The Subcommittee on Health Data Needs, Standards and Security of the National Committee on Vital and Health Statistics was convened on Tuesday and Wednesday, January 21 and 22, in the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public. Those present included:
Barbara Starfield, Subcommittee Chair
John R. Lumpkin, M.D., M.P.H., K2 Standards Work Group Chair
Simon P. Cohn, M.D., M.P.H., F.A.C.P.
Kathryn L. Coltin, M.P.H.
Lisa Iezzoni, M.D., M.S.
Vincent Mor, Ph.D.
Other NCVHS members
Kathleen Frawley, JD, MS, RRA
Robert M. Gellman, J.D.
Marjorie Greenberg, Acting Executive Secretary, NCHS
James Scanlon, Executive Staff Director, DHHS
William Braithwaite, M.D., Ph.D., DHHS
Bob Moore, Health Care Financing Administration liaison
Lynnette Araki, NCHS
Barbara Hetzler, NCHS
Steven Bass, Washington Publishing Co.
Roy Bussewitz, NACDS
Norma Border, NACAP
Dan Staniec, NCPDP
Gary Beatty, Mayo Clinic
D. Kathy Milholland, American Nurses Assn.
Pat Hamby, HBO&Co.
Sara Lambert, ALLTEL
Lyndalee Korn, TRW SIG
Mary Emerson, HCFA
D.H. McElhone, U.S. Office of Personnel Management
Susan Searl, Medicode
Sal Fazzolari, TRW
Robert Mayes, HCFA
Susan Winckler, American Pharmaceutical Assn.
Ronald Jordan, HCaliber Consultative Corp.
Chris Bergster, AAHP
Bruce Kelly, Mayo Foundation
Rosanna Coffey, AHCPR
Mary Siffermann, Gordon & Barnett
Pat Brooks, HCFA
Suzon Landek, MBS
Kathleen Kono, ASTM
Sherri Alpert, IRS
Bob Iadicicco, OPM
Lillian Gibbons, HCFA
Reld Cushman, Yale Univ./RW Johnson Foundation
Dan Ermann, HCFA
Richard Thoreson, SAMHSA
Craig Palmer, American Dental Assn.
Allison Eydt, EOMB
JM Fitzmaurice, AHCPR
Ellen McCloskey, BNA
Michelle Muth, U.S. Office of Consumer Affairs
Gib Parrish, CDC
Jane Harmon, NCHS
Derek Wang, SSA
Marilyn Abramovitz, HCFA
Brian Thiel, PMA
Paul Placek, NCHS
Michael Carleton, HHS
Frank Pokorny, Blue Cross/Blue Shield Assn.
George Arges, American Hospital Assn.
Henry Heffernan, EDPNS
Virginia Huth, OMB
Jack Emery, AMA
Mark Segal, AMA
Joy Glass, HCFA
Brian Riewerts, HFMA
Dan Rode, Healthcare Financial Management Assn. (HFMA)
William Applegate, American Society of Clinical Pathologists
Debbie Rudolph, IEEE
Robbi-Lynn Watnik, HFMA
Richard Sheldon, Association of Self-Funded Plans
Susan Jensson, State Farm
Nancy Perkins, Arnold & Porter
Barbara Comstock, State Farm
Henry Bachofer, Common Ground Consulting Services
Marion Ramey, Assn. of Federal Health Organizations
Dawn Jackson, BIBSA
David Ermen, Gordon & Barnett
George Pamtos, SHA
Michele Johnson, American Academy of Family Physicians
David Clark, HCFA
M. Bloomrosen, Aspen Systems
David Gencarelli, Guardian Life Ins. Co.
John Lavin, PLS Health Systems
Linda Lawrence, NCHS
David Evans, HFCA
(Note: Documents pertaining to this meeting can be found on the NCVHS web page at HTTP://ASPE.OS.DHHS.GOV/NCVHS/)
The Subcommittee on Data Needs, Standards and Security met on January 21-22 1997, to hear reports on the National Provider Identifier and the National Payer Identifier and to discuss with five panels the implications of the administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA). An underlying principle of the discussions was the Subcommittee's desire to ensure that administrative simplification results in improved patient care.
· Ask Dr. Lumpkin to outline a process whereby the Subcommittee will process and synthesize the perspectives it is exposed to through these hearings and make it available to the Department;
· Designate a NCVHS member as a liaison to each of the HHS Implementation Teams
· Formulate and circulate questions for all players about vision, cost, and other questions. Dr. Lumpkin and Dr. Braithwaite will draft and circulate. All those invited to testify will be included.
3. The Subcommittee will hold a third set of meetings to examine coding and classification issues -- e.g., the suitability of the ICD-10 as a standard, where CPT-4 fits, information on HCPCs, and questions about procedure classification.
4. (See also the actions promised to the Subcommittee, listed at end of minutes.)
Unique identifiers are an area for which standards are mandated in the legislation. HCFA has been working on payer and provider identifiers, and NCVHS is now considering what advice to provide to the Secretary relating to these proposed standards. The Subcommittee heard first from Joseph Broseker of HCFA about the National Provider Identifier (NPI), which HCFA has been working on for some three years. HCFA wants industry input on how and when to bring in non-Medicare providers. As the first of the standards mandated by HIPAA, the Provider ID needs a fast process so others can build on it. The National Provider System (NPS) is an enumeration system containing basic demographic information; it is not designed to be an enrollment system or a claims payment system. HCFA has found the location code to be a difficult aspect of the NPI, and has separated its development and process from that of the Provider Identifier.
