Presidential Advisors Call for ‘Systems-Engineering Approach’ to Healthcare
Key Takeaway: A high-level report from the President’s Council of Advisors on Science and Technology (PCAST) calls for a “systems engineering” approach to improve care delivery in the US.
Why it Matters: Historically, PCAST reports have been important – if not controversial – documents. Past reports have signaled priority areas of policy and technology development from the White House, such as the need to develop a system of health data exchange predicated on metadata.
An advisory group to the White House issued a set of recommendations in a report on how systems engineering principles could improve efficiency and outcomes in the healthcare industry. The report, “Better Health Care and Lower Costs: Accelerating Improvement through Systems Engineering,” said the Department of Health and Human Services (HHS) must accelerate alternative payment models and the development of a nationwide health data infrastructure to take advantage of systems engineering approaches that are bringing benefits to other industries. “With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal,” the report notes.
PCAST authors proposed the following approaches in which the White House could make a difference:
- Accelerate alignment of payment systems with desired outcomes
- Increase access to relevant health data and analytics
- Provide technical assistance in systems engineering approaches
- Involve communities in improving health care delivery
- Share lessons learned from successful improvement efforts
Train health professionals in new skills and approaches
OIG Calls for Better EHR Fraud Prevention
Key Takeaway: HHS’ chief watchdog called on the agency to improve their fraud prevention efforts to stop physicians from using “copy/paste” functions to bilk Medicare and Medicaid.
Why it Matters: As long as upcoding and copy/paste issues remain a priority for the OIG, HHS officials will extend that focus onto providers. CIOs should ensure that their clinical documentation improvement programs identify processes that may be vulnerable to auditors and ensure they have the ability to justify practices meant to improve documentation efficiencies.
The Semiannual Report to Congress covers the period from Oct. 1, 2013, to March 31, 2014, and “describes significant problems, abuses, deficiencies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.”
The report covers different areas of Medicare:
- Contractor performance and quality assurance
- CMS’s use of data for oversight of Medicare Part C contractors
- Part D sponsor reporting of fraud and abuse data
- Electronic health records vulnerabilities and safeguards
- State Medicaid information systems vulnerabilities
- Hospitals inpatient payment policies: DRG Window
In terms of electronic health records, contractors contended it was difficult to identify copied language in a record. At the same time, “CMS had provided limited guidance to Medicare contractors on EHR fraud vulnerabilities.” The report concluded that only 25 percent of hospitals have protocols governing the use of copy and paste functionalities in EHRs. As adoption of EHRs continues to grow under the EHR Incentive Program, CMS will have to identify best practices to prevent fraud involving the use of EHRs.
Medicare: Almost $7B Overpaid for Doc Visits in 2010
Key Takeaway: With growing healthcare costs putting pressure on the economy, HHS needs to address the amount of fraud and waste in the healthcare system. This report covers a time before the Meaningful Use Incentive Program began, but the rapid adoption of health IT has not necessarily discouraged fraud as reports of “upcoding” were widespread last year.
Why it Matters: This report, like the OIG report to Congress, shines a spotlight on fraud and abuse in Medicare. The estimate is important because it adds definition to the problem and gives watchdogs a target to monitor.
A separate OIG report published last week proved that Medicare overpaid “$6.7 billion for claims for evaluation and management (E/M) services in 2010 that were incorrectly coded and/or lacking documentation, representing 21 percent of Medicare payments for E/M services that year.” Medicare has embraced the first recommendation, but has not focused on the second recommendation because the agency does not want to increase the audit burden on physicians, even when one in five Medicare payments was overpaid in 2010. High-coding physicians tended to have higher rates of miscoded claims. The phenomenon, called “upcoding,” means a lower reimbursement level code would be more appropriate to describe an office visit than the one billed. Recommendations for CMS included:
1. Educate physicians on coding and documentation requirements for E/M services
2. Continue to encourage contractors to review E/M services billed for high-coding physicians
3. Follow-up on claims for E/M services that were paid for in error
