By the end of 2011, 58 percent of office-based physicians were using e-prescribing, with solo practitioners contributing the most significant growth, according to Surescripts.

Stage 2 Meaningful Use Rules Sharply Criticized by Physicians

The American Medical Association and state and specialty societies call for less aggressive criteria in the Medicare and Medicaid electronic health record incentive program.

EHR Best Practices: Adopting a Health IT Culture (Pt I)

Going live with EHR technology is a disruption of standard practice; it demands a wide and deep commitment to change so that an EHR system can truly factor in to improving the efficiency and effectiveness of patient care.

CMS Lists Names of EHR Incentive Recipients

The Centers for Medicare and Medicaid Services has published the names, business phone numbers, and business addresses of Medicare providers that have demonstrated meaningful use of an electronic health record and received an incentive payment as of March 2012.

GAO: Doctors Should Submit More Data to Get Meaningful Use Money

Physicians soon could be required to submit more documentation to CMS to validate whether they are authorized to receive meaningful use bonuses. CMS is taking the recommendation into consideration as it prepares to conduct audits on practices.

America Faces Organ Transplant Deficit as Donors Become Too Fat to Qualify

Last year the number of American organ donors hit a milestone when the 100 millionth person added their name to the list. But before you boast about signing up, you might want to step onto a scale.

In addition to the presentations and workshops, our conference organizers arranged for several social engagements during the conference. The pinnacle event was a spectacular architectural dinner cruise on the Chicago River. This included a brief foray onto Lake Michigan where we enjoyed remarkable views of the skyline as the sun set that evening. The social events created a wonderful opportunity for our users to network with each other and share best practices. Those venues also provided many of us with a chance create new relationships and to build upon relationships that have existed for several years.

The energy this conference has generated within our company is palpable. Our conference organizers are collecting feedback as they begin the process of planning next year’s event. Those of you who attended will soon receive a survey via email. Please let us know what you liked and what you did not like, what worked and what did not work so that we can make next year’s conference even better. If you would like to leave a comment to share with the community, we hope you’ll do so here.

I’d like to thank those of you who attended for taking the time out of your busy practices to join us. I hope the experience was as valuable for you as it was for me and the rest of the Acumen family. See you next year.

While May 7 was the last day to submit comments to the Stage 2 meaningful use proposed rule to the U.S. Department of Health and Human Services (HHS), five organizations have joined the din of democratic speech on the legislation.

Doctors’ Love-Hate Relationship with EHRs

By knowing what users say is good and bad about electronic health records, physicians in the market will have a better sense of what to look for.

Preventing EHR Data Breaches

Large data breaches involving sensitive patient information in EHRs can be avoided with a focus on file storage, transmission and destruction.

Docs Riled by FDA’s Proposal to Open Up Drug Access
Here’s the proposal: FDA would free up some treatments for chronic conditions, such as asthma and diabetes, so patients could obtain them without a prescription. For obvious reasons, doctors aren’t thrilled by the idea.

‘Bundling’ Report Expected at Kidney Meeting

Researchers attending this year’s National Kidney Foundation clinical sessions will get a glimpse of early data on whether a new method of reimbursement for intravenous dialysis medications is having an impact on care.

Early Dialysis Starts Associated with Worse Outcomes

Recent study findings add to mounting evidence of the deleterious consequences of early dialysis initiation, prompting researchers to question this approach, especially among older patients.

Our company has grown rapidly during the past few years, in parallel with a significant expansion in our customer base. One byproduct of that growth is the opportunity to host our first Users Conference. This Thursday and Friday we will convene in Chicago for the Acumen Connect Conference. The rising crescendo of excitement within our offices has been palpable over the past few weeks as we prepare for the conference. Hugh Gaston, Noell Bulka and Megan Wiley have worked diligently to prepare quite a treat for those of you able to attend.

The agenda includes a number of presentations and interactive sessions. Perhaps most fitting is the delivery of the keynote presentation on Thursday morning by our founder. In his new role as Chief Medical Officer for Fresenius Medical Care, Frank has continued to champion collaboration and is passionate about the role integrated care is likely to play in the future delivery of health care. In addition to the keynote presentations by Frank and Bill Rancic, attendees will be able to learn about a wide variety of topics including voice recognition and meaningful use.  Finally, there will be ample opportunity to network with Acumen users from around the country.

I have seen the attendee list and I know quite a few of you will join us. For those unable to do so, perhaps we can make it happen next year. I know a number of relevant topics will surface this week in Chicago. Next week I hope to share some of them with you. Safe travels to the Windy City!

Health IT Break Sought for Docs in Small Practices
The chair of a House subcommittee on health technology has asked the Centers for Medicare and Medicaid Services (CMS) to exempt doctors in small practices or those who are nearing retirement from new health IT requirements.

