MACRA proposed rule: Good intentions from CMS but a burden for small practices, says doc

Many physicians have waited with bated breath for the end of meaningful use, looking forward to a new era of less burdensome compliance requirements and more realistic reporting guidelines.

But after closely reading the Centers for Medicare and Medicaid Services’ thousand-page proposed rule for the Medicare Access & CHIP Reauthorization Act of 2015, or MACRA – which would sunset meaningful use for Medicare physicians – it seems many providers are realizing it’s not quite the fix they had in mind.

While it’s apparent CMS had “good intentions” when it crafted the proposed ruling, there are a lot of things the agency failed to consider, John Goodson, MD, staff internist at Massachusetts General Hospital and associate professor at Harvard Medical School told Healthcare IT News.

“What’s happening with MACRA is transformational: It’s the biggest thing since the Resource-based relative value scale,” Goodson said.

But just as “CMS didn’t consider how RBRVS – could tank providers,” the results of which are playing out right now, he said, the agency may have missed its mark here too. RBRVS stands for resource-based relative value scale.

According to John Squire, president and chief operating officer of Amazing Charts, a developer of ambulatory EHRs and practice management tools, there are two potential victims if the ruling is passed as is: small practices and Medicare beneficiaries.

“By basing penalties on outcomes, you may be ranking some of these physicians on circumstances out of their control,” Squire said. “There are behavioral things a physician can’t control. And it doesn’t allow for any exemptions, outside of low-volume.”

MACRA also removes the option for providers to opt-out of reporting by paying a penalty, which means all providers who accept Medicare patients must comply.

Many small practices won’t be able to keep up, he said. And according to Goodson, “Providers are being put in a position where it’s unattainable.”

“One unintended consequence, which happened with meaningful use, is some will look at the list of requirements and feel inundated,” said Squire. “They’ll just say, ‘The heck with it; I’ll just stop accepting Medicare patients or require cash-only.’”

Furthermore, the rule sets a very high barrier for practices hoping their existing participation in accountable care organizations counts for the Alternative Payment Model path, rather than  requiring them to attest for the Merit-Based Incentive Payment System, or MIPS.

Squire said, “Providers who have already bought into ACOs are crying foul: ‘I’ve designated resources to it and you’re saying that it doesn’t matter.’”

While Goodson recognizes CMS has a difficult task in responding to the pushback from the industry, he also recognizes that healthcare is “embarking on a whole new set of complications and implications.

“Quality is really focused around recording, but another piece is built around data interchange,” Squire said. “Physicians need to weigh how their systems support MACRA – and let the technology do the work to relieve the burden for the provider. It’s your practice methodology that would need to adjust.”

“A lot of people think this is going to be a whole new system,” said Goodson. “But it’s just a modification of the current system. This is a new complicated set of recording needs.”

Hospital company sued after FCC tightens medical debt collection rules

The bar was raised for medical debt collectors last summer when the Federal Communications Commission issued a ruling that made it harder to dial patients on their cellphones without their express consent.

Now a California-based hospital chain has become one of the first providers to be sued since the FCC’s July interpretive ruling.

The class-action suit targets Prospect Medical Group’s Southern California Hospital at Culver City. It alleges that the hospital used an automated dialer to call patient Donna Ratliff on her cellphone in order to collect a debt and did not have her express consent to do so.

The FCC issued its interpretive ruling after the medical debt collection industry—hoping for more flexibility—asked for greater clarification on the decades-old Telephone Consumer Protection Act to address issues such as auto-dialing cellphones, consent to call and reaching wrong numbers.

Instead, the FCC made it clear that debt collectors need express consent before dialing a cellphone and gave little leeway for when they reach a number that’s been reassigned.

Prospect Medical declined to comment on the Ratliff case, stating that the company hasn’t yet been served with the complaint.

However, the company insisted in a statement that it follows the necessary practices to obtain consent to call patients on their cellphones. “All of our patients are asked to sign an irrevocable authorization permitting our hospitals to contact them via telephone—including, specifically, via cellphone—in their efforts to collect outstanding debt.”

