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IS531_Lecture-14.ppt

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Lecture 14

Policy, Legal, and Regulatory Issues in HIS

(Chapters 18,19,20)

Learning Outcomes

Status of current healthcare delivery system and related policies in US

Legal issues and their implementation

Regulatory issues and agencies

IS 531 : Lecture 14

Status of U.S. Healthcare Delivery System

Higher expenditure
Standardization
Fragmented care
Unequal access to care
Less-than-optimal safety
Poor evaluation by patients
Payment for service rather than maintaining wellness
Lack of rewards for primary care

IS 531 : Lecture 14

Healthcare Reform

Health IT was seen as a tool to aid the reform process with HER, PHR, HIE
President Bush’s executive orders in 2004, 2006 to create National Health Information Technology Coordinator
President Obama’s ARRA 2009 supports 2014 goal for the EHRs

IS 531 : Lecture 14

National Health Information Technology Policy

Even with the creation many committees, taskforces, workgroups the United States has been very slow to follow.
The American Recovery and Reinvestment Act (ARRA) of 2009 supported adoption of a nationwide health information infrastructure.
Education of professionals and general public is needed.

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Our Roles

Public
Need greater awareness on benefits and risks
Nurses
Professional responsibility
Professional duty

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Issues

Lack of motivation to share information across institutions
Established constituencies are resistant to change

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Legislation

Electronic Signatures in Global and National Commerce Act (ESIGN) in 2000: legal status for electronic signature
Medicare Improvements for Patients and Providers Act (MIPPA) in 2008: financial incentive for e-prescribing
Health Insurance Portability and Accountability Act (HIPAA) in 1996: legal protection for personal health information
American Recovery and Reinvestment Act (ARRA) in 2009: provision for IT in HIS

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HIPAA

The Health Insurance Portability and Accountability Act (1996) called for the establishment of an electronic patient records system and privacy rules.
It also affects all aspects of health information management, including privacy and security of patient records, coding, and reimbursement.

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ARRA

The American Recovery and Reinvestment Act (2009) included provision for information technology in general and health information technology.
HITECH Act makes changes to HIPAA and provides more funding for EHRs.

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EHR Incentives

In 2011, Medicare and Medicaid will provide financial incentives to physicians and hospitals for meaningful use of health information technology.
Negative incentives will begin in 2015.

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Privacy and Security Provisions

Breaches in privacy and security are reportable to Department of Health and Human Services.
Patients can restrict some disclosure of personal health information.

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Patient Protection and
Affordable Care Act (2010)

Guarantees access to healthcare for all Americans
Creates new incentives to change clinical practice and improve quality of care
Gives practitioners more information to improve practice
Give patients more information to make conscious decisions

IS 531 : Lecture 14

Regulatory Agencies

Regulatory agencies are public authorities or government agencies responsible for exercising authority over some area in a regulatory or supervisory capacity.
Health insurance regulation is visible at every government level.
Each state determines how it will fill this regulatory role mandated at the federal level.

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Regulatory Issues

The ability to access sensitive health information in electronic patient records by many different sources generates growing concerns over privacy and confidentiality.

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Medicare

Medicare:
Part A: facility-related expenses (no premium, annual deductible)
Part B: medically necessary physician and outpatient expenses (80% with annual deductible)
Part C: Advantage Plan with some additional benefits (monthly premium)
Part D: certain prescription drugs and medical supplies

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Medicaid

Medicaid eligibility is determined by income and regulated by state
Medicaid covers approved expenses but not paid by Medicare

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State Health Departments

Public health conditions in marketplaces and workforces
Schools, mental health facilities, rehabilitation hospitals
Diseases , contamination
Regulated by federal, state, county

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Reimbursement Issues

Medicare, Medicaid, and other third-party payers dictate reimbursement criteria.
Documentation is key to documenting the need for service and reimbursement.
Automated systems enhance the quality of documentation, which can improve reimbursement, track claims status, report denials, and shorten the revenue cycle.

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Adhere to a uniform format
Common terms:
Common procedural Terminology
Healthcare Common Procedure Coding System
National provider Identifier
Unique Physician Identification Number

Electronic Data Interchange in Reimbursement

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Control for quality of healthcare services provided to patients by professional and facilities
Hospital-based
Physician-based

Pay for Performance

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ICD-10-CM codes

ICD-10-CM codes (WHO’s International Classification of Diseases)
System of codes for diagnoses and procedures
Provide reimbursement for services delivered in outpatient areas

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Healthcare Common Procedure Coding System (HCPCS)

Level I (Current Procedural Terminology [CPT])—numeric system used for services and procedures furnished by physicians and other providers, maintained by the AMA
Level II—products, supplies, durable medical equipment, prosthetics, and orthotics
Medicare and Medicaid services maintain and distribute HCPCS Level II codes

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Issues

Expansion of the “Do Not Pay” List for preventable complication
Financial incentives for implementing technology
Adoption for certified HER Systems and Medicare reimbursement
Meaningful use of EHR

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References

Health IT Legislation and Regulations

http://www.healthit.gov/policy-researchers-implementers/health-it-legislation

Health Information Privacy (HIPAA, PSQIA)

http://www.hhs.gov/ocr/privacy/

Medicare

https://www.medicare.gov/

Medicaid

http://medicaid.gov/

Medi-Cal (LA County)

http://dhs.lacounty.gov/wps/portal/dhs/coverageoptions/medical/

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