Subcommittee members and Department representatives focused their comments on concerns about proposed location codes and the scope and definition of "provider." Questions were raised about whether RNs should be enumerated and the plan to concentrate up front on providers who submit claims and are reimbursed by payers for services. It was noted that increasingly, providers do not bill for their services, and HCFA was asked to clarify whether it intends to identify all clinical services or is just interested in billing. The HCFA representative stated that the intention is to enumerate all providers of health care services, not just the sources of bills.
Subcommittee members expressed reservations about the plans for the location code and commented that they would need to revisit this question. It was not clear to members that the code would promote administrative simplification.
With respect to the National Payer ID, Stewart Streimer, HCFA, reported that its development has followed a parallel track to the NPI but it is not as far along and there are more issues to resolve. He stressed that this is a proposal, and HCFA anticipates continuing consultations with the industry as it is developed and implemented. HCFA hopes to publish a final regulation in July of 1997, requiring it for Medicare in January of 1998 followed by roughly two years for implementation.
The agency was urged to use caution in making sure that the public is not prejudiced by the planned decision to use the National Technical Information Service. Questions were also raised about the conditions under which payer/providers would use each ID, given the number of entities that are both, the number of gray areas, and the vagueness of the definition of "provider."
The overall focus of this meeting was administrative simplification, as mandated by HIPAA. The Subcommittee heard from five panels on their perspectives on this issue, all of which had been asked to respond to these questions:
1) their expectations for administrative simplification under HIPAA,
2) their degree of satisfaction with the Department's process for adopting HIPAA data standards,
3) current problems with the transactions identified for standardization, and
4) how the goal of administrative simplification can best be achieved.
In general, the presenters agreed on the need for and importance of standards and administrative simplification, and expressed satisfaction that the process is moving in the right direction. Common concerns related to the aggressive time frame and the need to better inform and educate the industry about HIPAA and its implications. Most presenters expressed enthusiasm for the new identifiers under development, tempered by concerns about location codes. In discussion, the Subcommittee elicited comments on the degree of variability needed and realistic implementation schedules and processes.
Norma Border, National Association of Claims Assistance Professionals (NACAP)
Shannah Koss, IBM
Ms. Border appealed for consistent, reasonable access for the consumer and those trying to assist them, and for the inclusion in enumeration systems of claims assistance professionals who work for small to medium-sized physician practices. Otherwise, Medicare beneficiaries might be unable to initiate an electronic appeal. She stressed the need for enough clues in the system to enable an aggrieved consumer (who has the burden of proof) to go back from the number to the appropriate entity to find out what went wrong. Another concern was that administrative simplification requirements could adversely impact small business owners.
Ms. Koss expressed concern about the potential for standards to diverge from current industry standards or to create barriers to innovation. The question arises due to the lack of "a bright line" where the standard ends and it touches upon the technologies that deliver it.
Mark Segal, American Medical Association (AMA)
Ken Rich, American Dental Association (ADA)
Kathy Milholland, American Nurses Association (ANA)
Ron Jordan, American Pharmaceutical Association (APhA)
The AMA representative argued that CPT was the most appropriate system for reporting professional services and asked for standards that do not impose the major burden on providers. A major issue for the ANA is the need for the standards to apply to all individual health care practitioners, as they will affect not only business entities but all individual providers. The ADA recommends migration to the ANSI ASC X12N formats, and supports the adoption of standards for the financial and administrative transactions listed in the HIPAA, except with regard to health claims attachments. Although some transactions in the model advocated by ANSI X12 are appropriate for pharmacy, APhA asks the Committee to advise the Secretary to encourage the continued use of pharmacies' NCPDP standards in addition to X12 and other standards where appropriate.
The discussion period focused on these topics: procedure coding, variability, vision and evaluation, the relevance of the NCVHS core data project, inclusion of nurses and other providers in the new ID system, priorities for standardization, and gaps and overlaps among coding systems. Dr. Lumpkin introduced the dimension of long-term vision into the discussion, asking panelists to comment on this question: How will we know that the goal of administrative simplification has been met?
George Arges, American Hospital Association (AHA)
Sam Schultz, University Health System Consortium
Dan Rode, Health Care Financial Management Association (HFMA)
Gary Beatty, Mayo Clinic
Some panelists called attention to the industry's uncertainty about the nature of the process and the need to get more information to the industry about it, including the rationale for decisions. Their organizations can help in this process and thereby facilitate the transition.
The discussion with this panel focused on these questions: whether, or how, to transition to X12 standards; the cost of implementation; the relationship between standardization and simplification; how to evaluate administrative simplification; coding issues; the implementation process; possible incentives; the various uses of administrative and clinical data; and the home health/nursing home arena.
Mr. Scanlon elicited comments about the optimal timing and overall process, in response to which the diminishing time and cost of successive implementation and the possibility of interventions such as clearinghouses were noted. Suggestions included interventions to make the curve less steep, especially for hospitals with fewer resources; the use of rewards and incentives; and a longer period of 30 to 36 months for implementation.
There was extensive discussion of the varied uses and overlaps of clinical and administrative information.
