Weekly compilation of health care reform developments in Washington, D.C. and state legislatures

Week of August 3, 2009

The timetable for federal health care reform was delayed again. No vote on health care reform by the full Senate or House is possible before September, and it could be much longer before debate ends and votes are cast.

The difficulties were all too apparent in the Senate Finance Committee last week, which has so far not been able to achieve the bipartisan bill its Chairman Max Baucus (D-MT) clearly wants. The Finance Committee had to issue an official denial to counter a Washington Post article touting a breakthrough deal among the six Senators (three Republicans and three Democrats) forging a compromise bill for the whole Committee to consider.

To emphasize the tenuous nature of the negotiations, Committee Member Senator Mike Enzi (R-WY) responded to the Post article by noting the story was "off the mark" and "not helpful."

Federal

As much as it has tried over the last week, Congress has only marginally moved the needle on health care reform. The Finance Committee will go home for the recess without a deal but with a promise to continue negotiating during the break, and with a target date of September 15 for Committee action.

In the House, the Blue Dog Coalition of 52 conservative Democrats put a halt to the Energy & Commerce Committee's process for 10 days when seven coalition members refused to proceed without concessions and compromises on the House health reform bill: a public plan that is optional to providers and that negotiates rates; preservation of the role of agents/brokers; keeping the bill under $1 trillion; and allowing state-based exchanges.

The compromise reached allowed the committee to continue its mark-up and ultimately approve the bill. There are 50 additional amendments that the Committee intends to address prior to floor debate in the Fall. The House will try to meld all three Committee versions into one bill in anticipation of a full House debate and vote in September, at the earliest. The Blue Dogs have made it clear that the larger coalition of 52 has not signed off on anything and that the compromise was chiefly designed to allow the Committee process to proceed. No sooner was the Energy & Commerce Committee/Blue Dog compromise struck when opposition came from both the House progressive caucus and the Congressional Black Caucus.

The bottom-line is that neither the House nor the Senate will be voting as a Chamber on health care reform until the Fall, when there will be a major confrontation of all competing interests.

States

ILLINOIS: The Illinois Department of Insurance (DOI) published second notice of proposed rulemaking regarding regulation of Preferred Provider Programs that will be considered for adoption by the Illinois Joint Committee on Administrative Rules (JCAR) on August 18. These rules affect both insurers and network administrators that offer incentives to insureds to utilize the services of contracted providers. For example, new network adequacy language would require that when a beneficiary has made a good faith effort to utilize network providers for a covered service but the appropriate preferred specialty providers are not under contract, then the administrator shall ensure that the beneficiary is provided the covered service at no greater cost than if the service had been provided by a preferred provider.

NEW YORK: The Departments of Health and Insurance released their report by the Urban Institute that examines several proposals to reform the state's health insurance system. The study analyzes the cost and coverage implications of:

1) the Public-Private Partnership proposal that would simplify and expand existing public programs and reform private health insurance;

2) New York Health Plus, which would give all New Yorkers an option to enroll in Family Health Plus;

3) Public Health Insurance for All, a single-payer public health insurance option; and

4) the Freedom Plan, an option that relies on regulatory flexibility and tax credits. Due to the growing state deficit and interest in federal reform, no immediate action is expected on these proposals. However, legislation based on one or more of the models is likely to be introduced, or reintroduced in 2010.

The report's key findings include: Three of the four proposals would cover all New Yorkers. The Freedom Plan would leave 13.3 percent of New Yorkers uninsured, down from the current 15.8 percent. There would be minimal change in employer-based coverage under the Public-Private Partnership and the Freedom Plan proposals. However, employer coverage would drop significantly under New York Health Plus and end altogether under Public Health Insurance for All. The individual insurance market would cease to exist under Public Health Insurance for All and New York Health Plus. Individual coverage would increase under the Public-Private Partnership and the Freedom Plan. Post-reform expenditures by employers and individuals would also vary widely. Under Public Health Insurance for All, employer and individual spending would be eliminated. New York Health Plus would reduce both individual and small employer spending. Individual spending would remain constant under the Public-Private Partnership proposal while small employer spending would drop slightly. The Freedom Plan would increase individual spending but somewhat reduce small employer spending.

OREGON: Oregon's health care reform efforts this year included passage of a 1 percent premium tax on health insurers. Recently, the Division of Insurance offered a draft opinion that the tax should be collected on group policies issued in Oregon and polices issued in other states that cover Oregon residents. The Division opinion is contrary to longstanding NAIC guidance and would result in the imposition of a double-tax on all group policies, as well as administrative hurdles in tracking where individuals reside.

No World Borders observation: The requirements to move to electronic health care records including HIPAA EDI 5010 for the electronic transfer of claims data, and the new medical coding standard ICD-10 will require all the time health care companies can get. Don't wait while the legislators debate the issues. Process impacts as well as data and electronic transfer issues have been under-estimated by may companies. Move ahead now. We can help. See our capabiliites brief and brochure.

Global Lessons: Planning and Preparation are Keys to ICD-10 Success

The Americal Recovery and Reinvestment Act (ARRA) provides incentives to modernize health care, including the upgrade to a new medical coding standard, ICD-10.

The Gartner Group, a leading research organization has called the transition to ICD-10 “a momentous change.” However, it also states that, “In the long run, ICD-10 is a key enabler for quality improvement, better management planning and better care.” Better care, isn’t that what every provider organization is trying to achieve?

For more than a decade, AHIMA has warned of the problems that exist with the ICD-9-CM system, while artfully promoting the value proposition of ICD-10. The AHIMA site offers a wealth of information from which CIOs and other senior executives can benefit.

