BAYONNE, N.J. — The most expensive hospital in America is not set amid the swaying palm trees of Beverly Hills or the luxury townhouses of New York’s Upper East Side.

It is in a faded blue-collar town 11 miles from Midtown Manhattan.

Based on the bills it submits to Medicare, the Bayonne Medical Center charged the highest amounts in the country for nearly one-quarter of the most common hospital treatments, according to a New York Times analysis of 2011 data, the most recent available. No other hospital was at the top of the price list more often.

Bayonne Medical typically charged $99,689 for treating each case of chronic lung disease, 5.5 times as much as other hospitals and 17.5 times as much as Medicare paid in reimbursement. The hospital also charged on average of $120,040 to treat transient ischemia, a type of small stroke that has no lasting effect. That was 5.6 times the national average and 23.6 times what Medicare paid.

For those prices, the quality of care at Bayonne Medical is no better — or worse — than that at most other New Jersey hospitals. In a 2011 state hospital quality report, Bayonne Medical scored only in the top 50 percent.

But profits at the hospital, which was bankrupt in 2007, have soared in recent years, in part because it has found a way to turn some of those high billings into payments.

The increasingly contentious issue of hospital charges drew renewed attention last week when the federal government released Medicare data showing that facilities nationwide submitted widely divergent bills for the same treatments.

And while the unassuming, six-story brick hospital here holds a notable place in those rankings, others stand out as well. The midsize Crozer-Chester Medical Center in Upland, Pa., was the top biller in the country for urinary tract infections. One prestigious Manhattan hospital, NYU Langone Medical Center, charged twice as much as the equally high-end NewYork-Presbyterian to implant a cardiac pacemaker. But Medicare considers the two New York hospitals so similar it pays them both about $20,000 for the procedure.

The hospital industry is quick to say that the charges are irrelevant because virtually no one — private insurers, Medicare or even the uninsured — pays anywhere near those amounts. Medicare sets standard rates for treatments and insurers negotiate with hospitals. But experts add that the charges reflect decades of maneuvering by hospitals to gain an edge over insurers and provide themselves with tax advantages.

Until a recent ruling by the Internal Revenue Service, for instance, a hospital could use the higher prices when calculating the amount of charity care it was providing, said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins. “There is a method to the madness, though it is still madness,” Mr. Anderson said.

A close look at the finances of Bayonne Medical Center sheds light on how hospital pricing at the extremes may financially benefit an institution. The practices at Bayonne Medical also highlight a new financial strategy used by a small number of hospitals to increase their profits by “going out of network” — severing ties, and hence contractual agreements that limit reimbursement rates, with large private insurers.

Neither officials nor owners of Bayonne Medical responded to multiple calls and e-mail requests for interviews. Because the company is privately held, it does not have to release financial data.

Bayonne Medical, which was founded in 1888, was losing nearly $1.5 million a month before it filed for bankruptcy in 2007. By 2011, under new ownership and a new financial model, its patient revenue had nearly tripled and its operating income had reached $9.3 million, according to the American Hospital Directory, a publication that compiles data from Medicare and other sources about health care facilities.

The hospital’s turnabout started in 2008 when it was acquired out of bankruptcy by a consortium of buyers in a deal valued at about $41 million.

Bayonne’s purchasers included Vivek Garipalli, who worked at the private equity giant Blackstone Group before co-founding the International Sleep Network, a company based in New Jersey that treats patients with sleep apnea and other disorders. Joining Mr. Garipalli was Jeffrey Mandler, the head of a health care imaging firm. To make money from Bayonne Medical, the new buyers made some big changes in the hospital’s business strategy.

First, they converted Bayonne Medical from a nonprofit to a for-profit hospital at a time when such hospitals were a rarity in New Jersey. Next, they moved to sever existing contracts with large private insurers, essentially making Bayonne Medical an out-of-network hospital for most insurance plans.

Under New Jersey law, patients treated in a hospital emergency room outside their provider’s network have to pay out of pocket only what they would have paid if the hospital was in the network. But an out-of-network hospital can bill the patient’s insurer at essentially whatever rate it cares to set. While the insurers can negotiate with the hospital, they generally end up paying more than they would have under a contractual agreement.

In recent years, Bayonne Medical put up digital billboards highlighting the short waits in its emergency rooms in an effort to attract more patients. Insurers complained that the hospital was seeking to take advantage of the higher rates it could charge.

While the law was aimed at giving patients more hospitals to choose from, it “has had the unintended consequence of rewarding folks for these inflated charges,” said Wardell Sanders, president of the New Jersey Association of Health Plans. “When people say these charges are just the sticker price and it’s meaningless, it’s not meaningless.”

Community leaders in Bayonne, fearing the hospital could close, said the buyers were always candid about the methods they intended to use to make the hospital a profitable enterprise.

“That raised a lot of concern, but what other choice did we have?” said Jeanne Otersen, who was a member of the Coalition to Save Bayonne Medical Center and is policy director for the Health Professionals and Allied Employees, a union that represents nurses at the facility.