Frank Pokorny, Blue Cross/Blue Shield Association, Confederation of Plans
Marion Ramey, Association of Federal Health Organizations
William Decker, American Association of Retired Persons (AARP)
The panelists stressed the need to educate the industry, as many not aware of HIPAA's implications for them. Discussion with these panelists focused primarily on the extent of variability needed. It also touched on the implications of NCVHS's core data element recommendations, the potential for getting data for evaluating quality of care, opportunities for future panel input, confidentiality issues, and state requirements. Panelists agreed that standardization should focus on the core areas, "aiming for the middle, with flexibility on the edges."
In general, there was a sense that a good deal of progress has already been made toward the desired goals, and optimism that payers could endorse a standardized form for major information processes. It was noted that the process is already in place for dealing with questions about the degree of variability permitted. One question may be whether the law will allow separate trading partner agreements.
Given the several mentions of paring down to a minimum core, Subcommittee members were interested in whether the NCVHS recommendations on core data elements were known in the field and might aid decisions about medical information as it is standardized. Members also pointed out that the trend away from generation of a bill from transactions and the possibility that data will increasingly be used for quality of care purposes.
John Lavin, PCS Health Systems, Inc.
Richard Sheldon (third party administrator)
Sue Jensson, State Farm Insurance Companies
These presentations and the discussion following them touched on a range of topics, including the rate of EDI penetration and other issues for self-insured employers; the prospects for X12, including the views of the pharmacy industry; State Farm's recommendation to enumerate property and casualty insurers; the optimal time frame for implementation; state variations and other variability questions, including the feasibility of requiring one standard; the application of these issues to code sets; and the financial and other ramifications of various standardization scenarios.
In general, panelists favored the X12 standards, with the exception of Mr. Lavin, who was queried about his organization's stance in this regard. He explained that NCPDP is involved with X12 and accepts the X12 for transactions other than claims transactions. Moreover, X12 is trying to develop an interactive claims standard. The hope is that X12 will adopt the NCPDP standard or at least have a transaction that could read the data sets.
The group began and ended the second day of meetings with a discussion of how they would use the testimony, the Subcommittee's role in the HHS process, and in general what they hope to accomplish. A focus was the Subcommittee's working relationship to the six HHS workgroups, and specifically how to stay abreast of, inform, and influence their recommendations based on these hearings, within the constraints of time and other factors.
A view evolved of what Dr. Lumpkin called "two parallel processes that will intersect," in which the Subcommittee synthesizes what it is hearing from the outside world and what it knows from its own experience and evaluates the Department's work product on that basis. Members also expressed a strong desire to be proactive, to have input in the HHS process as it is developing in order to be able to support the recommendations upon their release. They expressed interest in pursuing linkages to NCVHS core data element recommendations, and will ask the HHS work groups to analyze the inclusion of the core data sets and a map of where they are in standard sets under development.
Finally, the Subcommittee decided to appoint liaisons to the HHS workgroups, as follows:
· Claims/Encounters (Coltin)
· Enrollment/Eligibility (Van Amburg)
· Identifiers (Lumpkin)
· Systems/Security (Frawley)
· Medical Coding Classification (Iezzoni)
· Infrastructure (Cohn)
There was a good deal of discussion about what follow-up questions to send to panelists who have already testified, along with those who were invited but chose not to testify. These questions will be framed by Dr. Lumpkin and Dr. Braithwaite and circulated to members. They will focus on how the respondent distinguishes between standards and simplification, and how their constituents will know when simplification has been achieved. Related questions are how much variability is appropriate, and the anticipated costs of transition.
It was agreed that the Subcommittee would consider contracting for production of a background document compiling the papers received and a summary of the transcript.
In the final session, Mr. Moore reported on the HHS work group and development process, describing its relationship to the HCFA work already underway on identifiers and the Department's concerted effort to involve all stakeholders.
The group agreed to hold a third set of meetings to examine coding issues -- e.g., the suitability of the ICD-10 as a standard, where CPT-4 fits, information on HCPCs, and questions about procedure classification. These discussions will also include links to computerized patient records and to NLM's work, as well as ANSI's work on a functional status placeholder and to ICIDH. Although these issues are not immediate priorities for the Subcommittee, the sense was that its short-term work should be carried out within that broader context and long-term set of issues.
It was also agreed that identifiers should probably be studied at a full Committee meeting because of the cross-cutting nature of the issue.
Dr. Starfield called the meeting to order and welcomed participants. Following introductions, she reviewed the agenda and then turned the floor over to Dr. Lumpkin, Chair of the Working Group on Administrative and Clinical Data Standards (known as the K2 Working Group).
Commenting on the focus of this meeting, administrative simplification, Dr. Lumpkin spoke of the frustration of clinicians in having to spend more time with paperwork than with patients and clinical work, and of the growing number of forms and papers today's clinicians face. Thus, administrative simplification, as mandated by the Health Insurance Portability and Accountability Act (A.K.A. "HIPAA," "Kennedy-Kassebaum" and "K2"), can have a dramatic impact on clinical practice. Some of the questions to be resolved by the Committee are how simple is simple enough, and how many variations are necessary. He noted that Congress passed the administrative simplification section because "we have passed beyond the point of reasonableness."
Turning to the first agenda item, Dr. Lumpkin noted that unique identifiers are an area for which standards are mandated in the legislation. HCFA already has been working on national payer and provider identifiers, and the Committee is being asked to advise the Secretary on their adoption as HIPAA standards. He introduced the two HCFA officials directing the work on these identifiers.