The plaintiff’s exact argument is still unclear, said Justin Kay, a Chicago-based attorney at law firm Drinker Biddle, who described the suit as “threadbare,” perhaps to make it harder for Prospect to win a motion to dismiss. “Presumably, what (the plaintiff’s attorney) is going to argue is the scope of consent did not include this call based on the circumstances under which the number was provided,” he said.

Previous cases have generally given hospitals some latitude on calling patients for purposes of collecting a payment as part of an episode of care. But healthcare providers need to make sure that the debt is linked to the medical encounter during which the patient provided a cell number.

“The best practice for any hospital is to have written consent during the admissions process that is broadly worded to include all types of automated calls and texts,” said Bradley Andreozzi, a Chicago-based attorney at Drinker Biddle.

TCPA violations are already an active area for plaintiffs, with TCPA-related lawsuits increasing 560% between 2010 and 2014, according to ACA International, the Association of Credit and Collection Professionals.

“As the FCC gradually narrowed the scope of express consent, it became cause to litigate,” Andreozzi said. “We don’t see any sign that that’s going to change anytime soon.”

Penalties for TCPA infractions start at $500 per call and can reach as much as $1,500 for willful violations.

While the Prospect case deals with the issue of express consent, it doesn’t touch one of the thorniest and most controversial parts of the FCC’s recent ruling: what happens when a debt collector reaches someone in error. The FCC allows medical debt collectors to call a number just once without penalty, regardless of whether someone picks up.

“The problem is they left no room for the situation—and this is increasingly common—where the person doesn’t answer the phone,” said Lewis Wiener, a Washington-based attorney at law firm Sutherland, Asbill & Brennan. “You’ve put them in an impossible situation.”

As many as 100,000 cellphone numbers are reassigned everyday, Wiener added.

ACA International has sued the FCC challenging the July order.

“It’s impossible for companies to keep up with that level of risk factor,” Wiener said. “There’s really no way to confirm whether the person you’re calling is the right number. It’s a gotcha.”

The best ways for providers to protect themselves, Wiener said, is to have a rigorous process for getting consent, respect the wishes of people who opt out and, whenever possible, use e-mail. “You’re swimming in shark-infested waters,” he said. “Take as few laps as you can.”

2015 Healthcare Workforce Executive Insights Survey Results

To gain a better understanding of how healthcare industry changes have affected talent management practices, HealthcareSource and the American Society for Healthcare Human Resources Administration (ASHHRA) issued the 2015 Healthcare Workforce Executive Insights Survey. 

More than 400 people at healthcare providers across the country offered their views about how their talent management organizations are adapting to industry changes such as aging demographics, population health, accountable care initiatives, and the rapid growth of retail care clinics.

Check out our infographic for a breakdown of a few key data points.


2015 Healthcare Workforce Executive Insights Survey - HealthcareSource and ASHHRA

MedAssets deal could pave way for regional and provider-led GPOs

The VHA-UHC Alliance’s planned acquisition of MedAssets’ group purchasing organizations and consulting business will make health systems reconsider their GPO allegiances and open up the market to disruptive models, experts and industry insiders say.

Consultants, as well as former and current GPO executives, say the deal could push providers toward smaller, regional GPOs that focus on local sourcing and niches. The mega-GPO created from the merger could lose members who are uncomfortable with the GPO’s size and changes that may come after integrating the two companies.

MedAssets announced Monday that it had been acquired by Pamplona Capital Management for $2.7 billion, which would immediately sell its spend and clinical resource management segment to VHA-UHC for an undisclosed price. Pamplona said it would integrate MedAssets’ remaining revenue-cycle management business with Precyse, its own revenue-cycle software.

Several consultants expressed concern that VHA-UHC could become disorganized as it works to integrate yet another major acquisition. The company has said it would announce a new name in the coming weeks, as it continues to integrate the operations of VHA, a major not-for-profit hospital GPO, and UHC, an alliance of most of the nation’s academic medical centers. The merger between the two closed in April.

