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For today’s post, I would like to point out the opportunity that is available to comment on The Federal Health Information Technology Strategic Plan for 2011-2015. The Office of the National Coordinator for Health Information Technology has extended the public comment period through May 6, 2011.

For anyone concerned about healthcare, this document defines the government’s plan “to transform the healthcare system by improving the flow of information through health IT.” The Plan builds upon the current healthcare IT programs and also “charts new ground for the federal health IT agenda.”

This comment period provides an excellent opportunity for physicians, along with all other interested parties, to add their voices to the decisions regarding the direction that healthcare in the United States will take in the future.

Here is the link to the ONC website to review and comment on the Strategic Plan – Federal Health IT Strategic Plan Open for Public Comment – and I have included the comment that I submitted regarding of the Strategic Plan below.


Dr. Mostashari –

I appreciate the opportunity to comment on The Federal Health Information Technology Strategic Plan. I would like to first state that I am a supporter for the utilization of electronic health records and believe that health information technology can serve an important role in healthcare delivery. There is a major omission in the proposed Strategic Plan, however, that I find to be a significant area of concern.

Throughout the proposed Strategic Plan, there is the complete absence of a major component for any successful healthcare – responsibility. Responsibility is lacking within this Strategic Plan both figuratively and literally, as the word “responsibility” does not even appear within the document.

The absence of responsibility extends throughout the Plan. The government’s proposal includes efforts to “encourage”, “enhance”, “inspire”, and “promote” efforts for the implementation of health information technology, but at no point does the government take ownership or direct responsibility for the results of these efforts.

The establishment of the Nationwide Health Information Network serves as an example. This Network is supposed to serve as “the preferred solution to securely exchange information nationwide to support meaningful use.” While ONC will establish “a governance mechanism through rulemaking” for the Network, “governance rules will be established as a voluntary solution to health information exchange” and “the government will pursue various options to encourage participation in this preferred solution.” So while the government will create the rules for the health information exchange, and encourage participation in it, it abdicates any responsibility for the outcomes associated with the use of this Network as it remains a “voluntary solution.”

This aversion to responsibility is even more clearly evident in regard to the proposed requirements that are to serve as the foundation for stages two and three of the EHR Incentive Programs. The Plan calls for these stages to include incorporation of “more sophisticated uses of health IT, such as clinical decision support, patient registries, reminder systems, and changes to workflow and clinical care redesign.” The current Strategic Plan, however, fails to address or even consider the repercussions that these requirements will have on the participating providers.

Specifically, the Strategic Plan does not contain any assessment or consideration for the legal consequences and liabilities that these government programs will create. These consequences include important and very practical issues, such as the medical malpractice implications that may result from the incorporation of clinical decision support into the EHR system. The handling and management of patient data caused by participation in registries is another source of significant legal questions, such as when the provider’s responsibility for securing the patient’s data ends and the health information exchange’s responsibility begins.

To address this deficiency regarding the legal responsibilities, I would recommend adding an additional “Goal VI” to the current Strategic Plan. This Goal would be to “Address and Clarify the Legal Ramifications of the Adoption and Utilization of Health IT.”

Finally, the most significant omission of “responsibility” in the Federal Health IT Strategic Plan is the lack of any discussion regarding the responsibilities of one of the major participants in U.S. healthcare – the ‘private’ commercial insurance companies.

If the Mission for this Plan is “to improve health and healthcare for all Americans”, then the commercial insurance companies must be an active participant in this program. These companies play a major role in the management and utilization of healthcare resources in this country. If the current Strategic Plan truly represents the national health IT agenda, then the private insurance companies must be integrated into this plan to a degree commensurate with the position that they currently hold in healthcare, including fully defining their role, the degree of their participation, their financial contribution, and their responsibilities.

Once again, I am very thankful for the opportunity to comment on the Federal Health IT Strategic Plan. I hope that my comments are helpful and constructive, and I look forward to the final version.



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I was recently watching the morning program Squawk Box on CNBC when it ran a segment called “Masters of the Market”. The episode that morning featured Roger McNamee, managing director and cofounder of Elevation Partners. He was discussing his long-term outlook on technology and the important issues that he felt would shape the future of technology. He specifically felt that Microsoft Windows would experience a continued decline, particularly as smartphones and tablets continue to increase. He also believed that there would be a significant clash regarding the Internet, with the world wide web/browser model versus the app model.

