Category: healthcare

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Meaningful Use Regulations, CMS, HRSA FQHCs and the Stalled Push to Electronic Medical Records (EMRs)

According to Mother Jones, the United States has spent billions on electronic medical records (EMRs)* and we’ve got little to show for it. Digitizing healthcare records was supposed to save time, money, and lives. It hasn’t. That news resonates with us because we’ve written dozens of proposals, mostly for Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) RFPs that either explicitly or implicitly require a discussion of our clients’ use of EMR systems. These clients are usually hospitals, Federally Qualified Health Centers (FQHCs) or other primary care providers. From them we’ve heard numerous heard off-the-record stories about the fiascos that ensued for providers that have implemented EMRs. For example, we worked for a hospital in Southern California that interfaced with a much larger, nationally known hospital that attempted to implement a comprehensive EMR system. The large, famous hospital eventually scrapped a $30 million EMR system because the doctors simply refused to use it.

There seems to be no good solution to the EMR problem. EMRs have been touted for at least the last 15 years as a tech-based way of improving patient outcomes, while reducing healthcare costs or at least bending the cost curve downward (as health policy wonks like to say). EMRs got a got big push with huge amounts of EMR funding included in the 2009 “Stimulus Bill.” The advent of the Affordable Care Act (“ACA,” or, colloquially, “ObamaCare”) escalated the EMR drive. Various Federal and state agencies advocated and then effectively mandated EMRs.

But this well-meaning concept has at best moved sideways. HealthIT.gov promulgates the wonderfully bureaucratically named “Meaningful Use” regulations, which use a combination of incentives (e.g., higher Medicare/Medicaid reimbursements) and threats. The carrots are offered and the threats enforced primarily by CMS. Everyone is supposed to get to Stage 1 of Meaningful Use (data capturing and sharing) on a supposedly smooth trajectory to Stage 3 (improved outcomes). Stage 3 turns out to be like the intergalactic instantaneous travel through spacetime. We’ve yet to find an hospital, FQHC or other client that has reached Stage 3. Most are stuck at Stage 1, with a few bravely claiming Stage 2. We’ve never seen a client hit Stage 3, though they may be out there, perhaps in a galaxy far far away.

The problem is that EMRs are trying to map the extraordinary complexities of the real world into software. The complexity can be seen in the new International Classification of Diseases, ICD-10 Codes, published by our old friend CMS. ICD-10 codes are used by medical providers and billers to track patients and payments, based on the code or codes of the patient’s particular situation. When we talk to FQHCs, they invariably say that coding errors are among their major problems. ICD-10 has an astounding 68,000 individual codes, compared to only 14,000 codes in the previous ICD-9. In recent years, humans have invented or discovered an enormous number of new ways to get hurt. No one can remember more than a few hundred of these mysterious codes, which are easy to mistype into an EHR and/or be misunderstood by harried doctors and mid-level practitioners. The complexity of the codes, combined with human diversity and frailty, inherently generates huge numbers of mistakes.

Folks with too much time on their hands have published various funny ICD-10-CM codes. Some choice ones (we are not making these up) include: “V97.33XD: Sucked into jet engine, subsequent encounter;” Y92.146: “Swimming-pool of prison as the place of occurrence of the external cause” (how many prisons have swimming pools?); and my personal favorite, “R46.1: Bizarre personal appearance.” You can tweet your favorite bizarre ICD-10 codes to @healthcaredive.

Ask your doctor about their EMR system and you’ll likely here a lot of invective. I live with a doctor and so have heard the horror stories from her and her colleagues. Isaac’s primary care physician (PCP) hates EMRs but is more or less forced to use eClincalWorks, an EMR system that is also popular with our FQHC clients. Epic is another popular one. Still, however you feel about whether EMRs is efficacious or horrible or brilliant or whatever, pretty much every healthcare-related proposal has to mention EMRs, statistics, and tracking. That could be as minor as a project that works on childhood obesity or as major as a hospital chain implementing some new facet of EMRs.

Anyway, EMRs are a specialized case of a more general problem described in “Why Software Fails: We waste billions of dollars each year on entirely preventable mistakes.” EMRs, like other forms of software, have numerous moving parts and numerous human users. Anyone working in or around EMRs needs to read “Why Software Fails.” At Seliger + Associates, we expect to keep writing about EMRs for FQHCs and similar clients for years if not decades to come. In the real world, doing EHRs right is simply a Hard Problem—so hard that it deserves capital letters. EMRs are almost impossible to do “right” and yet have to be done right. They’re so hard that we don’t have a solution. “Why Software Fails” explains why a solution may not exist, no matter how badly HRSA or CMS wants one. As the Soviet Union discovered, mandates from above, no matter how strong, do not automatically translate into fixing problems from below.

