CMS Whispers

CMS is whispering. Can you hear it?

Traditionally, CMS releases proposed rules in the summer months. Thousands and thousands of pages of proposed regulations, changes to methodologies, and new payment codes have been or will be published over an eight-to-ten-week period. The sheer volume of documentation is overwhelming, and understandably, most of us rely on industry roundups and summaries to get a glimpse of what’s on the horizon for 2023.

And that shortcut may provide significant insight into why we are where we are in healthcare.

In our industry, it’s not uncommon to have a low-grade sense that CMS is a little unmoored. That they are changing course with every new program or program revision, or worst, that they are completely course-less with no thought to the turbulence that might ensue from their decisions. The initiatives CMS brings forward can seem disconnected from each other and from the realities of caring for an aging population. This can lead to the feeling that “winning” at Medicare requires you to game the system.

That’s when consultants are brought in to advise on how to stay ahead of regulations and rulemaking. Technology vendors develop software to improve efficiency in playing the game. Health systems and clinics invest millions of dollars of human capital into playing to win, even though they sometimes believe that this may be near impossible, because the house always wins.

What all of this misses, though, is that this isn’t a game. It’s a journey. And CMS is telling us exactly where we are headed, and what we need to do to get there.

But CMS is speaking in whispers. These whispers are buried in line after line of text, and layer after layer of complexity. CMS is murmuring to health systems where they should direct their efforts and how to optimize reimbursement. The exact coordinates where high-value care, improved patient outcomes and quality of life, and provider reimbursement meet is echoed throughout CMS policy and rulemaking. But few seem to hear it because there’s just too much noise.

What would it look like if, instead of trying to win a game that CMS isn’t even playing, you sought to amplify the whispers?

Maybe it would mean instead of scanning recaps or summaries of major provisions in proposed rules, you pursued nuanced conversations about what CMS is saying in the minor details and understood how proposed changes reflect the overall course that CMS is charting.

Maybe it would mean instead of scrambling for a technology solution that provides a workaround for a provision that seems to be more inconvenience than anything else, you understood the implications of addressing the provision instead of working around it.

Maybe it would mean instead of having your staff chase the “winning cards” in documentation, coding, or reimbursement, you invest in building programs that drive high-value care and reimbursement by doing what’s best for patients.

Whatever it looks like, one thing’s for sure: you can’t listen to the noise and listen to the whispers at the same time.  

If you’re having trouble hearing the whispers, connect with us for a free consultation.                                        

Dr. Stephen Strange and Puzzles vs. Mysteries

Medicine is often referred to as an art and a science. This is based on the knowledge that there is still much we don’t understand about the inner workings of the human body, disease, and treatment. We need science to help us move from observation and questioning to hypothesizing, experimenting, analyzing, and making conclusions. This is the nature of science. Even when you don’t yet understand it, science is still science, and it gives us the confidence of solving the puzzles in medicine with clear conclusions and answers. 

But what about the art of medicine? For anyone who has practiced, it’s undeniable that art will always be a part of medicine, because medicine contains mysteries. No amount of knowledge or understanding will remove mystery, and that’s one of the most fascinating elements of the pursuit of medicine. Unlike a puzzle, which has a single correct answer, a mystery is a problem where the answer can only be “correct for now” because there are innumerable conditions and interactions that can influence what the right solution is. With a mystery, as soon as you act on what you believe the answer is, the conditions change in a way that means the best answer changes. There’s no right answer, only the answer that is best in the current moment, under the current conditions. 

The concept that some problems are puzzles while others are mysteries was first conceived over 70 years ago for counterintelligence training. Counterintelligence agents and analysts needed to understand that there are two types of problems to solve: ones with one right answer and others that continuously evolved and developed with each action taken in support of the “best right answer.”

Dr. Stephen Strange explains it in Avengers: Infinity War

Peter Parker: Hey, what was that?

Dr. Stephen Strange: I went forward in time. To view alternate futures. To see all the possible outcomes of the coming conflict.

Peter Quill: How many did you see?

Dr. Stephen Strange: Fourteen million, six hundred and five.

Tony Stark: How many did we win?

Dr. Stephen Strange: One.

Of course, our heroes do (eventually) win, but not in one of the 14,000,605 ways Dr. Strange foresaw, because defeating Thanos was not a puzzle with a single correct answer. It was a mystery, where each action the heroes took changed the future and the next right action.

An example of a puzzle is when cybersecurity teams want to know how many mobile devices they have that could be vulnerable to attacks. There is one right answer- the number of devices can be counted. That number may change frequently as devices are added or decommissioned, but the answer can always be found.