I found his comments extremely interesting, particularly since his predictions were based on the current trends that are already occurring in tech. Although he was discussing the general market outlook for the technology sector, I quickly found myself reflecting on the current state of electronic health records in regard to his revelations.

While the current initiatives to promote EHR are looked upon as “transformative advances” in healthcare, after listening to this discussion, I was left feeling that it was possible that the upcoming “advances” in healthcare may unfortunately represent “yesterday’s technology” once they arrive.

The biggest reason for my concern is based on the fact that the current EHR systems are essentially Windows or browser-based systems. These two areas were focused on in McNamee’s comments as potential areas of significant change in the technology market.

While Microsoft Windows will probably never completely go away, the fact that corporateAmericahas already been moving away from its reliance on Windows could potentially represent a significant concern for physicians in the future, particularly in small medical practices. If there is a dramatic shift from Windows, or if Microsoft adopts a completely different strategy or platform, then small medical practices may be left with “legacy” Windows-based EHR systems that are no longer supported as healthcare IT moves forward. The economic repercussions of such a change could be devastating for small medical practices since they typically lack the financial resources that larger healthcare organizations can access (thereby reducing their ability to access significant IT support or to absorb the cost of having to obtain an entirely new EHR system).

This same scenario of an outdated platform could also affect the browser-based EHR applications. Although the economic impact would seem to be less of an issue, the fact that there is significant competition ongoing between the browser-based and application-based models may potentially have repercussions. In addition, the eventual introduction of HTML5 into the web-based systems may create potential compatibility issues unless the web-based EHR software companies are vigilant in maintaining their products.

Given the status of EHR/EMR from even a decade ago, the current environment for electronic health records obviously represents a dramatic leap forward in technology.  I raise these issues for consideration, however, to point out the simple fact that while the current EHR/EMR may represent a significant advance in healthcare, in many respects, healthcare information technology itself appears to still be significantly behind the times when compared to the advances in the overall technology sector. Hopefully, as the EHR initiative continues to advance, this gap between the current reality of healthcare IT and the current/next generation of technology (in general) will continue to close, thereby eventually allowing the electronic health record to deliver on its full potential for the future of healthcare in theUnited States.


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Now that the “lame duck” Congress is getting underway, the countdown toward a potential Medicare crisis has officially started. As I discussed last week, Congress has until December 1st to address the planned Medicare physician pay cut. If they adjourn without resolving this issue, then 2011 may start with a major Medicare crisis if a significant number of physicians opt out of Medicare.

This Medicare crisis would primarily result from a dramatic reduction in access to care for seniors created by a decrease in the number of participating providers. If the issue is not addressed, however, it has even greater potential to spread beyond Medicare to cause a major systemic healthcare crisis.

As I noted in my recent posts, Congressional inaction would result in a combined 28.5% reimbursement reduction on January 1, 2011. From a business standpoint, medical practices may be forced to accept the difficult conclusion that they can no longer participate in Medicare. Even after opting out of Medicare, however, physician practices will still face additional financial crises due to the domino effect produced by the dramatic reduction in Medicare reimbursement.

Although the Medicare reduction will be the headline, this reduction will have a ripple effect that spreads through the reimbursements from several other healthcare coverage sources. The reduction in Medicare will produce an immediate equal reduction in TRICARE reimbursement – the healthcare insurance for military personnel and their families – since TRICARE payments are directly tied to Medicare rates.

This reduction will also extend beyond the government-sponsored healthcare coverage and will be reflected in the private health insurance market. Despite the public perception that government healthcare and private health insurance are unrelated entities, the fact is that most private health insurance companies base their provider reimbursement rates on Medicare. This is not a supposition or fabrication; instead, it is a legal fact that is formally documented in the provider contracts with these insurance companies. These contracts typically specify provider reimbursement as a multiple of the Medicare allowable charges.

It also needs to be pointed out that these reductions are occurring at a time when medical practices in many states have already experienced Medicaid reductions of 10% or more. As the government stimulus money for Medicaid runs out, many states are already discussing future Medicaid provider payment reductions.