GAO Urges CMS to Tighten Meaningful Use Verification
GAO made four recommendations to CMS this week in order to improve processes to verify whether providers met program requirements for the Medicare and Medicaid EHR programs, including opportunities for efficiencies.

AHA Blasted for ‘Hail Mary Pass’ on Meaningful Use
No sooner had the American Hospital Association submitted its comments on the proposed rule for Stage 2 meaningful use than they came under fire for “spurious” arguments on patient access to online information.

Processed EHR Text Can Be Used to Develop CDS Tools
Processed EHR text can be used to develop Free text in electronic health records, with the help of natural language processing (NLP) technology, can be used to create accurate clinical decision support (CDS) tools

US Spends Far More for Health Care Than 12 Industrialized Nations, but Quality Varies
The United States spends more on health care than 12 other industrialized countries yet does not provide “notably superior” care, according to a new study. U.S. spending linked to higher prices and greater use of medical technology, not more doctor visits or hospital stays.

Routine Kidney Disease Screening Not Worthwhile
Experts think a mass screening of healthy people would find a lot of kidney disease, but that would only worry people and wouldn’t change their medical care.

Fish Oil Doesn’t Cut Failure Rate of Hemodialysis Grafts
Taking fish-oil supplements does not significantly lower the failure rate of grafts used for hemodialysis, a new study finds. However, kidney patients taking fish-oil supplements had fewer problems with clots, study says.

Facebook Is Urging Members to Add Organ Donor Status
Facebook announced a plan on Tuesday morning to encourage everyone on Facebook to start advertising their donor status on their pages, along with their birth dates and schools — a move that it hopes will create peer pressure to nudge more people to add their names to the rolls of registered organ donors.

2012

This is the first year nephrologists and other eligible professionals have faced a penalty from one of the CMS “big three” (eRx, PQRS, and Meaningful Use). Many nephrologists were shocked to learn they are receiving 99% of the Medicare Part B Physician Fee Schedule (PFS) for their entire Part B book of business this year. One percent sounds like a small number, but based on the reported 2010 results, it is approximately $3,200 for the average nephrologist. From a financial perspective this penalty hits the doc where it hurts—it comes right off the practice’s bottom line.

How do you know if you are taking the hit this year? A couple of months ago I discussed how you could navigate the quagmire and determine if you are indeed being penalized this year. Those of you who feel you are being inappropriately penalized should call the Quality Net Help Desk and make your case.

2013

As most are aware, the penalty increases to 1.5% in 2013. That’s roughly $4,800 based on the averages we saw in 2010 for nephrologists. The tragedy in this mess is that it is actually very easy to avoid the penalty (assuming someone in the middle does not drop the ball—more about that later). I have written about avoiding the penalty before and this brief PDF from CMS does a fantastic job of covering the topic. What I want to call to your attention is the following:

If you report the eRx G-code (G8553) for 10 Medicare PFS encounters during the first 6 months of this year, you will avoid the penalty. Note they will count this G code on any encounter. This is different from last year when the encounters all had to be incentive eligible (typically office encounters for nephrologists). For example, if I send a script electronically for a Part B dialysis patient while I am making rounds, I can add the G-code to the claim I submit for that month’s MCP charge. If I discharge a Medicare Part B patient from the hospital and send a discharge script electronically, I can add the G-code the claim I submit for that hospital charge.

One of our readers recently sent me an email stating they were receiving conflicting stories from CMS (what a shock). They were suggesting the G-code could be put on the claim, even if the prescription was generated and transmitted outside the context of the encounter (e.g. Part B patient calls in for a renewal, the doc sends the script electronically, patient comes in a month later for something else and the G-code is put on that claim). I have not been able to independently confirm this, but if you have information to share along these lines, comment below so we can share with the community. My concern with this line of thought is the description for G8553 which states the script was created during the encounter.

Potholes to avoid

Some of us learned some valuable lessons last year related to the magical mystery ride your claim takes between leaving your office and arriving at CMS. Unlike this example displayed on the CMS website, most providers are adding a charge of $.01 next to the G-code to prevent the code from mysteriously disappearing before it gets to CMS. The beneficiaries are not charged the penny, but some clearinghouses apparently have a nasty habit of deleting codes that are not accompanied by a charge. This practice should also be considered by those of you still submitting G-codes on claims as part of claims-based PQRS reporting. Registry reporting, on the other hand, is quite a bit easier.

One other pothole to consider: I heard from a reader last week that their practice management system discovered that their recent transition to the 5010 transaction standards had nixed every G-code they have submitted this year. Her practice uses an otherwise very reliable PM vendor. I would suggest picking up the phone and calling yours today to make sure you are not in the same boat.