Not surprisingly, the insurers fought back against the out-of-network model. In 2009, Horizon Blue Cross Blue Shield of New Jersey filed an injunction in New Jersey Superior Court saying Bayonne Medical’s owners had “flatly rejected” and refused to negotiate an in-network hospital contract with Horizon. When the existing agreement expired in early 2009, Horizon said Bayonne sharply increased its prices. Bayonne’s in-network charges to Horizon averaged $13,000 a day in 2008. A year later, when it was out of network, the charges soared to $29,000, the insurer said in a spring 2009 news release.

Bayonne Medical denied allegations in Horizon’s lawsuit that it was artificially inflating prices, and filed its own lawsuit against Horizon, claiming the insurer had intimidated patients and tried to get them to leave the facility before completing their treatments.

The two eventually settled in 2011, and Horizon became an in-network insurance provider. A spokesman for Horizon declined to comment on Bayonne Medical’s charges, citing terms of the settlement agreement.

Still, many other large insurance companies, including Cigna, United Healthcare and Aetna, remain out of network at Bayonne and are paying the higher bills.

“Their model is to charge exorbitant rates, particularly for emergency room services, and if the insurance companies don’t pay them, they threaten to go after the member for the balance of billing,” said Carl King, head of national networks for Aetna, whose in-network contract was also ended by Bayonne in 2008.

Like Horizon, Aetna said its bills from Bayonne Medical soared, and it also filed a lawsuit in 2011. The suit was dismissed.

Aetna’s internal data showed that Bayonne Medical’s emergency room charges jumped again in 2012 and are running 6 to 12 times as high as those of surrounding hospitals. Last fall, Mr. Garipalli bought the designer Tory Burch’s oceanside home in Southampton for $11 million, according to public records.

After purchasing Bayonne Medical, the investor group went on a buying spree, acquiring Hoboken University Medical Center in 2011 and the bankrupt Christ Hospital in Jersey City last year.

“This hospital is clearly pursuing an out-of-network strategy with a profit motive in mind and taking advantage of members who seek emergency services at their facility,” Mr. King said.

Although primary care physicians bring in more net revenue to the average hospital, their compensation still lags behind those in several medical and surgical specialties.

Last week, physician consulting firm Merritt Hawkins released its “2013 Physician Inpatient/Outpatient Revenue Survey.” Merritt Hawkins received responses from 102 hospital and health system CFOs. The CFOs indicated the combined net inpatient and outpatient revenue generated annually for their facilities by a single, full-time equivalent physician across several specialties.

Revenue was represented by procedures performed at the hospital, tests and treatments ordered and other factors. (For primary care physicians, hospital CFOs were asked to determine revenue generated from direct admissions, procedures performed, lab tests, etc., but not from indirect revenue primary care physicians may have generated from patient referrals to specialists utilizing the hospital.)

On average, a family practice physician brought in $2.07 million of annual net revenue to his or her hospital, only behind orthopedic surgeons and invasive cardiologists, but family practice physicians’ compensation was far lower. An orthopedic surgeon generated an average of $2.68 million per hospital, and average orthopedic surgeon compensation was $519,000 — meaning that for every $5.17 of revenue an orthopedic surgeon brought it, he or she received $1 in compensation. Family physicians saw $1 of compensation for every $10.94 of generated revenue, the widest gap of any specialty.

Otolaryngologists had the slimmest revenue-to-compensation ratio, as they earned $1 of pay for every $2 of revenue they brought into the hospital. Ophthalmologists, neurologists and neurosurgeons were not far behind.

Here are 51 statistics across 17 specialties on physician-generated hospital revenue, hospital salaries for physician and their corresponding revenue-to-compensation ratios based on data from Merritt Hawkins’ “2013 Physician Inpatient/Outpatient Revenue Survey.” Data is sorted by specialties that generated the most hospital revenue. To compare to 2010 data, click here.

Orthopedic surgeons
Median 2013 revenue: $2,683,510
Median 2012 hospital compensation: $519,000
Revenue-to-compensation ratio: 5.17:1

Cardiologists (invasive)
Median 2013 revenue: $2,169,643
Median 2012 hospital compensation: $512,000
Revenue-to-compensation ratio: 4.24:1

Family practice physicians
Median 2013 revenue: $2,067,567
Median 2012 hospital compensation: $189,000
Revenue-to-compensation ratio: 10.94:1

General surgeons
Median 2013 revenue: $1,860,655
Median 2012 hospital compensation: $343,000
Revenue-to-compensation ratio: 5.42:1

Internal medicine physicians
Median 2013 revenue: $1,843,137
Median 2012 hospital compensation: $203,000
Revenue-to-compensation ratio: 9.08:1

Hematologists/medical oncologists
Median 2013 revenue: $1,761,029
Median 2012 hospital compensation: $360,000
Revenue-to-compensation ratio: 4.89:1

Neurosurgeons
Median 2013 revenue: $1,684,523
Median 2012 hospital compensation: $669,000
Revenue-to-compensation ratio: 2.52:1

