On Saturday, September 22, the New York Times published an article “Medicare Bills Rise as Records Turn Electronic.” The journalists raise a question on how the use of electronic health records may be linked to increased billing of clinicians seeing Medicare patients.
The article cites a May 2012 report published by HHS’s Office of the Inspector General entitled “Coding Trends of Medicare Evaluation and Management Services.” (Evaluation and management services is an umbrella term used to describe clinical encounters between clinicians and patients, such as, but not limited to, chief complaint, history of present illness, exam, etc.)
The OIG’s report studies the period of 2001-2010; during this time period, OIG analysts found that physicians increased their billing of higher level E/M codes in all types of E/M services. Between 2001 and 2010, Medicare payments for payments for E/M services increased by 48%, from $22.7B to $33.5B. The number of E/M services billed increased by 13%, from $346M to $392M; and the average Medicare payment amount per E/M service increased 31%, from $65 to $85.
As a result of its analysis, OIG presented three recommendations to CMS, of which CMS concurred with the first two, and partially concurred with the third:
- Continue educating physicians on proper billing for E/M services;
- Encourage CMS’s contractor to review physicians’ billing for these services; and,
- Review physicians who bill higher-level E/M codes for appropriate action. (CMS partially concurred with the third because it wasn’t sure if the benefits of reviewing such physicians would outweigh the costs incurred to conduct the reviews.)
Now, let’s jump over to the EHR Incentive Program. Signed into law in February 2009, CMS published final regulations for the program in July 2010. The first payments were made in May 2011. These payments were made to the 320 eligible professionals and eligible hospitals that attested in April 2011 – in the first two weeks that CMS opened attestation.
I strongly believe that it is good and right to have reputable journalists, such as those at the New York Times, asking probing questions about the use of EHRs and other health IT. As more hospitals and clinical practices across the nation adopt and begin using health IT, it is imperative that those efforts support a transformed health system that improves the quality, safety, and cost-effectiveness of care, as well as improving the access to care.
At the same time, I do take issue with the introductory paragraphs of the Times’ article, which propose a causal link between the EHR Incentive Program payments and the OIG’s findings. As the dates above describe, the OIG’s findings are not connected to the Incentive Program.
Still, it would be naïve of us to not realize that there is, as in all sectors of our economy, the potential for fraud and abuse. Hence, I appreciate the spot-light reputable journalists and committed HIMSS members shine when asking probing questions, and digging for the truth.
As we witness an upsurge in the adoption and use of IT by clinicians, patients, and others, HIMSS has already begun building what we call the “third leg of the stool” – equipping stakeholders to harness the power of clinical and business intelligence tools. Our Clinical and Business Intelligence Committee, chaired by Diane Carr, Deputy Executive Director with the North Bronx Healthcare Network, is focused on creating tools, resources, and education around knowledge management tools to support accountable and quality care, and teaching users how to derive valuable knowledge from health data. Such tools, used effectively, can uncover fraud and abuse.
We are also exploring the “dark side of the Force”; uncovering the nefarious, foolish, or harmful outcomes can come from the worst use of IT and management systems. We want all stakeholders engaged in the conversation – those who share our passion to positively transform healthcare through the best use of IT and management systems.
Let’s work together to uncover the unintended consequences of health IT, to develop solutions that can mitigate these consequences, to self-police, be open to constructive criticism, and learn from each other.
I welcome you to join us on our journey.
That’s amazing article,thanks for the information.
I’m glad you’re addressing the idea of fraud and abuse. I know many doctors have told me how upset they are that they’re getting painted into a corner of fraud and abuse even when they’re not doing anything wrong.
However, I think this post doesn’t cover a really important point that I recently covered in detail in a related post: http://www.emrandehr.com/2012/09/25/ehr-incentive-increases-medicare-costs/ While Fraud and Abuse is a potential problem, the real issue that I see has to do with EHR taking under coding doctors and bringing their coding levels up legitimately. This isn’t fraud and abuse, but legal increase in coding thanks to EHR. This shift will cost Medicare and other payers billions of dollars.
