities), and public health reporting (by states or other entities).

While CMS came under fire in 2014 following the fallout of providers being unable to meet Stage 2 requirements, it is vital that practices continue to advance their use of electronic health information. As Medicare and private payers continue their evolution from fee-for-service to pay-for-performance, data is being used to report on quality outcomes and to differentiate high performing practices to patients.

In closing, it is crucial that providers and provider associations provide feedback when CMS proposes rules for Stage 3 to ensure the data being required isn’t arbitrary (as was the case with Stage 2), but that it meets the intent of the HITECH Act to begin with: reducing costs, improving access, and improving quality.

In our next blog on Meaningful Use, we’ll discuss proper Meaningful Use Attestation documentation and the ugly truth no one wants to hear: CMS plans to audit one in every 20 meaningful use attesters.

Does the “Doc Fix” Bill Help Telemedicine and Telehealth?


By Sumita Saxena, Senior Consultant, The Verden Group

In a word, yes. According to an article recently published by a leading expert in healthcare law, the “Doc Fix” could just be the solution providers have been wanting.  Telemedicine was one of the many beneficiaries of changes introduced by the so-called “doc fix” bill, formally titled the Medicare Access and CHIP Reauthorization Act (H.R. 2). The legislation was passed by Congress on April 15, 2015 and signed into law by the President on April 16, 2015. It introduces sweeping changes to the reimbursement methodologies and financing of health care in the United States, including a notable shift away from the traditional fee-for-service model and towards accountable care organizations (ACOs), risk-based payment, and a focus on quality and population health.

As organizations embracing telemedicine recognize, these new payment models are ideally suited to the improved access, quality and care management offered by telemedicine technologies. The Act is a signal to the provider community that embracing innovative care delivery, such as telemedicine and telehealth, is an important step to positioning your organization to best capture these new payment opportunities.

But the Act also includes specific provisions benefiting telehealth and remote patient monitoring (RPM), particularly for the Medicare program. It states:

  • Telehealth and remote patient monitoring are expressly recognized as, and included in the definition of, “Clinical Practice Improvement Activities” along with care coordination, population health management, and monitoring of health conditions.
  • New “Alternative Payment Models” may include payment for telehealth services, even if the service is not otherwise covered by the traditional Medicare program (42 U.S.C. 1395(m)).
  • The GAO is required to conduct a study on telehealth and the Medicare program, publishing the report no later than April 2017. Specifically, it states:

STUDY ON TELEHEALTH SERVICES

The Comptroller General of the United States shall conduct a study on the following:

  • How the definition of telehealth across various Federal programs and Federal efforts can inform the use of telehealth in the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
  • Issues that can facilitate or inhibit the use of telehealth under the Medicare program under such title, including oversight and professional licensure, changing technology, privacy and security, infrastructure requirements, and varying needs across urban and rural areas.
  • Potential implications of greater use of telehealth with respect to payment and delivery system transformations under the Medicare program under such title XVIII and the Medicaid program under title XIX of such Act (42 U.S.C. 1396 et seq.).
  • How the Centers for Medicare & Medicaid Services monitors payments made under the Medicare program under such title XVIII to providers for telehealth services.

The GAO is required to conduct a second study on remote patient monitoring and the Medicare program, publishing the report no later than April 2017. Specifically, it states:

 STUDY ON REMOTE PATIENT MONITORING SERVICES.

 The Comptroller General of the United States shall conduct a study:

  • of the dissemination of remote patient monitoring technology in the private health insurance market;
  • of the financial incentives in the private health insurance market relating to adoption of such technology;
  • of the barriers to adoption of such services under the Medicare program under title XVIII of the Social Security Act;
  • that evaluates the patients, conditions, and
  • clinical circumstances that could most benefit from remote patient monitoring services; and
  • that evaluates the challenges related to establishing appropriate valuation for remote patient monitoring services under the Medicare physician fee schedule under section 1848 of the Social Security Act (42 U.S.C. 1395w–4) in order to accurately reflect the resources involved in furnishing such services.

REMOTE PATIENT MONITORING SERVICES — The term ‘‘remote patient monitoring services’’ means services furnished through remote patient monitoring technology.

REMOTE PATIENT MONITORING TECHNOLOGY — The term ‘‘remote patient monitoring technology’’ means a coordinated system that uses one or more home-based or mobile monitoring devices that automatically transmit vital sign data or information on activities of daily living and may include responses to assessment questions collected on the devices wirelessly or through a telecommunications connection to a server that complies with the Federal regulations (concerning the privacy of individually identifiable health information) disseminated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, as part of an established plan of care for that patient that includes the review and interpretation of that data by a health care professional.

The Act contains many provisions intended to promote innovation and care delivery by incentivizing health care organizations to invest in and use the powerful telemedicine tools and technologies available in the marketplace.