Penalties are no fun and I do not relish writing about them, but we owe it to our colleagues to spread the word. Two months is plenty of time to avoid this penalty. Put that G-code on the appropriate claims between now and June 30, and do what you can to ensure it makes the journey all the way to CMS.

The Medicare and Medicaid electronic health record program has paid $4.5 billion to 76,612 physicians and hospitals in incentive payments through March 2012.

Study Finds Discrepancy Between Plans, Ability To Meet Meaningful Use

According to a study, although many physicians said they intended to apply for meaningful use incentive payments, significantly fewer physicians actually were prepared to meet the requirements of the program.

EHR Adoption Still Lags for Small, Rural Practices

Adoption of electronic health-record systems remains higher among large physician groups and hospitals than among smaller ones.

ATA 2012: Where “Meaningful Use” Becomes a Reality

The American Telemedicine Association applauds the ongoing development of electronic medical records and related health information technologies. ATA’s position represents a growing consensus among consumers, providers and payers that telemedicine should be an important component of reformed healthcare.

Telemedicine Can Significantly Reduce Healthcare Costs for ESRD Patients

A Harvard Business Review article by Vijay Govindarajan, a Dartmouth business professor, suggests that telemedicine can reduce the costs of treating patients with end-stage renal disease by up to 90 percent compared to traditional treatment.

Dialysis Leaders Recommend Policy Changes to Address Under-Utilization of Home Dialysis

On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates — leaders in the kidney disease patient, clinician, facility and industry communities — on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment.

OMONTYS(R) (Peginesatide) Injection Now Available for Adult Chronic Kidney Disease (CKD) Patients on Dialysis in the United States

The only once-monthly erythropoiesis-stimulating agent launched in the United States by Affymax, Inc. and Takeda Pharmaceuticals U.S.A., Inc.

An Even Bleaker Prognosis For Medicare?

If readers can bear the first 276 pages of bad news in the annual Medicare trustees report, released Monday, they will come to several pages in which Medicare Chief Actuary Richard Foster argues the program’s financial future is even bleaker than what the trustees suggest.

Classic economic theory is based on a fictitious individual commonly referred to as the “economic man.” Imagine a person who makes every decision with the unwavering logic Star Trek fans expect from Mr. Spock. If Spock were a gambling man (okay, a reach, but bear with me) and he was offered a bet in which he would either win or lose $100, he would always take that bet if his chances of winning were the tiniest fraction greater than his chances of losing. That is to say, from a utility perspective he is indifferent. He would feel the pain of losing $100 with the same magnitude as he would experience the joy of winning $100 (if Vulcans had emotions of course).

A substantial amount of economic theory is built on this fundamental assumption: that we are guided by logic in our decisions based on expected utility theory, and therefore we place an equal magnitude of value on losses and gains, of course always preferring the later. This idea was the gospel for many years. Then in the late 1970’s, a couple of psychologists by the names of Daniel Kahneman and Amos Tversky came up with a better idea. In a series of elegant experiments they made the case that people do not make decisions or choices in a vacuum of logic, and when it comes to comparing losses and gains, we feel the pain of losing more than we experience the joy of a gain. In fact, the differential approximates 2:1.

Let me be clear, I am taking liberties and cutting corners to explain a concept that is not easy to wrap your brain around. To put this in perspective, ask yourself the following: Suppose I have a coin I am going to toss one time. If the coin-toss results in tails, I lose $100. How much would I need to win for heads in order to play this game? Mr. Spock is all in if he wins $100.01. Most of us, however, need a larger incentive to play this game. This is displayed graphically in one of the most important images created in economics over the past 100 years:

Notice how much steeper the utility curve is on the left (loss) compared to the right (gain). Because the value function for losses is steeper than that for gains, losses “loom larger” than gains. For example, a loss of 1% of your part B allowable is felt more than a gain of 1%. The recognition of this difference creates a behavioral pattern commonly referred to as loss aversion. Prospect theory paved the way for the development of the field of Behavioral Economics and Kahneman went on to share the Nobel Prize in Economics in 2002. Think about that for just a moment. A psychologist won the Nobel Prize in Economics. That probably ruffled a feather or two.

Another intriguing result of prospect theory is captured in Thayer Watkins’ description of risk-aversion and risk-seeking behavior. Watkins writes, “One very important result of Kahneman and Tversky’s work is demonstrating that people’s attitudes toward risks concerning gains may be quite different from their attitudes toward risks concerning losses. For example, when given a choice between getting $1000 with certainty or having a 50% chance of getting $2500 they may well choose the certain $1000 in preference to the uncertain chance of getting $2500 even though the mathematical expectation of the uncertain option is $1250. This is a perfectly reasonable attitude that is described as risk-aversion. But Kahneman and Tversky found that the same people when confronted with a certain loss of $1000 versus a 50% chance of no loss or a $2500 loss do often choose the risky alternative. This is called risk-seeking behavior. This is not necessarily irrational but it is important for analysts to recognize the asymmetry of human choices.”