Mr. Broseker stressed that this HCFA initiative is currently in the proposal stage for a standard provider identifier, one that the agency hopes will prompt considerable feedback from the industry. A notice of proposed rule making will be published around February 21, with details on how HCFA proposes to implement the standard. Feedback will be taken into account in developing the final regulation, scheduled for publication in July 1997. Following that, HCFA will begin enumerating Medicare providers and require the use of the identifier for Medicare claims processing as of 12/1/97. This is the first of the standards mandated by HIPAA, and its fast start is needed so that other regulations can build on the experience.
Medicare physicians currently use the UPIN, nominally a unique identification number but actually one that providers have multiples of. This is one of the things HCFA is trying to avoid with the NPI. The agency began both of its new identifier systems in conjunction with the Medicare Transaction System, but broadened its effort into a nationwide system for enumerating all providers and payers in anticipation of legislation requiring them. This necessitates "keeping the national community in mind," which HCFA has done in part through its involvement with a range of standards activities that Mr. Broseker mentioned by name. It has also dealt with state Medicaid agencies, professional organizations, other government payers, other federal agencies, and private sector and provider groups.
He described the National Provider System (NPS) as an enumeration system containing basic demographic information, stressing that it is not designed to be an enrollment system or a claims payment system. Although its purpose is administrative simplification, he acknowledged that to achieve its anticipated benefits it will require initial changes. The end result is expected to be a standard can be embraced by many in the outside world.
The NPI is envisioned as an eight-digit number that will eventually be alpha-numeric, although initially only numeric IDs will be assigned. No intelligence is contained in the NPI, so that it will not have to change as provider characteristics change, and also to protect confidentiality. Providers will have one NPI but eventually be assigned a related two-position location code for every location in which they work. The location code is not part of the NPI but a separate data element. A decision of whether or how it might be used in any electronic transactions (e.g., claims) will be made as the standards for those transactions are developed. Mr. Broseker predicted that the location code would be the most controversial aspect of the provider identifier.
The NPS will enumerate individual providers, groups, organizations, and institutional providers, and will be able to link group members to their groups. HCFA will publish a comprehensive directory. It is seeking public feedback on what information should be released and what should be protected.
As for the process, HCFA will initially enumerate all Medicare providers. It has not decided on the process for non-Medicare providers, and is looking at different state needs among other things. It is also soliciting volunteers for baseline testing of the NPI from other healthcare sectors.
In conclusion, Mr. Broseker observed that there are likely to be some initial operational and implementation problems, which HCFA is committed to working with the industry to minimize and resolve. Status information on the NPI and system, including the contents of the national provider file, is available on the HCFA web site: www.hcfa.gov.
Subcommittee members and Department representatives had a variety of questions, with particular emphasis on the proposed location codes and the scope and definition of "provider."
Regarding the range of providers being considered, Mr. Broseker predicted that some three million providers would eventually be enumerated, starting with the 1.2 million in HCFA's UPIN, NSC and OSCAR files. To this base will be added dentists, and eventually other providers not normally enumerated through the Medicare program, such as obstetricians, pediatricians, and psychologists. He added that "we are aware of questions about whether RNs and other non-billing providers should be enumerated;" that the system would be able to enumerate them, and that although we would "concentrate up front" on providers who submit claims, we are defining provider broadly so that all providers of health care services would eventually be enumerated. He offered to provide the Subcommittee with the taxonomy proposed by X12, and was asked to do so. Asked about home health agencies, he said they would be treated as individual providers if they bill Medicaid or Medicare. Information may be developed to link chains to their headquarters.
Clarifying the plans for the location code, Mr. Broseker said it would be developed and implemented on a separate track from the NPI, with extra time allowed for input from the claims industry, states, and others. The intent is to support the commercial world as fully as possible and to make the regulations as flexible as possible.
Asked what is meant by "provider," he said a provider could also be a biller, and in fact the providers that initially will be enumerated are HCFA's billers. Eventually, others who are not billers may be enumerated. Anyone who provides health care services to an individual is considered a provider. The ANSI X12 taxonomy should help clarify definitions. Dr. Starfield noted that increasingly, providers do not bill for their services, and she urged that HCFA clarify whether it intends to identify all clinical services or is just interested in billing. Mr. Streimer (the next speaker) said the premise is to identify the providers of health care services, not just the sources of bills, with attention to all transactions.
Dr. Lumpkin expressed concern about the capacity of the NPS, given the number of providers and the limitations of a strictly numeric system. Mr. Broseker assured him that HCFA would have the full alpha-numeric system up and running by February 2000, which should be before the numeric system is overloaded. HCFA intends to support the entire health care delivery system and any type of provider. In response to a stated concern about inadvertent revelations through the numbering patterns, he said the numbers would be randomly assigned.
Asked about loading and maintenance of the system, he said the industry would be asked for suggestions and help on how and when to bring in non-Medicare providers. HCFA hopes that the industry will provide an interface with the NPS for collecting and submitting baseline information. There will be algorithms for merging and purging redundancies, similar to that used for Social Security Numbers. Numbers will not be reused. There are provisions for regular updates, which will be the responsibility of the provider. As changes are made, historical data and an audit trail will be stored.
Dr. Mor asked about the possibility of providing sanction information, such as is required on nursing assistants. Mr. Broseker said that within HCFA's legal authorizations, any entity or individual who is sanctioned by a federal program is automatically also barred from other programs.