Obstetricians/gynecologists
Median 2013 revenue: $1,439,024
Median 2012 hospital compensation: $268,000
Revenue-to-compensation ratio: 5.37:1

Urologists
Median 2013 revenue: $1,428,030
Median 2012 hospital compensation: $461,000
Revenue-to-compensation ratio: 3.10:1

Gastroenterologists
Median 2013 revenue: $1,385,714
Median 2012 hospital compensation: $433,000
Revenue-to-compensation ratio: 3.20:1

Psychiatrists
Median 2013 revenue: $1,302,631
Median 2012 hospital compensation: $224,000
Revenue-to-compensation ratio: 5.82:1

Cardiologists (noninvasive)
Median 2013 revenue: $1,232,142
Median 2012 hospital compensation: $396,000
Revenue-to-compensation ratio: 3.11:1

Pulmonologists
Median 2013 revenue: $1,009,868
Median 2012 hospital compensation: $321,000
Revenue-to-compensation ratio: 3.15:1

Otolaryngologists
Median 2013 revenue: $825,757
Median 2012 hospital compensation: $412,000
Revenue-to-compensation ratio: 2.00:1

Pediatricians
Median 2013 revenue: $787,790
Median 2012 hospital compensation: $189,000
Revenue-to-compensation ratio: 4.17:1

Ophthalmologists
Median 2013 revenue: $725,000
Median 2012 hospital compensation: $295,000
Revenue-to-compensation ratio: 2.46:1

Neurologists
Median 2013 revenue: $691,406
Median 2012 hospital compensation: $280,000
Revenue-to-compensation ratio: 2.47:1

A significant portion of the physician market has still not adopted an EHR, despite the lure of government incentives and the fear of the penalties looming on the horizon. The stock prices of most publicly traded ambulatory EHR companies are down sharply, as sales are lower and earnings projections have not been met throughout the industry. How can this be, when the EHR incentive program has successfully increased EHR adoption and was expected to be such a boon to EHR vendors?

I know why, and it is not—as commonly thought—because the initial EHR-adoption rush fostered by the incentives has ended. Rather, it is because of rampant physician dissatisfaction that has reached a more-than-palpable level. I have noticed a dramatic change in the tenor of conversations with physicians, most recently at professional society conferences, where physicians who have not yet purchased an EHR are frozen in their tracks. They are worried by the horror stories they hear from colleagues—even from those who have succeeded at meaningful use—because many of those physicians continue to experience major workflow disruptions and significant productivity losses from which they see no potential to rebound. Recent surveys point to the number of physicians looking to replace their EHRs, and based on my company’s experience in the replacement market, that number is growing. A recent article summarized the findings of a large study on EHR satisfaction and presented an insightful analysis of the potential reasons for these disappointing results.

This heightened level of frustration has resulted from frantic, insufficiently researched EHR purchase decisions by physicians and rushed, inadequate implementations conducted by resource-strapped vendors. Massive EHR failures are exactly what I predicted in an EMR Straight Talk post on the unintended consequences of the EHR incentive program in February 2010:

After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. . . . The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.

So, what can physicians do to avoid falling victim to EHR failure, and to instead reap the benefits of successful EHR adoption—government incentives and practice productivity? I have written extensively about the importance of physicians doing thorough and objective reference checking—that advice is as valid now as when I first wrote about it, and perhaps is even more critical today. For guidance on how to conduct a thorough and fair evaluation of an EHR, read EMR Selection: How to Uncover the Truth or 100% EHR Success – A Clinical Approach.

This story was produced in collaboration with

At a critical point in a complex abdominal operation, a surgeon was handed a device that didn’t work because it had been loaded incorrectly by a surgical technician. Furious that she couldn’t use it, the surgeon slammed it down, accidentally breaking the technician’s finger. “I felt pushed beyond my limits,” recalled the surgeon, who was suspended for two weeks and told to attend an anger management course for doctors.

The 2011 incident illuminates a long-festering problem that many hospitals have been reluctant to address: disruptive and often angry behavior by doctors. Experts estimate that 3 to 5 percent of physicians engage in such behavior, berating nurses who call them in the middle of the night about a patient, flinging scalpels at trainees who aren’t moving fast enough, demeaning co-workers they consider incompetent or cutting off patients who ask a lot of questions.

“We’re talking about a very small number of physicians, but the ripple effect is profound,” said Charles Samenow, an assistant professor of psychiatry at George Washington University School of Medicine, who evaluates doctors with behavioral problems.

For generations, bad behavior by doctors has been explained away as an inevitable product of stress or tacitly accepted by administrators reluctant to take action and risk alienating the medical staff, particularly if the offending doctors generate a lot of revenue. Recently at one Virginia hospital, according to University of Virginia School of Nursing dean Dorrie Fontaine, a veteran operating-room nurse with 30 years’ experience walked into her supervisor’s office and quit after a surgeon screamed at her — his usual reaction to unwelcome news — when she told him that a routine count revealed that an instrument was missing. Hospital administrators shrugged off the episode, saying, “Well, that’s the way he is.”