How Does This Affect Your Practice?

As with practically all healthcare legislation the catch, not surprisingly, is how these changes will play out for physicians and their reimbursements. Payers are claiming the field and limiting the scope to only those specific telemedicine companies they decide to work with in order to provide such services. For example, UnitedHealthcare is partnering with Doctor On Demand, Optum’s NowClinic and American Well’s Amwell to provide video-based virtual visits in 47 states and Washington, D.C. to its participants through the UnitedHealthcare’s Health4Me™ mobile app, using its in-network virtual care provider groups. Because of this, physicians are finding a third party in their relationships with their patients, disrupting the continuum of care, fragmenting delivering and running opposite to the tenets of the triple aim and goals of unifying and centralizing patient care…

As healthcare and technology continue to evolve and interlink to provide greater access and convenience to the consumer, the question remains how this changing landscape will ultimately impact physicians and their relationships with patients and payers. One thing is for certain, telemedicine is poised to take off, as industry leaders further develop their programs and explore new payment options. The law, in turn, will catch up, it’s just a matter of time. Meanwhile, make your voice heard to the commercial Payers about the disruption to care posed by having third party entities deliver services to YOUR patients, and demand the same accessibility and coverage that companies such as Doctor On Demand currently enjoy.

 

 

The Verden Group has been working with an exciting new company, TruMed Systems, on their revolutionary new approach to vaccine storage and management.


They started by asking the question; how would you design a better vaccine storage and handling solution?

Running a vaccine ‘business’ is an essential yet very costly component of your primary care practice. A study conducted by The Verden Group in 2009 quantified the costs of vaccine storage and handling for averaged sized primary care practices (3 providers) and estimated the costs of handling, storage, wastage and missed billing at $16,000 annually.

TruMed Systems looked at the process of vaccine storage and handling and set out to find a better solution. Assembling a network of physicians, nurses, practice managers and vaccine industry experts, they set about designing AccuVaxTM a fully automated vaccine storage and handling solution. We happen to think it’s AWESOME.

We thought we’d share this latest white paper from TruMed – click here to read it and see what AccuVax can do, and how it may help transform your vaccine business.

Cyber Risk Insurance – Should you consider getting it for your practice?


By Sumita Saxena, Senior Consultant, The Verden Group

The cyber-attack on Anthem, which left 80 million customers and employees vulnerable to identity theft, has quickly elevated the question of whether to purchase cyber risk insurance to the forefront of discussion among healthcare providers. The attack will certainly impact the market of cyber security insurance for healthcare providers, payers and others. Small to medium-sized healthcare organizations that have not considered such coverage may do so now while insurers will be re-evaluating underwriting standards and likely premium levels in the wake of the Anthem attack.

Most policies provide broad coverage for what constitutes a privacy breach, whether it results from a hacker, unauthorized access by an internal rogue employee or a laptop that was lost or stolen. Coverage can be divided into two categories: first-party and third-party costs.

Typically first-party costs involve those direct costs related to responding to a privacy breach or security failure. Such costs include forensic investigation of the breach, legal advice to determine notification obligations, notification costs of communicating the breach, offering credit monitoring to customers or patients as a result, and loss of profits and extra expenses during time network is down (business interruption).

Generally third-party costs include legal defense, settlements or damages or judgments related to the breach, liability to banks for re-issuing credit cards, cost of responding to regulatory inquiries and regulatory fines and penalties. Optional coverage can encompass underwriting for cyber-extortion, where hackers access a network and demand a ransom in exchange for not stealing data (many companies would rather pay the ransom and make the problem go away).

Larger organizations are more likely to purchase coverage than smaller ones given their access to risk managers and in-house IT security. Smaller companies, like physician practices and local clinics, may not have access to such resources and may forego coverage as unnecessary or too expensive. Data breaches, however, are continuing to garner significant attention and some insurance experts have commented that more and more small and mid-sized organizations are actively seeking out this coverage. Premiums for a $1 million plan are generally $5,000 to $10,000 annually though the cost can vary based on several factors, including company revenue, cyber-risk management efforts and the coverage chosen.

The cost of insurance coverage and breach response is minimal, however, when compared to the legal and regulatory costs associated with a data breach, which depending on the size of the attack, can run into the millions and substantially impair a company’s profitability if the response is not adequate.

Any large, well-publicized breach such as the one that struck Anthem will affect the market for cyber security insurance, as noted by industry experts, by influencing coverage terms, increasing coverage prices and making underwriting requirements more stringent, especially for healthcare companies as the industry sees more large-scale breaches. In light of these changes, it is prudent to re-assess network security and adequacy of breach notification, and to consider cyber risk insurance as an additional safeguard against the substantial cost associated with data breaches.