Dr. Cohn and others expressed reservations about the plans for the location code and commented that the Subcommittee would need to revisit this question. It was not clear to members that it would promote administrative simplification. Dr. Lumpkin asked Mr. Broseker to think about the linkage between the location code and the provider ID in the light of K2 requirements.
Mr. Streimer noted that the Payer ID initiative has followed a parallel track to the NPI, but is not as far along and has more issues to resolve. He invited the Subcommittee's input. The Payer ID is to be a unique identifier for health plans and employers. HCFA originally intended it for payers only, but expanded it to include employers with the enactment HIPAA. As with the NPI, he stressed that this is a proposal, and HCFA anticipates continuing consultations with the industry as it is developed and implemented. The consultation partners are largely the same as those for the NPI.
Coverage of the Payer ID was addressed in HIPAA. The anticipated benefits to the industry include standardization of data (e.g., it will replace all narrative names and addresses), elimination of existing numbering schemes, and provision of a core data element for health care transactions. In keeping with the legislation, HCFA is considering other uses for the unique identifiers to maximize their usefulness to the industry.
The Payer ID is a nine-position unique identifier, a registry, an electronic phone directory, and an enumeration system with the capacity for 100 million plans and employers. (Current estimates are that there are 4 million payers and health plans in the U.S.) HCFA plans to allow companies to tailor parts of the number for internal purposes. The only intelligence in the number, added at the request of the health care industry, will be two digits to identify whether the plan or beneficiary is a medigap plan.
HCFA hopes to publish a final regulation in July of 1997, requiring it for Medicare in January of 1998 followed by roughly two years for implementation.
Given what the agency is learning from the industry about its needs for the identifier, Mr. Streimer said it is a challenge to stay on this schedule. Implementation will be very dependent on the registrants (health plans and employers), who will have direct access to the system in order to provide initial data and then update as needed. Another challenge will be to facilitate industry compliance, given that not everyone will be happy with the change. The intention is to make implementation as simple as possible.
The Payer ID has already been approved by the USA Registration Committee, an ANSI group, for use on health care cards. Mr. Streimer said this endorsement is a major step toward standardization. Consultation will continue with federal and external groups, and work will continue on implementation strategies. Testing is about to begin.
Asked about the relationship between employers and payers, Mr. Streimer said the employers that need to have Payer IDs are those self-funded employers that do their own EDI for health care transactions. Regarding the possibility of confusion between this ID and the NPI, he noted that the two are of different lengths (9 vs. 8 digits, resp.). Members raised a few technical issues.
Mr. Gellman noted the difficulties IRS has had with the Cyberfile program developed by NTIS, HCFA's proposed contractor for the Payer ID, and asked what arrangements had been made for making the information public. Mr. Streimer said he has stressed to NTIS that this is a chance to redeem its reputation, and also that "this is not an opportunity for NTIS to make money;" rather, it must develop access methods to the PAYERID registry which will be either on-line via the Internet or through paper or electronic directories. There will be fees associated to these access methods to fund registry operations. He is waiting to hear how they will meet this charge. Mr. Gellman cautioned him to make sure that the public is not prejudiced by HCFA's decision to use NTIS.
Mr. Streimer was asked under what conditions payer/providers would use each ID, given the number of entities that are both, the number of gray areas, and the vagueness of the definition of "provider." He said HCFA would be very explicit about definitions and protocols in its rules. Mr. Moore added that the Subcommittee would receive copies of the NPI proposed regulation now being reviewed in the Department, which should help clarify this issue. At Dr. Lumpkin's request, Mr. Broseker and Mr. Streimer will also provide written explanations of the interrelationship between the Payer ID and NPI systems.
Concluding this portion of the meeting, Dr. Lumpkin thanked the presenters and invited those in the audience with questions or comments to submit them directly to HCFA.
Introducing the next segment, he noted that the overall focus of this meeting is administrative simplification, with various panels presenting their perspectives on this issue. All panels were asked to respond to the same four questions:
1) their expectations for the HIPAA,
2) whether they had any concerns about the HHS process,
3) current problems with the transactions identified for standardization, and
4) how the goal of administrative simplification can best be achieved without undermining individual business interests.
Ms. Border noted that she would be "the sole representative for the American consumer" to be heard from during this meeting. Like all of the presenters to follow her, she conveyed her organization's hearty endorsement of the goal of administrative simplification. She likened health care processing issues from the consumer's perspective to "a black box" and the IRS 1040. NACAP's members include claims assistance professionals (independent consultants working as consumer ombudsmen) and professional claims processors (who generally work for providers).
Turning to her concerns, she focused initially on the prospect of a shift to number systems that could eliminate critical narrative information that helps consumers interpret services, costs, and denial or low payment that they may need to challenge. She appealed for consistent, reasonable access for the consumer and those trying to assist them. Also in regard to enumeration, Ms. Borden noted that claims assistance professionals work for small to medium-sized physician practices; thus they must be included in the NPI system, and unless they are "identified in the loop," Medicare beneficiaries might be unable to initiate an electronic appeal. In general, the appeals process needs to be simplified, she said. She then responded to the questions.
Dr. Lumpkin asked Ms. Borden to comment on the proposed location code, and she said the provider ID number and a location number should be kept separate.