But that same cybersecurity team also asks questions that are a mystery. For instance, where is the system most vulnerable to attacks? They may agree that their servers represent a significant risk, so they better secure them. As soon as they take action to secure the servers, the answer immediately shifts. Now the system is most vulnerable to attack through their mobile devices. Eventually they will work through addressing all the areas of vulnerability that they can identify, and may even come back to servers as the area of greatest vulnerability as technologies and hacking evolve. This question is a mystery because there is never a single right answer- the process itself of finding and acting on the answer changes the answer.

The instability of the system- and the answer- has direct applicability to the art of medicine. 

Diagnosis is a puzzle problem. When we want to find out what is causing a patient’s symptoms, there is one right answer. In rare cases there may be multiple diagnoses to be made, but there is still one correct, quantifiable answer. 

Treatment is not a puzzle. A treatment that is working today may cause harm tomorrow. A patient might be stable on their blood pressure medication for years, but aging changes the situation and now that medication might contribute to a fall because the patient’s blood pressure is too low. The treatment that might be the absolute best for a condition may be too expensive for the patient. A patient with Type 2 diabetes may take weight loss seriously after starting insulin and lose 75 pounds, completely changing the course of their disease and treatment needs. Treatment happens in the real world where there are innumerable circumstances and interactions that can influence what the right treatment is. There is only the best option for right now, which is why treatment is a mystery.

Medicine is a science and an art, but perhaps more importantly, medicine is a series of puzzles and mysteries. When we fail to understand the difference, we create all sorts of issues. 

For instance, technology and analytics solutions. Technologies that solve puzzles can’t support managing mysteries. And technologies that manage mysteries don’t solve puzzles. Programming a solution to find a single right answer is very different from programming it to suggest the next high quality action in the setting of evolving environments. Before building a healthcare technology, developers need to know if they are solving a puzzle or pursuing a mystery. Without this basic understanding, we end up with Watson, who is great at solving Jeopardy’s fact-based puzzles, yet failing when trying to address mysteries in healthcare.

What other areas do you see where we are failing to understand the nature of the problem and are creating solutions designed to solve puzzles when we need them to manage mysteries or applying solutions that can manage complex mysteries to simple puzzles?

Are Problem Lists Problematic for Risk Adjustment?

If you are even tangentially involved in the risk adjustment efforts in healthcare organizations, you’ve probably fielded a question that goes something like this:

I’m auditing charts for HCC coding. Our Problem Lists are confusing. There’s a variety of acute problems that have been resolved, acute problems still being monitored or treated, chronic conditions that are not actively being treated, chronic conditions that are being treated (and are usually the primary diagnosis for most care interactions), and duplicate diagnoses that are clinically the same problem. What am I supposed to do with all of this?

How would you answer? 

The Problem List is a place where risk adjustment, clinical conditions and treatment, and EHRs intersect, and ultimately, converge. One of the problems with these types of intersections is that very few people in a healthcare organization understand all the roads that lead to this intersection, all the folks traveling on that road, or what’s needed to make the path forward smooth, compliant, useful, and patient-centered. This results in well-meaning staff sometimes doing disadvantageous things because they are acting from a narrow viewpoint without a clear understanding of what lies ahead. Unless the organization has a clear strategy, buy-in from all relevant stakeholder groups, impactful training, and a standardized process, this can be a difficult problem to solve.

Here are four things you should consider as you build your Problem List strategy.

1. The Purpose of the Problem List

   The problem list is a reference tool for clinicians to aid in providing good clinical care. It provides a bullet point view of the patient’s medical history by highlighting the conditions that impact the trajectory of the patient’s health over their lifetime. Any condition that is being actively managed, passively managed (watchful waiting), contributes to medical decision making, or relevant to future clinical care should be on the problem list in a way that describes the condition’s relevance to current clinical care.

2. The Users of the Problem List

   While it’s easy to think of doctors, nurses, and other clinicians as the users of the Problem List, it’s easy to forget that patients are also users. With increasing transparency of medical records, it’s important for the Problem List to reflect what the patient knows about their own health. They may expect acute injuries, such as a fall that resulted in stitches or a cast seven years ago, to appear on the Problem List, because it was an important and painful event, while their 20-year history of tobacco use that they quit 10 years ago may not seem important to them. The balance between the purpose and the users of the Problem List is one that requires active and ongoing conversation between patients and clinicians. 

3. People Who Don’t Use the Problem List

   Clinicians are the primary people performing data entry and “clean up” of the Problem List. Unless they have been educated accordingly, they likely do not know that ICD-10 codes are not assigned to claims from the Problem List. Many providers have thought they were helping with risk adjustment by keeping the Problem List comprehensive and up to date, but that’s not always the best use of their time since HIM professionals cannot use the Problem List to assign codes to claims. It doesn’t mean Problem List maintenance isn’t valuable- it definitely is! But for capturing HCCs, that’s not the best place for the billing provider to focus their time.