* EMRs are alternatively referred to as Electronic Health Records (EHRs), particularly in HRSA and CMS RFPs. In ones types “EHR” into Word, or any other word processor, and the autocorrect feature will change it to “HER.” This in annoying, but does result in some unintentionally funny typos. When finished with proposal draft involving EHRs, always do a find and replace for “HER”.

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Thought of the Day: Funders Could Provide Proposal Templates in Word

Federal, state, local and foundation funders could save everyone, including themselves, a lot of grief and heartache by including a Word proposal narrative template with every RFP.

Let me explain: this may not be the most compelling way to start a post, but if you don’t like to waste your time, energy, and precious life on this planet you’ll stay with me even when I write about how last week I was formatting a particularly tedious HRSA proposal. This proposal’s narrative instructions alone have more than ten pages of headers, sub-headers, sub-sub-headers, inconsistent number/bullet patterns, and instructions. For example, one should:

Learn to love outlines. If the RFP has an outline format, reproduce it. If not, develop a simple outline format of your own, indenting .2 or .25 inches as the outline descends. It is easy to do this in Word by using paragraph styles. Make Outline 1 “A” with no indent, Outline 2, “1″ with a .2 indent, Outline 3 “a” with .4 indent and so forth.

Not surprisingly, I succeeded in creating an attractive outline.* But I also spent many hours creating styles, copying and/or rewriting header text, and deciding on the formatting necessary to reproduce this relentlessly, tediously verbose HRSA RFP. Towards the end of the process I realized: HRSA didn’t have to make me do all this! HRSA doesn’t have to make each applicant use subtly different sub-heading text, as is currently the case. They could offer an optional proposal template in Word that already has all the narrative headers in a style that’ll make proposals easier for HRSA to read and easier for applicants to write. Everyone wins!

Standardized proposal templates would be slightly bad for our business, because plenty of people see the byzantine narrative structure, become distressed, and think hard about how quickly they can pay someone else to make the pain go away. But they’d be a net win for humanity, and, at heart, I am a humanitarian. Think about it, funders: a tiny amount of work on your end could be a great virtue for all mankind.

* Don’t underestimate the value of instant attraction in just about any domain. Publishers spend a lot of time and money getting book formatting right for a reasons. They know that readers judge a book based not only on the particular words used but on the way those words are shaped and presented. We’ve seen many, many clients who turn in sloppily formatted proposals or who sacrifice readability for more words. Those are mistakes.

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The HRSA Health Infrastructure Investment Program (HIIP) Illustrates Why It’s Hard to Handicap Chances of Getting a Grant

Anyone who’s been to a race track or Vegas knows that the odds of a given race or sporting event are being constantly updated by pros who seem to know how to handicap future events. Prospective clients often ask me to handicap their chances of winning a grant competition (and we’ve written before about why grant writing is not like the Olympics). Trying to handicap a particular grant competition is like trying to handicap a horse race in which you don’t know the horses, riders, or venue until after the race is completed. If grant writing was really like a horse race, you’d just pick the cutest horse or jockey with the best colors and hope for the best.*

A prospective client raised the odds issue on Friday, regarding the recently issued Health Resources and Services Administration (HRSA) Health Infrastructure Investment Program (HIIP) FOA. HIIP has $150,000,000 available, with about 175 grants up to $1,000,000, for Federally Qualified Health Centers (FQHCs). FQHCs are sometimes called “Section 330 grantees” and provide primary health care to publicly (Medicaid) and uninsured patients. HIIP is a great opportunity for FQHCs: there’s a lot of money up for grabs, the grants are large, and the money is for facility improvements (facility improvements are always hard to fund).

Not surprisingly, we’ve received a number of inquiries from FQHCs. On Friday, a FQHC CEO in rural Montana called. I learned a bit about his agency and provided a fee quote. Then he popped the question: “So, what are my chances of being funded?” As I was starting my standard reply to this standard question, he interrupted. He said he didn’t think his chances were very good, because “thousands of FQHCs would apply.”

I said that’s not true, since there aren’t that many FQHCs. We got into a bit of a tiff over this, so I double checked after the call. The Henry J. Kaiser Family Foundation says there were only 1,202 FQHCs as of 2013. I would’ve guessed closer to 1,000, but the numbers are in the same ballpark. While new FQHCs are created every year, there are likely less than 1,300 today. Thousands of FQHCs can’t apply for HIIP because not that many exist. My caller was trying to talk himself out of applying.

Let’s try estimating the likely competition.

For various reasons, not every FQHC will want to apply for a HIIP grant. Some are already happy with their current facilities, while others are undergoing leadership changes. Let’s assume that 1,000 FQHCs want to apply and that HRSA will ultimately make about 175 grants. This would mean around a 20% chance of any given application being funded, which is pretty good odds in submitting a grant proposal or buying a lotto ticket.