Dr. Iezzoni agreed with Ms. Borden that the consumer must be kept in mind in the course of administrative simplification, noting concerns about eliminating information needed by consumers and also that a potential source of confusion is the separation of ownership from the name of the institution where care is provided. Ms. Borden added that there must be enough clues in the system to enable an aggrieved consumer (who has the burden of proof) to go back from the number to the appropriate entity to find out what went wrong.
To another question, she estimated that 60 percent of claims problems stem from clerical errors and missing information; 30 percent relate to medical review, and the rest have to do with coordination of benefits. She added that in the last category, much of the solution lies in consumer education about benefits, rather than in administrative simplification.
Dr. Cohn asked Ms. Borden's views on the need for variability versus standardization - - a question he subsequently asked most panelists. She asserted that everyone should be required to recognize the validity of every standard data element and not be allowed to select from within a system and tailor or restrict it. Asked what coding systems she sees predominantly, she said CPT, ICD-9-CM and HCPCS. To another question, she said the use of EDI in claims processing has improved markedly in the last four years, although it remains a problem with small to medium-sized practices.
At Dr. Lumpkin's request, Ms. Borden agreed to send written comments to the Subcommittee on the cost implications of 1) non-simplification, 2) the move to simplification, and 3) the long-term effects of simplification.
Ms. Koss said that IBM's health benefit program has evolved to a competitive and integrated management model from an entitlement model prior to 1984, and it needs a range of affordable plans. The company participates in the national HMO purchasing coalition and conducts plan evaluations using existing information streams. Standardized transactions would improve underlying information.
Asked to elaborate on her concerns about limiting innovation, she explained that the question arises due to the lack of "a bright line" where the standard ends and where it touches upon the technologies that deliver it. Mr. Moore commented that advancing technology may in fact render some standards obsolete before they are established. Dr. Cohn noted that most standards under discussion combine the envelope and the data content, and these comments seem to focus attention on the data content. Ms. Koss stressed the need for a flexible user interface, so that definitions are not so rigid as to drive the technologies or the interfaces linking the two.
Regarding using information for secondary analysis, she said IBM and the purchasing coalition have a hard time getting consistent information. Generally, IBM relies on reports such as those generated by NCQA, based on aggregated data; in addition, it sometimes has outside experts audit this activity, and the Coalition sends people on site.
Asked about the international context, she said she has seen nothing that either surpasses or seriously challenges the current U.S. work on standards. Indeed, although the European process is driven by international standards, the systems themselves are less well evolved than those used to deliver care in the U.S.
1. The AMA has high expectations for HIPAA, which it believes strikes a good balance between federal mandates and market development and begins to redress problems that have been a major bar to increased physician use of EDI. AMA's concerns have to do with the possibility that implementation will overreach the core focus and seek premature standardization of clinical transactions and computerized patient records.
Dr. Segal noted that standards for the nine specified transactions have been completed by the X12N committee, which should be coordinated with pertinent standards developed by other organizations. The AMA is concerned that some implementations could penalize payers and providers for mutually agreeable departures from specified standards. Specification of data content standards for non-institutional claims and encounters should adhere to NUCC recommendations.
2. The AMA is impressed with the Department's process.
3. AMA members are especially interested in standardization of claims and encounters, attachments, and claims advice. On the first, a major issue is whether payers should bear transition costs; on the second, it is the importance of minimizing the need for attachments; and on the third, AMA calls for reduced physician responsibility for non-clinical data elements.
4. The Department appears to recognize the need for careful implementation with all affected parties. In general, the AMA sees the X12N process as an appropriate means of meeting the intent of the HIPAA. If the decision is to use the NSF as the initial standard, it urges a timetable for moving toward the applicable X12N standard, the 837. It believes that professional services within the specified transactions can best be reported through the CPT; moreover, requiring a system other than a combination of CPT and ICD would result in substantial cost to all concerned.
The organization's priorities for the process include concise and clear regulations, enforcing a single set of standards, ensuring confidentiality, and involving key stakeholders.
ANA supports the HIPAA provisions for administrative simplification. It takes "provider" in the Act to mean "facilities, physicians, nurses, dentists, pharmacists, and others involved in the delivery of health care." Dr. Milholland stressed that standards will affect not only business entities but all individual health care practitioners.
Pharmacists use computers more consistently than most other health professionals, and have a unique perspective on standardization. They see great promise in the work on administrative simplification, tempered by awareness that any required change will have huge financial implications given pharmacy's investment in technology. Nevertheless, APhA recognizes the need to integrate pharmacy's EDI more fully with care.
The discussion period focused on these topics: procedure coding, variability, vision and evaluation, the relevance of the NCVHS core data project, inclusion of nursing practice in a new ID system, priorities for standardization, and gaps and overlaps among coding systems.
The Subcommittee went first to the issue of procedure coding systems, stressing the need to revisit the multiplicity and overlaps among them. To a question, Dr. Milholland said the ANA recognizes three classification systems that include nursing intervention classifications. The ADA has its own sets of codes. Ms. Brooks of HCFA said the new system being developed for hospital use by 3M for HCFA will not include nursing, dentistry and pharmacy.
Dr. Mor asked about attachments, and was given various examples of the kinds of things that could be attached as supplemental data strings or code sets. Dentistry might move from procedure codes to more diagnostic codes.