But that time-honored tolerance is waning, Samenow and other experts say, as a result of regulations imposed in 2009 by the Joint Commission, the group that accredits hospitals. These rules require hospitals to institute procedures for dealing with disruptive behavior, which can take passive forms such as refusing to answer pages or attend meetings. The commission has called for a “zero tolerance” approach. Such behavior is not unique to doctors; researchers have found that nurses act out, too, mostly to other nurses, but that their behavior is less likely to affect patients.

Corrosive Effect On Morale

Growing attention to the problem, which appears to be most common among surgeons and other specialists who do procedures, has spawned a cottage industry of therapists who provide anger management counseling, which is sometimes billed as “executive coaching.” Programs are flourishing at Vanderbilt, the University of Virginia, the University of California at San Diego and, most recently, George Washington University.

(Illustration by Jan Feindt)

Most doctors who enroll are middle-aged men sent by hospitals or state medical boards that have ordered them to shape up.

Experts say that doctors’ bad behavior is not merely unpleasant; it also has a corrosive effect on morale and poses a significant threat to patient safety. A 2011 survey of 842 hospital administrators for the American College of Physician Executives found widespread concern: 71 percent said disruptive behavior occurs at least monthly at their hospital, while 11 percent said it was a daily occurrence. Ninety-nine percent said they believed such conduct negatively affected patient care, while nearly 21 percent linked it to patient harm. Those findings mirror a 2008 study of more than 4,500 doctors and nurses, in which 71 percent tied it to a medical error and 27 percent to the death of a patient.

“Many hospitals and health-care systems are beginning to address it just to keep their accreditation,” said Peter Angood, chief executive of the physician executives group. Angood, formerly chief patient safety officer at the Joint Commission, compares the problem to road rage. Like its automotive counterpart, it can have deadly consequences.

Laura Sweet, deputy chief of enforcement for the Medical Board of California, has said that the licensing body has investigated several maternal or fetal deaths resulting from the failure of nurses to contact doctors about a worrisome reading on a fetal monitor “for fear of being chastised or ridiculed.”

“Hospitals can no longer afford to look the other way,” said California internist Alan Rosenstein, who has written extensively about the issue, beginning with an influential 2002 study that found that bad behavior by doctors drove nurses from the profession, contributing to the nursing shortage. Bad conduct, notes Rosenstein, former West Coast medical director of the VHA hospital network, can have expensive consequences in the form of lawsuits by employees alleging the existence of a hostile workplace and an exodus of experienced nurses who are expensive to recruit and difficult to replace.

‘The Patient Died’

Sometimes patients are the victims. Rosenstein cites one case of a physician who ridiculed a nurse after she called him at home, worried that a patient in the intensive care unit had developed aspiration pneumonia, a potentially lethal complication that occurs when a substance such as food or vomit is inhaled into the lungs. “He told the nurse to ‘get better training’ and refused to address the issue,” Rosenstein said. “The patient died.”

Changes in the way health care is delivered — along with escalating demands to see more patients, reduced nursing staffs and uncertainty as hospitals buy medical practices — may help foster bad behavior, said J. Kim Penberthy, co-director of the University of Virginia’s Effective Coping and Communication Skills Program. “So much of what we see is the frustration and difficulty of coping with change” by older doctors.

Care is now delivered in teams, making interdependence, not autonomy, paramount, said Fontaine, who has written about disruptive behavior and confronted it as an operating-room nurse. “Forty years ago, medicine was more hierarchical” and teamwork less important, she said.

Most doctors who wind up at Vanderbilt or similar anger management programs have long histories of conflict with colleagues and administrators, sometimes dating back to residency training, said GWU’s Samenow. Those whose outbursts are the result of underlying substance abuse or psychiatric disorders are usually diverted to other kinds of treatment.

Many are technically excellent and some are beloved by patients — even if their colleagues can’t stand to work with them. “Sometimes the guys who are most disruptive are winning teaching awards or Washingtonian top-doctor awards,” Samenow said. Frequently they are narcissistic, compulsive perfectionists who insist that they are the real victims when complaints are lodged and defend their behavior by saying they were doing what was best for their patients.

“Other people experience them as disruptive, but I like the term ‘distressed,’ ” said William Swiggart, who co-directs Vanderbilt’s Program for Distressed Physicians. Swiggart said he tells participants in the course, which costs $4,500 per person, “This is a course based on how you’re perceived. I’m happy to assume your heart’s good. But your behavior sucks.”

The Vanderbilt team gathers considerable information before a doctor arrives in Nashville, interviewing co-workers and administrators about his or her skills, behavior and other factors.

To one doctor who complained that he didn’t know why he had been sent, Swiggart said he responded, “ ‘They think you’re an arrogant ass is why they sent you.’ “

George Anderson, a social worker in Beverly Hills, Calif., has been offering anger management counseling for 25 years to people in a variety of professions. Doctors, whom he treats individually, not in groups, account for a growing share of his practice.

“You’re working with the smartest group of people on the planet,” said Anderson, whose clients include doctors from UCLA Medical Center. “These are people with high IQs . . . [but] their emotional intelligence scores are really pathetic.” Anderson said he worked with one surgeon who booted an anesthesiologist out of the OR, leaving the patient unmonitored during surgery, after the two physicians had gotten into an argument.