The Medicare reductions, therefore, not only affect Medicare patients, but could also have implications for almost the entire healthcare marketplace. A failure to address this problem will quite possibly have repercussions that start as a Medicare crisis but compound into a general systemic healthcare crisis for the entire country.

One would think that the issue of the Medicare physician pay cut, therefore, would be a significant topic of concern for this upcoming Congressional session. Other than an Associated Press article published on the topic this weekend, it does not appear to be garnering any significant coverage in the mainstream media. Perhaps there is general “healthcare burn-out” after the debate over the healthcare reform bill and the recent elections; hopefully, the “lame duck” Congress realizes the stakes. It is now up to Congress to demonstrate some leadership and take action to avoid a Medicare crisis as they are now “on the clock” starting today.


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After last week’s election results, there has been discussion in the EHR/EMR communities regarding the implications of the political power shift on the electronic health records initiative. The general consensus is that the EHR initiative has bipartisan support and there should not be any significant changes to the HITECH Act programs under the new Congress.

As I discussed in yesterday’s post, however, there is potentially a major Medicare crisis on the horizon if the “lame duck” Congress does not address the physician pay cuts during its upcoming session. A failure to correct this problem not only has the potential to create a catastrophic crisis in access to care for Medicare beneficiaries, it will also have significant repercussions for the EHR initiative and for the Medicare EHR incentive program’s participating providers.

This cascade effect will occur because of two factors. One factor would potentially dramatically limit provider participation in the program. The other factor could directly affect the program incentive payments and potentially frustrate providers, thereby discouraging participation.

This first factor is straightforward in that providers must participate in Medicare in order to qualify for the EHR incentive program. As I detailed yesterday, failure of the “lame duck” Congress to address the expiration of the temporary fix to Medicare physician reimbursement on December 1st could lead to a confluence of events that force a significant number of providers to withdrawal from Medicare. The MGMA survey that I referenced yesterday indicates that this could be over 25% of providers.

Such a significant reduction in participating providers will obviously limit the success of CMS/ONC in moving toward their goal of creating a national healthcare infrastructure.

In addition, providers who remain in Medicare may experience significant financial difficulties from the reimbursement reduction and therefore may not be able to move forward with capital expenditures, such as an electronic health records system. The same MGMA survey revealed that 45.3% were likely to delay purchase of EHR systems if decreased reimbursement occurs, with 37.3% having already delayed EHR purchases due to previous Congressional failures in resolving this pay cut problem.

The second factor in this cascade could have a direct effect on the provider incentive payments under the Medicare EHR program. Since the incentive payment is based on the provider’s Medicare allowable charges, any reduction in Medicare reimbursement will therefore also potentially produce a reduction in the provider’s EHR incentive payment.

With the current Medicare reimbursement rates, providers need to have $24,000 in Medicare allowable charges in order to qualify for the full $18,000 of incentive payments next year (incentive payment = 75% of Medicare allowable charges, with a maximum amount set per year). If the Medicare cuts take effect, providers will need to effectively increase their charges to a comparable amount of $33,566 in current charges in order to qualify for the full payment. This means that providers will need to increase their productivity by 39.9% in order to maintain the same amount of incentive payment next year.

With reduced incentive payments coming on top of reduced reimbursement rates, this compound effect will probably leave many providers frustrated and disgusted with anything Medicare. Experiencing “double reductions” may actually create a disincentive for providers to participate in any ongoing Medicare-related programs, including the EHR incentive program.

Therefore, while the HITECH Act may be safe next year under the new Congress, its success appears to be deeply dependent on the efforts of the current Congress this year.


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Now that the election hype has started to subside and the pundits have weighed in on the results, the time to address the healthcare challenges of the country is approaching far more quickly than the politicians seem to be aware of. While many promises were made regarding the direction of healthcare for the next Congress, the upcoming “lame duck” session may predetermine the course of those plans. The post-election discussion has primarily focused on the Bush tax cuts and the budget, but there is a significant deadline approaching that has the potential to produce a major healthcare crisis before the new Congress is even sworn in. The deadline is December 1st, when the previous temporary Medicare physician payment “fix” is set to expire.