Dr. Cohn asked for comments on the need for variability in the move toward standardization. Dr. Segal responded that NUCC has been grappling with this, particularly regarding which data elements should be required for a format considered to be standard. He also thinks flexibility is needed in the implementation path. Dr. Milholland agreed with these points. Mr. Jordan suggested looking at this question in the context of a business model that specifies what level of the system is being talked about; and at the most granular level, there should be no variability. He added that a single data dictionary would be a big move toward interoperability, and better technologies will almost certainly reduce the variability.
Dr. Starfield returned to Dr. Segal's statement about the connection between standardization and computerized patient records. He explained that the technology is at different places, and care must be taken so that progress in administrative transactions does not prevent doing proper things with the CPR, while at the same time not letting "the perfect be the enemy of the good." The AMA's key focus is getting the first part of Kennedy-Kassebaum going.
To another question about variability, Mr. Jordan expressed confidence that systems can be built to bridge the pharmacy world and other arenas -- one that he hopes places the burden of translation outside the pharmacy world. On the other hand, it would be a significant burden if pharmacy were suddenly forced to connect to other arenas through a new syntax.
Dr. Lumpkin then introduced the dimension of long-term vision into the discussion, asking panelists to comment then or later (in writing) to this question: How will we know that the goal of administrative simplification has been met, resulting in improved clinical care? He noted that it is too easy to get caught up in standardization issues as an end in themselves.
In response, Dr. Milholland referred back to her introductory comments, which envision practitioners who are less involved in putting together the information, and administrative data that "fall out" of the clinical transaction. Mr. Jordan predicted that the world would "begin to align" once unique identifiers are in place. Dr. Segal suggested articulating some empirical questions based on a set of specifications and baseline data, and using them for a formal evaluation based on Dr. Lumpkin's question.
Various panelists offered to follow up on this question, rephrased by Ms. Borden as an articulation of the ideal patient encounter from their constituencies' standpoint, including information collection and transmission. Dr. Lumpkin said the Subcommittee would frame the question and send it out to all panelists to address the topic. Dr. Starfield suggested also asking about possible linkages to the Committee's recent core data elements recommendations.
Asked to elaborate on her comments about identifier systems from ANA's perspective, Milholland urged the Committee to look at HCFA's proposed system in the light of other identifier systems. She noted that at least until recently, HCFA has been "very claims oriented and...not oriented to a bigger picture of a computer-based health record." What is needed is a single, unified system that identifies all providers. Mr. Jordan added that ADA endorses HCFA's work but wants to see it accelerated and expanded. Mr. Moore observed that the Department is constrained by limited staff and financial resources, and he noted that the NPI includes a plan to enumerate nurses; Dr. Milholland countered that this is "way down the road." She praised the new indications of HCFA plans to use the number for purposes beyond claims processing. Mary Emerson of HCFA spoke from the audience that HCFA has always intended the NPI for all health care professionals.
Mr. Moore said he envisions a staged process, in which administrative simplification and electronic commerce are achieved in the short run, but with attention to the long-term view of improving the quality of health care. Dr. Lumpkin noted that NCVHS "has its roots in basic public health" and is charged with this bigger picture, even as it tries to simplify in the short run.
Turning to a new topic, Mr. Scanlon asked panelists which of the nine specified transactions either have priority or might be implemented more easily than others (what Dr. Detmer calls "low hanging fruit"). Mr. Jordan said APhA is ready to move on enrollment and payment and remittance advice; he reiterated that the Department should start with a uniform identifier to build the data base on. In his view, in fact, there should be a single uniform identifier for every individual related to health care, whether a provider, patient or payer. Dr. Milholland agreed. Mr. Moore described the practical and political problems with such a scenario, partly a function of differing needs for privacy and confidentiality.
Returning to code sets, Dr. Mor noted the absence of a voice from the mental health world on the panel and the broader question of how to handle different professional domains' use of different coding systems to describe similar or overlapping activities. He asked how different activity codes could co-exist, and panelists offered some specific examples. Dr. Segal noted that CPT is increasingly involving non-physicians in the advisory process and the codes themselves. To address the coexistence issue, the X12 transaction includes a qualifier indicating which coding system is being used. Cross-walks will also be needed, along with "as clean lines as possible" between the domains. Dr. Rich said these issues are not a priority from dentistry's perspective. Concluding this discussion, Dr. Lumpkin remarked that the Subcommittee would clearly have to revisit the issue of coding.
AHA members support the HIPAA's goal of administrative simplification, as they contend with continual and costly increases in the demand for diverse, complex, open-ended and multi-purpose data.
Regarding the electronic format to carry the data content, while the X12 holds great promise, its use in health care is low compared to flat files. AHA members worry about changes that disrupt the flow of data, e.g. to Medicare, and prefer not to move to "an untested and untried format" like the X12 837. The selection process should use rigorous criteria. The Department should also be clearer about distinguishing data content from format. Also, AHA asks the Department to consider requiring all payers to accept and use something like the UB- 92 data set. Payers that wish particular items should have to go through a process like the NUBC to discuss their merits.
3. One problem for providers is the need for customized routines to handle billing data for each payer. Another relates to the need to use multiple coding systems in outpatient care (CPT or ICD-9). The selection of one code list and a single set of reporting requirements would make reporting easier. The process for deciding which code to use should be open and national, and should presuppose the abolition of local codes. This would "force the issue to a national forum."