4. The Nature of the ICD-10 Code Set

   To date, there are almost 73,000 ICD-10 codes. That’s a massive leap from where the US was in 2014, with only about 14,000 ICD-9 codes available. The dramatic increase in available codes comes largely from ICD-10 becoming a more granular and flexible taxonomy. Codes can describe active conditions, their sequela, the resultant chronic conditions, or a personal history of the acute condition. All of these are relevant to your Problem List strategy and contribute to success in risk adjustment.

As risk adjustment methodology continues to evolve, understanding how the Problem List contributes to the accurate reflection of the complexity of your patient population, excellence in clinical care and outcomes, and addressing health equity is vitally important to creating a strategy for near- and long-term success. Your strategy doesn’t have to be complicated, but it does need to be thoughtful and comprehensive. To get started building a better strategy with actionable tactics that deliver results, check out our Risk Adjustment and Health Equity workshop or schedule a consultation with us.

How to Spot a Technology Unicorn

How do you know a unicorn is a unicorn? That’s so simple, a 7-year-old can tell you.

You know what’s harder to answer? How do you know an AI technology is a true unicorn- not just something that looks like a unicorn. Good question, huh?

Remember when IBM Watson Health was the next AI unicorn in healthcare? Using a highly developed purpose-built core technology (Watson) that was ubiquitous for winning the game show Jeopardy, Watson Health brought together several other successful healthcare technologies with the goal of making healthcare delivery faster and better. This was going to transform the industry, right?

Except, it didn’t. In fact, in January 2022, IBM divested it’s Watson Health data and analytics assets  in favor of focusing on their core technology. What went wrong? How did the industry miss that this wasn’t a real unicorn horn- just something that looks like one?

Having lived through the hype, I think what went wrong is this: developers and investors were making decisions based on the technology’s potential without sufficiently considering its acceptability to the real-world users. If they had evaluated the technology from a functional framework and better understood the personas that were intended to use it, they could have made decisions that increased appeal or overcame the lack of naturally occurring alignment between the AI and the user.

The New York Times reported on the journey of Watson Health, including this:

Martin Kohn, former chief medical scientist at IBM Research, recalled recommending using Watson for narrow “credibility demonstrations,” like more accurately predicting whether an individual will have an adverse reaction to a specific drug, rather than to recommend cancer treatments.

“I was told I didn’t understand,” Dr. Kohn said.

In essence, Dr. Kohn was suggesting that Watson Health be used to augment the provider’s knowledge rather than automate the provider’s workflow. Using the Showalter Functional Framework for AI and an understanding of provider personas, it’s evident that automating technologies lacks natural appeal to physicians, while augmenting AI has natural synergy. When naturally occurring appeal is lacking, the strength of the AI, how advanced or accurate it is, or how buzzy it is in the market is not sufficient to overcome user resistance. For that, you have to create appeal through value, function, or motivation.

That’s why we created the Vitruvian Appeal Assessment. The Assessment provides a comprehensive view of the technology solution, it’s functional impact on the intended users, the user personas and what their values and motivations are, the existing or future workflows impacted by the technology, and the alignment across these variables. Whether you are considering an investment, actively developing a solution, preparing to purchase, or tasked with deploying and driving adoption, the Vitruvian Appeal Assessment gives you the ability to determine if that’s a real unicorn, or just something that looks like one. With our detailed recommendations, you are equipped with the information you need to be successful in your next step.

If you’re ready to learn more or get started, schedule an appointment or drop us an email.

AMA brings forward a functional approach to classifying AI

Unless you are a medical coder, changes in the CPT code set are probably not that exciting to you. Many who work in healthcare don’t know that Current Procedural Terminology (CPT) codes are the universal language of the American health care system to describe the services and procedures provided to patients. In addition to being the basic language used in medical billing, these codes paint a picture of the type of care patients are receiving, from a basic sick visit in the office with their primary care provider, to the specific type of anesthesia provided during surgery, to the length of discussion and outcome of conversations about who is responsible for a patient’s medical decision if they are no longer able to make those decisions themselves. Like ICD-10, CPT codes are precise in their meanings, include guidance/prefatory language that is important in the application of the codes, and play a significant role in healthcare reimbursement.

In September 2021 the AMA released updates to Appendix S to describe work associated with AI-assisted medical services and procedures. The CPT Editorial Panel clarifies that the descriptions in Appendix S are applicable to all types of artificial and augmented intelligence (AI) applications used in clinical care, whether they are expert systems, machine learning, algorithm-based services, or other technologies. They also clarify that these classifications do not describe all work that is performed by machines in healthcare, but specifically they classify the work performed by the machine on behalf of the healthcare provider in the delivery of clinical care.