We need first to understand some of the baseline deficiencies inherent as we continue to use the ICD-9-CM system. ICD-9-CM is obsolescent. The system is quickly running out of space for new codes, thereby limiting the inclusion of new procedures and diagnoses. Further, it is not sufficiently precise to fully enable an EHR, conform to pay-for-performance reporting requirements, adversely affects DRGs by grouping different procedures into a single code, and decreases our already considerable investment in SNOMED-CT.

Whether you work for a provider or payer, keep this in mind as we move to the October 1, 2013 compliance date.

• HIPAA X12 5010, the EDI standard required for implementing ICD-10 has an earlier date than 2013.
  
• Implementation of the EDI standard needs to be well in hand for your organization by 2011. That isn't far away if you are a large enterprise organization.
• Process impacts are easy to miss if IT and busines aren't partnered.
• Planning and preparation are keys to success
• Education is a must
• Network and reach out to others to learn from their experiences

We can learn from ICD-10 implementations that have already taken place in other countries. Thailand *yes Thailand* implemented ICD-10 in 1994. The U.S. is implementing a version of ICD-10 which the W.H.O. granted permission for it to modify, ICD-10-CM

Here is a summary of lessons learned from the Canadian experience with ICD-10 implementations.

According to a post from AAPC:

"The International Classification of Disease (ICD) is used for classifying diseases and other health problems recorded on many types of vital records including death certificates and hospital records. The International Statistical Classification of Diseases and Related Health Problems, 10^th Revision (ICD-10-WHO) is maintained by the World Health Organization and was endorsed by the 43^rd World Health Assembly in May 1990. Many countries around the world began implementing ICD-10 for mortality statistics in 1994. In the natural progression of coding medical records, various countries around the world began to contemplate the idea of using ICD-10 for morbidity data.

Since the World Health Organization (WHO) holds the copyright to ICD-10, those countries seeking to modify the system had to request permission to do so. All modifications must be approved by WHO to keep certain standards and conventions in place. By imposing standards and restrictions the coding integrity is maintained allowing for comparative analysis between counties on global conditions and diseases.

Countries that have sought and gained approval to create their own ICD-10 include Australia (ICD-10-AM), Thailand (ICD-10-TM), Germany (ICD-10-GM), Canada (ICD-10-CA) and the United States (ICD-10-CM).

Of particular interest to the United States is the experience Canada had in the implementation of ICD-10. Our neighboring country, Canada sought approval to modify ICD 10 from WHO in 1995, began work to modify the codes in 1999 and commenced adoption in April 2001.

The rollout of the new code set in Canada was different in some respects from the anticipated rollout in the United States. Canada’s universal, single-payer system is funded and regulated at the federal level but coordinated at the provincial level. In the Canadian ICD-10 rollout, each province had the ability to determine the date for their specific implementation. As a result, provincial implementation of ICD-10-CA was staggered beginning in 2001 with completion by April 2005. We do not have a single-payer system nor do our states have the same control as the Canadian provinces; as such, our implementation effort will not be staggered.

A somewhat interesting challenge that Canada had was that when they rolled out the ICD 10 system, Windows-based computer software was just making the scene. Not only were Canadian coders faced with a new code set, but they were also faced with the challenge of changing from using hardbound books to desktop Windows-based applications for their reference materials.

What they did implement that we should take note of as we embark on this journey is focused attention to planning and early commitment from industry stake holders including government leaders and agencies, professional associations, colleges and universities, providers and vendors.

The Canadian experience suggests three key points to remember:

• Planning and preparation are keys to success
• Education is a must
• Network and reach out to others to learn from their experiences

Whether you work for a provider or payer, keep this in mind as we move to the October 1, 2013 compliance date."

No World Borders Expands Health Care, Process Improvement Practice to Latin America

Newport Beach, CA - No World Borders today announced that it has expanded its health care and process improvement practices to Latin America, with projects under way in Mexico, Puerto Rico, with teams available for new market opportunities in Panama, and Uruguay.

Michael Arrigo, President & CEO of No World Borders said, "The world continues to become more global and borderless in terms of the need to align business and information technology. Latin American companies in the health care insurance business need bilingual English-Spanish speakers who understand process improvement, claims adjudication, electronic health records, claims systems, and the new HIPAA EDI standards X12 5010 and ICD-10. Recently, our partners and customers have turned to us, our team and our relationships to help reduce cost and risk in their business as they seek to become more efficient and paperless."

Renato Escobar, with Latin American services for No World Borders in Miami Florida added, "Our company brings multi-cultural, bilingual skills to emerging markets in health care and other industries. The U.S. has long been a model for health care best practices and process improvement. We are excited about our new offerings in this dynamic, high growth market place, and our innovative approach timed well for new business opportunities there."

To follow other company updates: www.twitter.com/marrigo on Twitter, or go to the company blog at noworldborders.blogspot.com

For Press inquiries, please email press@noworldborders.com

For more about No World Borders go to www.noworldborders.com

CONTACT INFORMATION

Public Relations
No World Borders
Email No World Borders
949-335-5580

Interview with TriZetto's Rob Scavo (AHIP)

While at the America's Health Insurance Plans conference in San Diego (AHIP) we met with Rob Scavo, President of Product Management and Core Administrative Solutions at TriZetto.

We asked Rob to provide TriZetto's view on what the new HIPAA standards, X12 5010 and medical coding standard ICD-10 mean in terms of not only compliance but opportunities to innovate and improve operations for both payors and providers.

Click play below to view the interview.