While disruptive behavior is rooted in personality traits and often cemented by dysfunctional childhood experiences, Rosenstein and others say the brutal way in which doctors have been trained plays a role.

Traditionally, “medical students were told, ‘You don’t know anything, so shut up until you do,’” Rosenstein said. Many, he said, emerge from training as “autocratic, independent and dominant,” and they imitate the ways they were taught. “It’s a setup for disaster.”

Swiggart said that the three-day program at Vanderbilt, which is followed by three follow-up sessions over six months, focuses on developing and practicing coping and communication skills. Sessions are held about six times per year and are limited to six physicians, who must role-play the incident that brought them to Nashville.

“You need a group, and [participants] need feedback,” Swiggart said.

Few studies assessing the effectiveness of such programs exist. A preliminary study of 100 doctors who completed the Vanderbilt course showed statistically significant reductions in disruptive behavior as rated by co-workers, administrators and the doctors themselves. But Swiggart added, “Not everybody makes it. There are some individuals who really need to leave.”

One Surgeon’s Story

The surgeon who fractured the tech’s finger described it as an accident fueled by sleep deprivation and a crushing workload. His hand, she said, was “where it shouldn’t have been” — on the patient’s metal leg strap.

“I was completely distraught that I had it in me to do that,” said the surgeon, who spoke on the condition that neither her name nor the Midwestern state where she practices be published. The hospital recommended she go to Vanderbilt at her own expense; about 20 percent of enrollees are women.

Although there had been no other overt incidents, she said that her career had been marked by “difficult interactions,” especially with nurses. “I felt hated,” she said, adding that she thought some were jealous of her. She did not cultivate relationships with co-workers and later learned that others avoided her because of what they regarded as a harsh style and chronic bad mood.

Now in her mid-40s, she said she behaved as she had been taught during residency and fellowship training.

“I was trained by all men who walked into the room and barked, ‘Get the NG [nasogastric] tube working.’ ” One time, she recalled, her mentor threw an instrument at her in the OR. “I never had a female mentor, and what I was told when I went into surgery as a woman was, ‘You’ve got to be tough.’ I think men get away with a lot more than women” when it comes to bad behavior.

She arrived in Nashville feeling as though she was being “sent away and punished” but said that the program helped her better regulate her emotions and soften her brusque demeanor.

“It’s really like group therapy,” she said. “The most powerful part was listening to other people’s stories and telling my story.” Role-playing the incident was particularly hard.

The course has helped her immensely, she said, teaching her relaxation and self-monitoring skills and improving her outlook about her practice. “I was not functioning well, but I did not realize it.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Association cites negative impact EHRs have on docs

By Tom Sullivan for HealthcareITNews

As the healthcare industry moves to EHRs, the medical record has essentially been reduced to a tool for billing, compliance and litigation that also has a sustained negative impact on doctors’ productivity, according to Steven J. Stack, MD, chair of the American Medical Association’s board of trustees.
“Documenting a full clinical encounter in an EHR is pure torment,” Stack said during the CMS Listening Session: Billing and Coding with Electronic Health Records on Friday.

EHRs are also driving the industry toward charts that look remarkably similar because they’re based on templates created by the technology vendors — that includes often using the same words. And that threatens to make doctors appear to be committing fraud by the practice of record cloning, or cutting and pasting from one record to another, when they are not, in fact, acting fraudulently. Alongside the federal mandate to implement an EHR under threat of a monetary fine, that creates what Stack called “an appalling Catch-22 for physicians.”

Put another way: The government mandates that doctors use an EHR, the EHR vendors’ templates can sometimes create an appearance of fraud and that, in turn, opens the door for payers to decline reimbursement or, even worse, the government to prosecute doctors for the crime.

As dire as that sounds, it’s an exception that belies the unproven perception that EHRs perpetuate fraud. “Upcoding does not necessarily equate to fraud and abuse,” said Sue Bowman, AHIMA’s senior director of coding and compliance at the same event. “This is an area where more study is needed. We really need to know the causes. Further research is needed on the fraud risk of using EHRs.”

Indeed, Jacob Reider, MD, CMO of ONC, explained that the government and industry do not have good data right now proving whether or not EHRs trigger fraud and abuse.

“There is concern that some doctors are using the EHR to obtain payments to which they are not entitled,” said Mickey McGlynn of Siemens Medical Solutions and HIMSS EHR Association. “Any fraud is an important issue and we, as the vendor community, take that very seriously.”

AMA’s Stack offered a triptych of suggestions to CMS and ONC: address EHR usability concerns, provide guidance on EHR use for coding and billing, and make meaningful use stage 2 more flexible for providers.

“My purpose is not to denigrate EHRs,” Stack said, explaining that he believes CMS and ONC are genuinely trying to better the current situation.

There are efforts underway, within the government and industry, to more comprehensively understand the unintended consequences of EHR implementation.

McGlynn said that the EHR Association is working on a code of conduct for developers that it hopes to release before summer.