But, of the hypothetical 1,000 or so applicants, many will not finish their applications, so perhaps 700 applications will actually be submitted. Of these, a fair number, say 100, will be technically incorrect and will not even be scored. Now the pool is down to 600. Many of these will be poorly written, fail to demonstrate need, etc., and will not score high enough to be funded. Let’s assume that 350 – 400 score high enough to be funded.

Now the odds are close to one in two!

Still, grant handicapping is more complex than this simple analysis. Of my theoretical 400 potential grantees, some will be urban, some rural, some will serve special populations (e.g., homeless, Native Americans, etc.). Some will serve African Americans, some Hispanics and so on. Since, like all governmental funders, HRSA is a semi-political entity, the organization wants to spread the sugar. Even if the top 200 applications, based on points alone, were somehow clustered in the Northeast, applicants in other areas would still be funded.

My 400 possible grantees are actually competing against similar applicants, rather than all applicants, because not all applicants are equal in the eyes of HRSA administrators. If your FQHC is the only highly scored applicant that serves rural Native Americans, your chances of being funded could be 100%. If your FQHC serves a general population in a large city like New York or LA, you might be one of ten possible grantees in that city. HRSA will likely make multiple awards in a given big city, but not ten. Now your odds could be one in three. This particular exercise can be played ad infinitum, but it doesn’t mean much because no one outside of HRSA knows the organization’s subjective priorities in advance and because you don’t know who else is going to apply.

Not knowing who else is going to apply really counts. If four other FQHCs similar to yours operate in a given region, they may all say they’re going to apply—just to scare you, or intimidate you, or impress you, or for any number of other reasons. Will they? Maybe, maybe not. You can’t control them, and we recommend that you not be dissuaded by their rhetoric. They may claim to have juice with power players in Washington, or any number of other advantages. You don’t know and can’t know if they’re telling the truth.

My advice to all callers is the same: if your agency is eligible and you want to provide the service, you should disregard real or imagined odds and apply. The logic is similar to seeking a new job. In most cases, you don’t know the other job applicants. Most people apply for jobs they want to do in places they want to live. Say you’re a highly qualified lion tamer and there is a great job open at a circus in Seattle. You should only apply if you like rain, coffee, and tech / nerd culture. If you like sunshine, Cubano sandwiches, and salsa dancing instead, wait for a circus opening in Miami.

The same is true for HIIP: FQHCs who need facility improvements should complete technically correct and compelling proposals that are submitted on time. Worrying about the odds is an interesting but pointless enterprise.

* This is actually the way I bet at horse races, which is why I’m not much of a gambling man.

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“You Can’t Shovel Tens Pounds of Shit in a Five Pound Bag:” The New York Times Ignores CHCs, Section 330 Providers, and HRSA

In “For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says,” Robert Pear discovers something that has long been obvious to our many Community Health Clinic (CHC) clients: having insurance doesn’t mean you can see a doctor. Many if not most doctors won’t see Medicaid patients. CHCs, however, are a class of primary care organization designed specifically for Medicaid patients and the uninsured. We’ve written numerous Health Resources and Services Administration (HRSA) proposals for CHCs, and everyone one of those proposals is supposed to expand access to care. This year’s New Access Point (NAP) program, for example, has $100 million available. Pear apparently does not know that CHCs exist and are funded through HRSA mostly to serve Medicaid patients.

The bigger problem regarding real-world healthcare is the number of doctors. Any discussion about the difficulty of finding care that doesn’t mention the limits on the supply of doctors is specious at best. There have been around 100,000 residency slots since the 1980s. Medical schools stopped expanding long ago. These facts are well-known to experts. Physician Assistants and Nurse Practitioners are to some extent filling in the gap, but in most states they still must practice under a doctor.

Our CHC clients’ biggest problem is rarely recruiting patients—when you subsidize goods or services, people consume more—it’s finding doctors. CHCs usually serve a high-need, difficult-to-treat population. Consequently, physicians often prefer to seek higher pay and lower stress jobs. Although there are lots of people trying to go to medical school—in Educating Physicians: A Call for Reform of Medical School and Residency, the authors note that 42,000 people applied for 18,000 medical school spots, and that at least 30,000 were likely qualified to become doctors—med school and residency act as bottlenecks to this process.

You can give every person health insurance without ensuring that they’ll actually get care, much like you can give everyone a degree without ensuring they have a brain. In the United Kingdom, care gets rationed through wait times. In the U.S., a similar dynamic is happening via provider shortages. While it is laudable that the Affordable Care Act (ACA) significantly increased the number of Americans covered by Medicaid, the landmark legislation did little to increase the number of providers to serve the newly insured. Or, as they used to say in the old days, you can’t shovel ten pounds of shit into a five pound bag. It’s a vulgar phrase but applicable to this article and the overall challenge of helping the newly insured actually access affordable, quality healthcare.