To make matters more confusing, MedAssets hasn’t quite integrated the culture of Broadlane Group after acquiring its former rival in 2010 for $850 million, said former Broadlane CEO David Ricker, who is now CEO of BroadJump, a developer of software that helps hospitals manage their costs and see what others are paying for supplies. Some former Broadlane members liked the GPO’s stricter, more-committed model instead of MedAssets’ more flexible models that let hospitals use other vendors, he said.

“You’ve got former Broadlane clients still with MedAssets who were still pushing very hard to get to that Broadlane model,” Ricker said, adding that those hospitals may not wait to see what VHA-UHC decides to do next.

Dallas-based Tenet Healthcare Corp., a former member and majority owner of Broadlane, announced earlier this year that it wouldn’t renew its MedAssets contract. It chose to sign a five-year contract with HealthTrust, a committed-model owned by HCA. Experts said Tenet officials wanted a higher-commitment model in hopes of it leading to better prices.

Former Broadlane executive Brian Pellegrini, now managing director of spend performance consulting at the Advisory Board Company, said he expects HealthTrust executives to go after MedAsset members, especially the legacy Broadlane customers. Those members “are probably going to be the ones with the hardest time seeing a path that makes sense for them to remain with this new organization,” Pellegrini said.

Ricker and Pellegrini said they expect emerging regional GPOs, often developed by health systems, will be winners in this deal. Smaller, regional GPOs tend to pick a niche, such as physician preference items or purchased services, and focus on delivering strong contracts mainly in that space that can supplement a provider’s national GPO.

“Hospitals are going to be a lot smarter about how much their supply cost goes up every year, and savings touted by some of these organizations just aren’t real,” Ricker said. “The only way to get your physician-preference item spend under control is to source locally and regionally, and that’s not what a massive org with (VHA-UHC) and MedAssets is going to accomplish.”

These smaller firms now have a chance to show hospitals executives why it pays to have more than one GPO, said Daniel May, a managing director at Huron Healthcare. He pointed to the Plano-based Texas Purchasing Coalition and Atlanta-based Partners Cooperative that have been successful honing in on certain supply segments, with TPC showing strength in physician-preference items and Partners focusing on commodities.

Ricker, Pellegrini and May all mentioned that provider-led GPOs such as Amerinet, which is owned by Salt Lake City-based Intermountain Healthcare, and HealthTrust could also benefit from the MedAssets fallout. Amerinet CEO Brent Johnson is betting on that too, as he transforms his organization from a traditional GPO to a professional supply-chain organization.

“These people do this to make money,” Johnson said. “Intermountain didn’t. We did it because we trusted that you were going to be a model to the industry, teach us best practices … and we’ll go from there. If down the road people just aren’t willing to get off the administrative fee and the traditional GPO, then maybe our model is wrong, but I don’t think so.”

Johnson fully acknowledged that national GPOs have a hard time adopting the committed model that tends to get the best prices from vendors. He sees customers doing increasingly more on their own and within their respective regions to get more efficient contracts, which is why Amerinet–which will get a new name in 2016–is rolling out consulting solutions and outsourcing services over the next year to help customers manage their supply spend beyond their contracts with the GPO.

“We see ourselves as a very unique alternative rather than being connected to a huge GPO that’s out of touch with service,” Johnson said. “People will understand the importance of total non-labor spend. That isn’t done through a traditional GPO.”

These services will be offered at a lower cost than Amerinet’s competitors and the GPO will charge fewer administrative fees, Johnson said.

As more and more customers look into creating their own regional GPOs, the new Amerinet could help them plan out their administrative fees structure and other complex systems needed to manage it, Johnson said. And if they don’t have the talent or resources to handle some of those processes, they can outsource them to Amerinet.

“We welcome the change (at MedAssets) because we think it adds flux and a lot of confusion in the market that allows us time to build our solution, and I think it builds a lot of uncertainty for a lot of their customers, which allows us to go to people who didn’t want to talk to us before,” Johnson said.