“CMS has a long history of coding trends,” said Jonathan Blum, deputy administrator of CMS. “So we are looking to see if there are differences between people using EHRs or not.”

Several speakers called on CMS to provide more guidance on coding and billing with EHRs.

“I would think some conversation around national guidelines would be helpful,” said Benjamin Chu, MD, chairman of the American Hospital Association, and president of Kaiser Permanente Southern California region.

As CEO of the American Health Information Management Association (AHIMA), Lynne Thomas Gordon, MBA, RHIA, FACHE, has been charged with the task of overseeing the 70,000-strong organization during its efforts to help providers gear up for ICD-10 implementation. Thomas Gordon sat down with EHRintelligence to talk about some of the issues facing the industry during its transformation, and how providers can successfully complete the necessary preparations before October 1, 2014 rolls around.

What is AHIMA doing to help providers prepare?

We are asking our members to really try to collaborate with physicians and people who need their help. We tell people to go to our website. If you don’t know what to do, take a look at the free stuff we have out there. We obviously have products and services, but if you just want to know what to do next or how to get started, go to the website. We have also asked our state groups to reach out to physicians, as well. We have almost 70,000 members, and obviously we can’t do it all from Chicago. So we’re trying to galvanize our local chapters. They know what to do.

We know that just like any time you do anything, there are early adaptors and pioneers, and those people are phenomenal at what they’re doing. They’re so far ahead with ICD-10. And then there are those providers who are lagging behind. So if we can encourage our members, who are everywhere, to reach out and help, then we want them to do so. In the long run, ICD-10 is going to be so much better for so many reasons, and we want to be there to help people learn how to get there.

What are some of the main problem areas you’ve seen during the preparation process?

What I’ve heard is that things are moving along well with the exception of one group that people are worried about, and that’s small, rural physicians. The big concern is that the little guys don’t have the support they need. We’re looking at how we can work with those folks to make sure they can get ready. Other than that, I think people are moving along pretty well.

One of the main problems is not having checkpoints. Someone I spoke to said that with ICD-10, you should have a canary in the coal mine. If you have that early warning signal that something’s going to go wrong, then you can fix it. If there’s something that’s not going right, that gives you a chance to fix it before you get too far down the road.

The other thing that we all know, but we still have to tell people, is that there are limited resources. There’s limited time and limited staff. When you talk to your clearinghouse or your vendor, you have to remember: they’ve got to talk to all their other clients, too. They’re not just waiting for your call. Just think about getting a meeting at a hospital. It’s impossible. Just getting the people in the hospital together, much less your vendor, your clearinghouse…people need to make sure they’re not waiting around to try to make that happen at the last minute.

What do you think about the one-year delay and the ongoing resistance to ICD-10?

When the one-year delay came in, it was putting the major breaks on. And of course, all the money went to different places, the resources went elsewhere, and I think it hurt the industry. I know why we did it; it made sense at the time. But now, looking back, I think it was a shame. It’s just like anything: you take care of what you have to. ICD-10 was on the top of the to-do list, and then it not only got pushed to the bottom, it fell off the list completely.

We’ve heard very strongly that it’s definitely going to be October 1, 2014. Some people think they’ll put it off again, and that they won’t have to worry about it. We’re human – it’s human to think that if it’s not immediate, you won’t have to bother. But that’s not how it’s going to work out.

People need to understand more about ICD-11. Even if ICD-11 was ready today, to do the clinical modification for our country is going to take a long time. If I wasn’t part of the process, and if I didn’t know about the modifications that need to be made, I’d wonder why we don’t just skip to ICD-11, too.

But with ICD-9, I like to use this example. Let’s say you move to a new neighborhood, and you want to get a new telephone number. But they said, “We’re sorry, there’s no more room. You can just be grouped with your neighborhood, and we’ll call that one number if we want to get ahold of you.” That’s kind of what’s happening with our system now, because we’ve run out of space. If they really understood that better, they’d realize that we can’t wait for ICD-11.

What is your opinion on computer assisted coding (CAC) for ICD-10?

I do think the artificial intelligence is going to get better and better. I don’t think we’re going to be able to stay with just a human to do the coding, and I don’t think we can rely on the computer to do everything. The best is going to be both of them working together. That way, it will increase productivity, but it’ll make sure you’re getting to the place you want to go. Computer assisted coding is inevitable. If you’ve got normal mammogram, normal mammogram, normal mammogram, it’s crazy to have someone coding that. However, if you have a really complex inpatient case, you have to have a person look over it and make sure it’s correct. I think CAC is an enhancement. These systems could help prompt doctors. Because if you have really good documentation, the coding will follow.

What would be your advice to providers at this point in the process?

Don’t procrastinate. Don’t put off until tomorrow what you can do today. It’s going to take longer than people think. And the other thing is that you should look to the people who can help you. It really does take a village. What we’re finding that there are so many systems that are impacted by this coding change that you have to work together with your entire organization to get you where you need to go.