The title of the post is spot on: Unintended Outcomes of EHR.
Thanks for your comment, John. Yes, the option you lay out here is certainly in-play. I appreciate you adding this link so that others can read your post.
John – That has been our experience as well. I am sure that fraud and abuse goes on in our industry, however, I believe a good share of the increases in charges are legitimate because the EHR is able to improve charge capture.
All the evidence, on both sides, is anecdotal. It’s time we performed a rigorous cost-benefit analysis of EHRs. Actually, it’s way PAST time!
The substantial negative impact of most EHRs on physician productivity adds to the direct financial cost of implementing these systems. There needs to be a highly significant benefit to justify this system-wide expense. Interoperability alone doesn’t cut it. See my brief opinion article at http://smartype.com/id11.html.
Thanks for your comments, Joe. Determining the return on investment of a health IT implementation is very important. HIMSS has published some research on ROI models tailored for healthcare. Last week, I posted a blog on this. Please check it out. Also, in April, HIMSS Analytics and Press Ganey jointly-published an analysis of physician satisfaction with a hospital by the EHR capabilities of the hospital. http://www.himssanalytics.org/research/mktResearchLibrary.aspx
In general, physicians have a low view of a hospital’s EHR; when the data was reviewed by age, the younger the doc, the higher the satisfaction levels. Advanced sophisticated use of an EHR within an hospital can be very challenging for a hospital leader to achieve. We highly encourage hospital leaders to engage their docs in the development & implementation of the EHR,
Great article and view of this issue. There is no doubt that any new technology (term used broadly) requires a lot of education and governance to ensure proper use. But, if we never tried a new technology because it might be used incorrectly, we wouldn’t have the wheel, either. The positives far outweigh the negatives, and we’ll work the negatives out of the system quickly, especially if payment is involved.
The doctors now have to schedule 20 minute appointments when previously they allotted on 15 for a routine appointment. Of course, if they are typing their own notes and coding they can be more mindful of checking ALL appropriate boxes, even ones they may have forgotten to mention if they were just dictating.
An additional consideration not previously mention is the important impact that the rapid adoption of ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) could have on inappropriate coding, including inadvertent and fraudulent. ICD-10-CM/PCS will provide more accurate payment structures and add much needed precision. ICD-10 will also make detection of inappropriate coding much easier. Additionally, ICD-10-CM/PCS will have positive implications for patients. The resulting improved clinical intelligence data can describe multiple levels of severity, which will result in improved care will support accurate, more individualized patient care and lead to or promulgate improved outcomes.
Notice, as with all of the technical articles on electronic patient records, that their is no mention of improvement of care for patients. The more accurate and timely image or test result, the lessening of duplication, and the more efficient medical professionals is not a concern of these rabble rousers.
The raise in the level of Medicare billing is pretty much a result of ACA stealing a billion dollars from Medicare by lowering the amount reimbursed — note that the article is all about “billing” — see if the Hospitals didn’t actually get LESS money from the program. Can you believe the President, with a straight face, says that he didn’t steal the trillion dollars to give to Medicaid ! He is just not going to pay the bill!
Good morning David, HIMSS supports a blog environment in which civil discourse can thrive. We welcome hearing from you in a constructive narrative. Debate through civil discourse is healthy. If you are interested in continuing to engage in the discussion, we welcome your fact-based opinions.
It may turn out that the expanded use of EHRs will improve the quality of clinical documentation to such an extent, that healthcare providers will deserve increased reimbursement for care! One example is fewer claims denials by payors —a labor intensive effort for all involved, with no benefit for the patient —through thoughtful analysis and application of clinical and financial data prior to billing. Improved efficiency and elimination of waste is one goal of EHR implementation, and supporting this goal is a focus of the HIMSS Clinical and Business Intelligence Committee as we begin our inaugural year.
Diane M. Carr
FY 2013 Chair, HIMSS C&BI Committee