The administration kicked things off with the HITECH Act and its health records, health information exchange and privacy/security provisions. I.T. executives' plates were pushed to overflowing with implementation of the HIPAA 5010 transaction sets and ICD-10 code sets, and the annual modifications to Medicare and Medicaid policies and payments.
The federal government now has served up the Patient Protection and Affordable Care Act, commonly known as the health care reform law, also frequently referred to by both proponents and critics as ObamaCare.
Health Data Management's June and May issues covered several new reform-related challenges, including new "operating rules" to further standardize HIPAA transactions, electronic enrollment for public health and human services programs, lower Medicare/Medicaid reimbursements, and demonstration programs to better coordinate care and adopt best practices.
Warning: I.T. minefields
But there are more I.T. minefields sprinkled throughout the massive reform law. The bill mandates establishment of state-level insurance exchanges to enable consumer analysis and purchase of coverage, as well as a "medical loss ratio" calculation for payers. Buried deep in the bill is a new tax on medical devices. In addition, there's a requirement for adoption of a unique health plan identifier, and a mandate for the Internal Revenue Service to take on new data collection and reporting requirements.
So what does this all mean to health I.T. executives? There may be more questions than answers at this stage, but the short answer is: a lot. For instance:
* Reform law provisions, most notably the operating rules for HIPAA transactions, will have a direct affect on provider organizations, says Chantal Worzala, director of policy at the American Hospital Association. Care facilities will have to use the operating rules to improve their revenue cycle to cope with Medicare cuts that pay for some of the reform tab, and millions of new enrollees entering low-paying Medicaid programs.
* Other provisions might not have an immediate impact but likely will have monumental consequences down the line. For instance, the law authorizes Medicare and Medicaid pilot programs to bundle services resulting from inpatient stays. When, not if, the pilots become industrywide requirements, a new level of data exchange and sharing will need to be standard practice during care coordination.
* The new law also requires the federal government to set standards for collecting data on disparities of care based on race, ethnicity and other factors, which will change the data reporting landscape for providers.
* Hospitals and physician practices will be affected by efforts to develop more uniform eligibility and enrollment processes across government-sponsored health and human services programs, Worzala says. "Hospitals play a role in helping people understand their eligibility for Medicaid, so that's something they will be looking for."
While industry experts figure out what's in the bill, here's what's not: Reform did not bring socialized medicine to the United States, although already heavy government regulation just got expanded; and no government entity was given statutory authority to kill grandma.
State exchanges
The reform law calls for development of state insurance exchanges across the nation by 2014. The exchanges will be Web portals enabling consumers and small businesses to compare and purchase public or private health insurance coverage.
Setting up the insurance exchanges will be taxing on the many states already in dire financial condition, says Angie Petty, senior analyst at INPUT, a Reston, Va.-based consulting firm serving public sector agencies and companies seeking government business.
Providers will benefit from insurance exchanges if the exchanges, as hoped, ease consumer purchases of coverage with a resulting increase in the percentage of patients who are insured. But the affect to providers' information technology operations, if any, isn't yet clear.
As states start working on insurance exchanges, they're also working on statewide health information exchanges funded by HITECH. Could the projects dovetail with states building a single comprehensive exchange controlling both programs?
"We haven't heard talk of piggybacking," says John Thomasian, director of the Center for Best Practices at the National Governors Association in Washington. "They are very different missions and each will take a lot of work. But I won't rule it out. We're going to have to see how these kinds of functions evolve."
One scenario could be that some administrative data, particularly coverage details, may be common to both insurance exchanges and HIEs, he adds. But it's not yet clear if there will be a lot of complementary data between the different types of exchanges.
Under the reform law, consumers with incomes up to 400 percent of the federal poverty level will be eligible for federal subsidies to make coverage more affordable. States are not mandated to establish an insurance exchange, but must inform the federal Department of Health and Human Services by 2013 whether or not they will. If a state opts not to build an exchange, the feds will step in and operate an exchange in that state, either directly or under contract with a not-for-profit entity.
Thomasian doesn't see many, if any, states opting out of doing the insurance exchange work. "States won't want the feds to come in and work with local payers, and lose that contact with the payers and opportunities to increase competition," he believes. There's also an inclination that if exchange costs don't dig deep into state budgets, the states will want to build the exchange and so will their payers, he adds. "They're used to negotiating with each other."
The data needs for a state insurance exchange will be significant, even though states already collect some of the data from insurers.
The exchanges will display to consumers a range of information on private plans operating in a state, as well as the public Medicaid and SCHIP programs. The data includes, among other information, insurer name, types of products, summaries of services offered, links to provider networks, contact information, eligibility criteria, coverage limitations, premiums, and enrollment and disenrollment processes.
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