Why bring this up in a blog about health IT and nephrology? Perhaps the author was out in the sun too much this weekend, but I think prospect theory describes why Dan Green is hearing so much about the penalty phase of the eRx program. Sure it’s only 1% of the doc’s Part B Allowable, but the “sting” is much greater than that. Next year heralds the arrival of the payment adjustment period for the upcoming penalty phase of both the PQRS and Meaningful Use programs. Failing to successfully participate in both in 2013 could result in sustaining two penalties in 2015. Many providers did not see the eRx penalty coming. Now that it is here, most are preparing to avoid it in the future. I suspect we will see the same thing with PQRS and Meaningful Use, and prospect theory suggests providers will avoid the penalties with substantially more vigor.

Deadline Extended for Appealing Medicare EHR Bonus
Physicians who believe they were incorrectly denied a Medicare bonus for using an electronic health record (EHR) system last year have a few more weeks to appeal their case.

Search Is on to Cure EHR Alert Fatigue
Researchers, physicians and others are coming up with strategies to ensure that warning alerts generated by health IT systems are less frequent — and more meaningful.

5 Steps to Transform EHRs into Modern Patient Collaboration Tools
With the rise of accountable care organizations (ACOs) and patient-centered medical homes (PCMH), the spotlight has been put on IT to help make a smoother transition to those new care models.

Value of Screening for Kidney Disease Unclear
Screening people to catch early kidney disease may sound like a good idea, but there is no research to prove that it’s worthwhile, according to a new review.

A Common Cholesterol Medication May Impact Kidney Health
Recent evidence from clinical trials and case reports suggests fibrates can cause an increase to serum creatinine, an indicator of kidney health measured by a blood test, which indicates a loss of kidney health.

CMS Gives Affymax’s Omontys Special Reimbursement Code
Affymax Inc. and Takeda Pharmaceuticals said Friday that the Centers for Medicare & Medicaid Services created a special reimbursement code, a Q-code, for their new anemia drug Omontys.

Beginnings

The PQRS program began in 2007 as a claims-only process over the second half of that year. Registry reporting and the reporting of measures groups followed in 2008. Reporting options have literally exploded in the interim as the following graphic from the report describes.

Numbers of Measures in the Physician Quality Reporting System by Reporting Option (2009 to 2011).

This trend continues in 2012 as there are now 210 individual measures and 22 measure groups available for reporting.

Registry Reporting on the Rise

During the program’s first year, reporting was restricted to submitting a quality data code (QDC) with the claim for the Medicare Part B beneficiary. Registry reporting was introduced as an alternative reporting method in 2008. Over the past few years registry reporting has exploded in popularity among eligible professionals. This is also true for nephrologists as is depicted in the following graphic I have abstracted from the CMS report referenced above.

Nephrologist Participation: Rise of Registry Reporting

 IM and MG in the graphic above refer to “individual measures” and “measures groups” respectively. Note the absence of growth in the number of nephrologists reporting PQRS via claims compared with substantial growth in registry reporting. The popularity of registry reporting is related to several factors, not the least of which is the success rate associated with registry reporting which is depicted in the graphic below. This, in large part, is related to the opportunity to report retrospectively as opposed to being required to submit QDCs with the claim on the date of service.

Nephrology Success Rates

As the graphic depicts, nephrologists reporting PQRS via a registry are successful over 90% of the time compared with claims-based reporting of PQRS where the success rate is closer to 50%.

Impact on Nephrology

CMS has not published their 2011 results as the registry reporting window only recently closed. Of interest, almost 2,400 nephrologists submitted PQRS data to CMS in 2010. That year was the first year more nephrologists reported via a registry than via claims, reflecting the rising popularity of the registry reporting method. Almost 1,900 nephrologist or 79% of those submitting data were successful in 2010. As you may recall, the incentive in 2010 was 2.0% of the provider’s Medicare Part B allowable for the calendar year. CMS paid these 1,900 nephrologists an average of $6,300 for their successful participation in the program.

The incentive dropped to 1.0% last year, and drops further to 0.5% of the Part B allowable in 2012. One might anticipate this will result in a drop-off in demand for PQRS reporting in 2012. I think that is likely to be the case. However, PQRS reporting is likely to increase again in 2013, which is the first PQRS adjustment payment-reporting period. Not reporting PQRS in 2013 will result in the provider sustaining a 1.5% reduction in their Medicare Physician Fee Schedule in 2015. If this sounds familiar, it should, as it is identical to the method employed by the eRx program, which is in play today. I plan to address this aspect of the PQRS program in a future post.

Have you participated in PQRS? Join the conversation and let us know what you think about the program.