Appendix S describes three types of work that AI may perform on behalf of the healthcare provider:

Assistive AI: The work performed by the machine for the physician or other QHP (Qualified Healthcare Provider) is assistive when the machine detects clinically relevant data without analysis or generated conclusions. Requires physician or other QHP interpretation and report.

Augmentative AI: The work performed by the machine for the physician or other QHP is augmentative when the machine analyzes and/or quantifies data in a clinically meaningful way. Requires physician or other QHP interpretation and report.

Autonomous AI: The work performed by the machine for the physician or other QHP is autonomous when the machine automatically interprets data and independently generates clinically relevant conclusions without concurrent physician or other QHP involvement. Autonomous AI includes further classification based on the level of conclusions made by the AI and the role of the healthcare provider in response to those conclusions.

The AMA’s new AI taxonomy validates the Vitruvian Functional Framework for Workplace AI, which classifies AI by the impact it has on workers in performing and completing workplace tasks and decisions. In the Vitruvian Framework, AI can:

Accelerate: Increase worker efficiency in completing tasks and making decisions

Augment: Increase worker effectiveness in completing tasks and making decisions

Automate: Reduce worker effort in completing tasks and making decisions

Although the word choice is different between Assist and Accelerate, the meaning is the same because Assistive AI brings the relevant information to the physician or other QHP, which is designed to improve the clinician’s efficiency.

Importantly, the AMA brought forward a functional approach to classifying AI. They specifically emphasize that the type of algorithm used to generate intelligence is not important- it’s how the AI impacts a clinician’s tasks and decisions that matters most. The importance of this for AI adoption in healthcare cannot be overstated.

A functional approach facilitates designing solutions that appeal to end users, rather than designing them to conform to a mathematical or informatics construct. It enables AI designers, those tasked with selecting AI solutions, and those who are implementing AI technologies the insight needed to ensure the solution will appeal to the target end user. Clinical users of AI are not a monolith, and physicians, nurses, pharmacists, and social workers will not find the function of every AI solution equally appealing.

To learn more about how a functional approach to workplace AI can help drive appeal and create sustained adoption in healthcare or other industries, click here to download our paper.

Can you address sdoh and disparities for $15?

What can you buy for $15?

Recently we have been busy doing quite a bit of shopping. Two of our kids have birthdays around Thanksgiving, and it feels like the holidays are immediately upon us as soon as the birthday presents are unwrapped.  This time of year we need gifts for all sorts of people in our lives, from teachers to postal workers, not to mention the kids’ school gift exchanges and white elephant games.

So what can you buy for $15? Or maybe a better question is, can you buy better health for $15? I’m inclined to believe you can. Which is why the Office of the Inspector General’s guidance around nominal gifts is so important. OIG initially offered guidelines around nominal gifts for Medicare and Medicaid beneficiaries in 2002. The guidelines clarified that providers could supply gifts of nominal value to patients as long as they met certain standards:

• Gifts could not be cash or cash equivalents (e.g., money orders or gift cards to “big-box retailers”

• Each gift could be valued at no more than $10

• Each patient could receive no more than $50 worth of gifts per year

In 2016, OIG updated their guidance. While cash and cash equivalents are still not allowed, providers can now supply gifts valued at up to $15 each and patients may receive up to $75 worth of gifts per year. And that is definitely enough to impact patients’ health, especially when the gifts are focused on addressing health disparities and social determinants of health (SDOH).

Which means providers have to be smart about the nominal gifts they provide. While grocery or gas gift cards may be useful, do they benefit patients who live in a food desert or who don’t have access to a vehicle? To make nominal gifts meaningful and impactful, the gift should be personalized and address the root causes of patient health and outcomes.

Your patient with depression and anxiety may find that a few months of a paid subscription to an app like HeadSpace that can provide targeted meditation and mood tracking, to be helpful in managing their mental health.

Your patient with COPD or other chronic respiratory illness may benefit from receiving monthly air filters, especially in seasons or areas where air quality is poor.

How many patients with chronic disease would benefit from a senior citizen membership to a gym like Planet Fitness?

Each of these can be provided within the $15/$75 nominal gift limits. Or how about:

• Grocery and pharmacy home delivery using a service like Walmart+ to help patients who live in a food desert or who lack transportation

• A set of low weight dumbbells or resistance bands to help build muscle mass in elderly patients without access to safe exercise spaces

• A pill organizer that holds a month of medications (especially if the pharmacist or clinic nurse fills it) for patients who struggle with complex medication regimens

• A water filter or water filter pitcher for patients living in areas where water supply may be prone to contamination

• A few sets of reading glasses (you may have heard them called “cheaters”) to help patients who have trouble reading instructions or drawing up insulin

Health disparities are a systemic problem that need a systemic solution. But the patients who are experiencing those disparities are individuals who need personalized care. Nominal gifts can’t solve everything, but they are an underutilized tool in the pursuit of equitable care.