The Centers for Medicare and Medicaid Services (CMS) will maintain their commitment to the current ICD-10-CM/PCS compliance date of October 1, 2014, according to a letter sent to AHIMA President Kathleen A. Frawley.

The letter was sent in response to AHIMA’s call for CMS to stand firm on its ICD-10 implementation date after more than 80 physician groups represented by the American Medical Association called on CMS in January to delay or abandon the ICD-10 conversion.

Robert Tagalicod, director of CMS’ Office of E-Health Standards and Services, wrote that CMS agrees with AHIMA’s recommendation to continue progress toward ICD-10 implementation.

“Based on your feedback and other stakeholder input, the Centers for Medicare & Medicaid Services believes that the one-year extension offers physicians adequate time to train their coders, complete system changeovers, and conduct testing,” Tagalicod wrote. “Furthermore, we have found that many private and public sector health plans, hospitals and hospital systems, and large physician practices are far along in their ICD-10 implementation.”

CMS’ Acting Administrator Marilyn Tavenner formally declined the AMA’s ICD-10 request in a letter sent February 6, stating a halt of implementation “would be costly, burdensome, and would eliminate the impending benefits” of ICD-10, according to an American Academy of Family Physicians blog post.

The AMA said that implementing the new code set would create additional and unnecessary burdens on physicians at a time when they are already inundated with other healthcare system changes.

Tagalicod wrote that CMS believes ICD-10 is a key part of ongoing healthcare reform efforts, and a “cornerstone” of several programs working to modernize and improve the healthcare system and lower costs.

“Integrated programs such as Version 5010, the ICD-10 code-set itself, the Medicare & Medicaid Electronic Health Record Incentive Programs, and the Physician Quality Reporting System are all aimed at accomplishing these outcomes,” he wrote. “Together they move America’s health care system towards better coordinated care through greater interoperability and ease of transmitting electronic data; better quality measurement and reporting of clinical outcomes data; and lower costs achieved through operational efficiencies.”

AHIMA has launched a state-level ICD-10 Advocacy Initiative to assist the physician community with ICD-10 education and implementation issues. AHIMA’s component state associations will be reaching out to physicians, physician groups, and organizations to offer assistance and access to resources to insure compliance by October 1, 2014.

An advance notice of proposed rulemaking by the Office for Civil Rights Department of the Department of Health and Human Services titled “HIPAA Privacy Rule and the National Instant Criminal Background Check System (NICS)” was published yesterday in the Federal Register.

Drafted following Executive Actions signed by President Barack Obama in January, the notice claims “Concerns have been raised that, in certain states, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule may be a barrier to States’ reporting the identities of individuals subject to the mental health prohibitor to the NICS.”

Absent from that summary explanation is an identification of who raised those concerns, how widespread they are, and if they reflect a political agenda driven by government officials and special interest groups.

“The Department … is issuing this Advance Notice … to solicit public comments on such barriers to reporting and ways in which these barriers can be addressed,” the notice states. “In particular, we are considering creating an express permission in the HIPAA rules for reporting the relevant information to the NICS by those HIPAA covered entities responsible for involuntary commitments or the formal adjudications that would subject individuals to the mental health prohibitor, or that are otherwise designated by the States to report to the NICS.

“In addition, we are soliciting comments on the best methods to disseminate information on relevant HIPAA policies to State level entities that originate or maintain information that may be reported to NICS,” the summary continues. “Finally, we are soliciting public input on whether there are ways to mitigate any unintended adverse consequences for individuals seeking needed mental health services that may be caused by creating express regulatory permission to report relevant information to NICS.

“The Department will use the information it receives to determine how best to address these issues,” it declares.

Gun Rights Examiner addressed this development on Monday, along with a “clarification” of the Attorney General’s powers “for purposes of permanent import controls” of defense articles and services. That report reminded readers of an ongoing action in New York, where it has been alleged the State Police are cross-referencing medical records with handgun owner permit lists in apparent partnership with the Department of Homeland Security.

The HHS Advance Notice invites public commentary, giving alternative ways for citizens to communicate their concerns, but perhaps the best way is to simply fill out their online form (via “Comment Now” button at Regulations.gov). Note that comments must be submitted on or before June 7. But that is only the first step concerned gun rights advocates must take.

As “Authorized Journalists”/“legitimate media” — who time and again demonstrate they are hardly disinterested players — will hardly be inclined to play government watchdog on this, it’s up to the same gun groups and online activists who mobilized in the face of the Senate gun threat to once more pick up a burden. That means spreading this news and getting others to follow suit, it means keeping up with developments as those with legal knowledge assess likely outcomes, and it means pressuring representatives in the legislature to provide oversight in the interests of rights, of separation of powers, and, just as a telling curiosity, of determining exactly where in the Constitution any of this has been delegated within the purview of Executive powers, that is, where any of this would be even remotely lawful under the federal system established by the Framers.

Now that schedules are returning to normal, it’s appropriate to review the events of last week and reflect on the lessons learned with the benefit of hindsight.

1.  Risk planning is forever altered

To me, risk is the likelihood of an event multiplied by the impact of that event.