This deadline may not seem like a significant event, particularly since it appears to be flying under the radar of the media and the politicians’ talking points, but the potential repercussions if the “lame duck” Congress fails to act may be massive. The expiration of the previous “fix” is occurring during a time when events seen to be aligning to produce a “perfect storm” to create a severe Medicare crisis starting January 1st. Dr. Cecil Wilson, president of the AMA, describes the potential outcome as “catastrophic”.

This “perfect storm” is the byproduct of a bipartisan effort, as both Democratic and Republican Congresses have practiced the classic Washington tactic of “kicking the can down the road”. They have been passing “temporary fixes” to physician Medicare payments since 2003 but have never bothered to permanently fix the cause. Their procrastination in addressing this problem has now led to this confluence of events, with the healthcare of U.S. seniors hanging in the balance. Ironically, after all of the recent election cycle rhetoric regarding healthcare, this potential Medicare crisis has nothing to do with the healthcare reform law passed earlier this year.

There are multiple contributors to this potential tempest. The primary force is the Medicare physician pay cut that results from application of the sustainable growth rate formula used to determine Medicare reimbursement. The impact of this primary force was delayed when the “temporary fix” was passed this summer, but this will expire on December 1st. Once it expires, Medicare providers will immediately experience a 23.6% cut in Medicare reimbursement. While this “temporary fix” may have worked politically, this delay will result in exponentially greater damage if the pay cut goes into effect in December. This is because the full force of this pay cut will be further magnified when an additional 6.5% reduction occurs on January 1, 2011.

There are also additional forces contributing to this storm from the provider standpoint. For many providers, the Medicare pay cuts represent additional reductions in reimbursement on top of Medicaid cuts of 10% or more in the last year, with further reductions still possible. There is also the December 31st, 2010 deadline looming for physicians to decide on their Medicare participation status for 2011 (a decision that is binding throughout 2011).

Combine these forces with a “lame duck” Congress and the Democratic Party’s defeat in the recent elections, and the stage is set for a potentially cataclysmic healthcare crisis. If the political parties decide to play a “game of chicken” during the upcoming session, and neither party blinks (or “compromises”, to use the current political ‘word of the day’), then their failure to act may unleash a cascade of events that creates a massive Medicare crisis to start the new year.

Medicare participating providers will be forced to make a decision on participation status for 2011 with a combined 28.5% reimbursement reduction in place. This will be a very difficult choice as providers try to determine the effect that Medicare participation will have on their practice from a business standpoint; many may have to opt out of Medicare in order to keep their practices in business. I realize that this statement may seem over-the-top, but a recent MGMA survey is consistent with this reality. The recent MGMA survey revealed that if the pending cuts take place, then 49.5% of surveyed physician practices plan to stop accepting new Medicare patients, and 27.5% say they will stop seeing all Medicare patients.

The repercussions of this “perfect storm” would create a healthcare crisis that would make the recent healthcare debate appear temperate. There are already issues with provider access for Medicare patients in many areas. If a marked reduction in Medicare providers were to occur, just as even larger numbers of baby boomers are becoming Medicare-eligible, it is possible that such a dramatic limitation in access to medical care could undermine the very framework of the Medicare system itself.

Clearly, our elected officials in Washington are facing an issue that demands bipartisan action to avoid a major crisis. The straightforward solution is to pass another temporary fix and “kick the can down the road” again. This seems like a very reasonable option, but unfortunately, given the bitter partisanship in Washington, Congress’ recent track record suggests that even the simple and reasonable can be impossible. This fact was demonstrated earlier in the year when they failed to pass the current temporary fix by the June 1st deadline and the cuts were in effect until this recent fix was passed in July.

The clock is therefore ticking on Congress to take action during this “lame duck” session. If time runs out, the new Congress may take office in January 2011 in the middle of a massive Medicare meltdown.

I realize that this post has a political theme that is out of character with my usual posts. This topic, however, does have a direct impact on the initiatives for the adaptation of electronic health records/electronic medical records. Changes in Medicare reimbursement have a direct effect on the EHR incentive program, and I will discuss these repercussions in my next post.