A lot of health systems were already considering their options for switching GPOs before this announcement, said Dr. Mitch Morris, U.S. leader of Deloitte’s providers industry practice. Many of his clients have been stepping back and evaluating what they’re getting from their current GPO relationships.

The new GPO entity created following the merger will have to put together a story of how it will perform even better and drive even greater value, Morris said.

“If I were them, I’d be talking to my customers and reassure them that not only are things not going to get worse, they’re going to get better,” Morris said. The impact as far as lost customers will probably not be felt for years, he added. The scale of the company will be hard to beat in its ability to negotiate better prices because of its volume, “but clients won’t feel very special when they’re a part of something so big,” he said.

MedAssets was successful because it offered an alternative model from some of its competitors, said Doug Pedersen, a managing director at Accenture Strategy who focuses on healthcare.

For example, while VHA-UHC’s Novation GPO and Premier have private drug label brands and lean toward contracts with just one vendor, MedAssets officials have said that they’re against private labeling and that their customers prefer multi-source contracts. VHA-UHC executives have similarly pointed out that MedAssets hasn’t engaged in guaranteed-volume contracts that some believe can prevent drug shortages, a known strategy for Novation.

“It’s up to the purchaser to bring in the value of what you’re buying without breaking it,” Pedersen said. “It wouldn’t be wise to just take their members.


want to have the ability to demonstrate to all of those customers that they have a really good product.”


Eight Ways Physicians Know They’re Overworking

Overwork is not pretty, and in some cultures it’s deadly. In Japan, “karoshi” or death from overwork, annually claims anywhere from 10,000 workers to 30,000 workers. The range is vast because, without autopsies, it’s difficult to accurately assess the cause of death of people at their desks, slumped over.

Karoshi does not appear to be a significant phenomenon in the U.S. Still, among over-workers and the highly fatigued, high blood pressure and heart disease are exceedingly common.

Danger ahead

Given that you work very long hours — why can that be dangerous? When you encounter stressful situations by working longer and harder, your muscles contract, your blood thickens, your heart pumps blood faster, and your arteries narrow. You’re prepared for fight or flight. If you actually did fight or flee, the situation would largely take care of itself.

Instead, your internal “engine” is revving for eight hours to 10 hours on end. You arrive home, where more stressors may emerge. You cannot sleep as many hours as your body requires, or if you do, it’s fitful sleep with tossing and turning. As a result, you’re being worn down and your immune system is becoming weaker. Thus you’re more susceptible to illness.

Some researchers believe that consistently having too little sleep could impact your whole life, to your detriment. Combined with too much work and too little sleep, any illness that you might contract can be more troublesome.

Beyond tired

You feel tired, but when are you bordering on danger? Among many signs, here are a few:

1. Lack of appetite or indigestion. You normally look forward to meals, but when highly fatigued, you have trouble getting them down. Maybe, you’re eating less. Your fatigue is prolonged.

2. Extra sleep doesn’t help. Getting many nights of extra sleep in a row or sleeping for an entire weekend doesn’t seem to diminish your fatigue. Perhaps worse, you feel as if you’ll never “catch up.”

3. Excessive sleepiness. You doze at inopportune moments, such as during an important meeting, or when driving!

4. Loss of sex drive. This isn’t obvious because decline in libido usually occurs a bit at a time and you don’t notice, although your partner likely will.

5. Interrupted sleep. At night, you wake more often or toss and turn, and then, worse, you spend the rest of the night overly concerned that you’re not attaining good sleep.

6. Persistent fatigue. You feel tired upon arising even after a full night’s sleep. Realistically, if, by 9:30 a.m. or 10:00 a.m., you can hardly keep your head up, it’s time to take heed.

7. Poor concentration. Your focus on the task at hand is poor. Your concentration is diminished and is not due to your aging.

8. Feeling ineffective. Finally, you feel that you’re no longer in control. In many ways, this can be the most worrisome of all signs. Roll back your number of working hours as soon as you reasonably can.

If one or more of these has been a lingering issue for you, it’s time to take a personal inventory and make some decisions about how you are going to change things