Risk management for BIDMC IT now uses the NIST 800 framework, so areas of risk are formally enumerated, however, it still requires judgement about mitigation strategies.

At 2:50pm on April 15, seven BIDMC IT staff were volunteering in the medical tent/working at the Marathon finish line, a few feet from the explosions.   They were among the first responders assisting the injured.   Their work in a medical community gave them the strength to stay calm but could not have prepared them for the scenes of destruction they witnessed.   All my staff were safe and unharmed, but given their proximity to the bombs, the outcome could have been devastating.

As we think about risk planning in the future, we’ll need to consider the events of last week when told something as innocent as “the  majority of the database administration team is going to volunteer at the Marathon”

2.  Secure remote access to all systems is critical to operations.

As we continue to enhance the security of our applications and networks, we’re limiting remote access to those with a true need to use systems from off campus.    As the events of last week illustrated, we need to plan for future events which shut down the city for 5 days and require many people to work from home if travel is restricted or a “shelter in place” order is given.

3.  We need to consider restrictions on physical access to the data centers.

The restrictions on travel to and from communities plus restrictions on entering/leaving BIDMC were imposed with an unknown duration.   Our disaster recovery planning needs to include scenarios such as no staff able to enter the data center and no staff able to leave the data center.

4.  We may need to consider novel audit workflows.

We capture every lookup in real time and perform many analytics to ensure patient privacy preferences are respected.

We placed the following message at the top of our intranet for every staff member to see on every page:

Urgent Reminder for All BIDMC Staff About Patient Privacy
Staff must completely protect patient privacy according to federal HIPAA regulations and BIDMC’s own privacy policies. That means:

1. No sharing of ANY patient information through email, Twitter, Facebook, Flickr or other photo sites, any other social media, phone calls or conversations – or any other way.
2. Do not look at, or access by computer, medical records or other protected health information (PHI) or personal information (PI) unless you are authorized to access that information AND you need that information to care for the patient.
3. Send all media calls to the Communications Department or page the Media Relations staff on call.

Violation of these regulations and policies will lead to disciplinary action up to and including termination of employment.

Most importantly, thank you to the overwhelming majority of BIDMC staff who are doing an excellent job of keeping all patient information secure.

Might there be new workflows required in the future such that appropriate individuals are paged/notified within seconds after a lookup occurs?  In an emergency/mass casualty disaster, how can we balance the need for increased security/privacy and appropriate access with real time auditing alerts?

5. The need for healthcare information exchange in a mass casualty disaster is very clear.

When patients have a choice of caregiver – a patient centered medical home or accountable care organization – a lifetime medical record is likely to be available, supporting safe, quality, efficient care.

The events of last week required patient routing based on acuity, urgency, and availability of resources.   BIDMC, Massachusetts General, Brigham and Womens, and Childrens did a remarkable job treating every patient even with incomplete medical information.   The Massachusetts Healthcare Information Exchange (“the MassHIWay”) is currently in production for “pushing” summaries from organization to organization.   Last week’s events illustrate the importance of our second phase, now under construction, for secure retrieval of information based on a record locator service and a patient consent registry.    By the second quarter of 2014, we should have the infrastructure in place to support the kind of data exchanges that would have been helpful last week – a first in the country kind of capability.

IT in general experiences more demands than supply.   Last week, we learned firsthand how technology can support a disaster. As we think about all the work on our plates,  our plans going forward must incorporate our recent experiences.

Physicians will be a key part of making the ICD-10 transition successful. This post focuses on helping doctors become more comfortable with the new code sets.

HealthStream outlined these steps in the white paper “Preparing a Successful ICD-10 Transition : Helping Physicians Succeed in an ICD-10 World.”

Physicians need to look at the ICD-10 transition as more than an administrative burden because ICD-10 implementation will be part of more than just medical claim reimbursements:

• The ICD-10 data will be used in heathcare reform initiatives.
• More expensive treatments and diagnoses will require more documentation.
• Physicians will be judged on documentation.

Learning ICD-10 coding will be a huge task but physicians won’t need to learn the whole code set. Thus ICD-10 training programs need to emphasize coding strategies not codes:

• Focus on documentation principles that can apply to any disease
  • Site
  • Laterality
  • Timing
  • Manifestations
  • Stage
  • Status
  • Drug, alcohol or tobacco dependency
• Focus on areas that need improvement
• Do not focus on principal diagnosis
  • Learn how to code underlying conditions
• Prepare EHRs
  • Incorporate ICD-10 into templates and prompts
    • Code and code descriptions
    • Documentation requirements

Remember there are many ways to teach people:

• Online lessons and webinars
• Peer led workshops and classes
• Mobile apps and resources
• CDI specialists
• Simulations
• Printed resources
• Video games
• One-on-one coaching

It’s OK to use different learning tools to reach different physicians.

Physician training steps

• Identify physicians and staff members who need training
• Assess physician documentation strengths and weaknesses
• Develop lessons based upon specialties and documentation gaps
• Develop training timeline
  • Estimate time needed
  • Schedule start and finish dates
  • Allow for practice and follow up assessments