4. AHA members want an incremental approach. Mr. Arges noted that much has been accomplished on a voluntary basis, and those who have followed NUBC's deliberations will find the transition to national standards easier. In conclusion, he stressed that the standards must apply to everyone; include uniformity of content and format; be cost-effective; rely on a balanced forum for deliberation; and involve a predictable process of review and update and an effective communication infrastructure.
The 10-year-old Consortium (formerly the University Hospital Consortium) includes 70 major academic health centers and 50 of their health system partners. It has just formed an alliance with the National Association of Public Hospitals. A major function is to collect and organize data and provide it to members to help them improve operations. Dr. Schultz is also founding Chair of HL-7.
HFMA's 34,000 members work in various financial information and administrative settings. The organization helped found the NUBC, set up the Health Care Task Force of the X12, and sought passage of the HIPAA. Mr. Rode called attention to two key principles: the necessity of uniformity, and the need for it to apply to the entire health care industry.
1. HFMA's expectations were met in HIPAA because it stresses uniformity. It hopes NCVHS and the Secretary can make sure that everyone participates, including states, to achieve genuine uniformity. HFMA does not support the Act's two-tiered implementation because this delays uniformity; it suggests, if necessary, delaying the implementation schedule so everyone can come on board at once. In addition, HFMA prefers incentives to penalties and points out that the penalties are too low to have effect.
The organization is pleased with NCVHS's participation in the process, which should be industry-wide. Mr. Rode noted that HFMA can help educate providers and payers who may not be up to speed. It suggests starting with the core transactions and having that serve as a model for building in other activities. The main need is for simplified transactions and the use and collection of data. Some HFMA members are vendors, and (contrary to rumor) they welcome the prospect of simplification. Although all 9 or 10 standards are desirable, the organization gives priority to the 837 and the 835.
2. The greatest concern is uncertainty about the nature of the process and the need to get more information to the industry about it. More also needs to be known about the rationale for decisions. HFMA recommends that the Secretary and Committee put together a technical advisory process to get input from the experts, to complement the work of NCVHS. Once industry organizations know what the goal and process is, they can begin educating members for the transition. At this point, people in the industry are hesitant to begin the move to EDI before standards are in place. Specifically, HFMA recommends choosing the transactions for the entire industry, and looking at international standards, including X12 as a good starting point. It acknowledges its own commitment to educating the public and working with the Committee.
The discussion with this panel focused on these questions: whether, or how, to transition to X12; the cost of implementation; the relationship between standardization and simplification; how to evaluate administrative simplification; coding issues; the implementation process; incentives; the various uses of administrative and clinical data; and the home health/nursing home arena.
Dr. Iezzoni noted apparent differences in panelists' enthusiasm for X12, and Mr. Arges explained that while the "end game" should probably be in an X12 environment, AHA members are now comfortable with the flat file and reluctant to shift until the X12 has been tested against firm criteria, data element content has been clarified, and implementation guides are developed. He agreed with Mr. Rode that the process should start with the four core transactions.
Mr. Beatty offered examples of implementation scenarios and associated costs, stressing that some solutions are available over the Internet and that clearinghouses and other services such as translation software will ease the way for providers. Although Dr. Lumpkin noted that some of the shifts described seem to achieve standardization without simplification, he described benefits such as not having to chase down claims and reducing the administrative burden for re-entering information.
Mr. Arges cautioned that EDI-readiness can require a heavy investment, and he suggested viewing the benefits in terms of content rather than the success of communication.
Commenting on the earlier discussion of how to evaluate the success of administrative simplification efforts, Dr. Schultz said his organizations keep an eye on this, but it is difficult to separate the variables and get meaningful results. Nevertheless, he estimated that interfaces that cost $50-100,000 before 1990 now cost $5-15,000. His consortium tracks both the "distal and proximal" outcomes of interfaces and their costs, and he suggested that to pursue its interest in evaluation, the Committee confer with institutions of varied sizes with the capacity to track such things. He offered to share the Consortium's data with the Committee.
Dr. Braithwaite remarked on the contrast between the Consortium's EDI use rate and the rate HCFA has found; Dr. Schultz attributed this to the disparity between large academic centers and small institutions. The key question here, he said, is what the Department is "trying to hit," or harvest, and he cautioned against letting the perfect get in the way of the good.
To a query from the Committee, Mr. Arges said he has no preference among the existing coding systems, but merely wants to see one used by all institutional providers for both inpatient and outpatient care. He urged a process that looks at which provides better information, is applicable in an institutional setting, is updated frequently, and provides a forum for discussing issues.
Dr. Cohn recommended inviting state representatives to talk to the Committee about their experiences. He asked Mr. Arges to comment on the viability of the UB-92. Mr. Arges said AHA members are quite satisfied with it, thanks to its flexibility; their concerns are with those people who operate outside the NUBC process. Mr. Beatty agreed that the national standard format and the UB-92 format do a good job, and that the problem is those trying to go "outside the box" -- something he added that "most people do."
Mr. Scanlon elicited comments about the optimal timing and overall process, given the legislated time frame for the nine categories, the existence of candidate standards, and the need for "a fair amount of migration." Mr. Beatty reiterated his earlier point about the diminishing time and cost of successive implementation, also noting that providers can use intermediary clearinghouses. Dr. Schultz suggested considering interventions that will make the curve less steep, especially for hospitals with fewer resources -- e.g., "managing the front end of adoption" with some rewards. Mr. Rode noted that HFMA has suggested a longer period of 30 to 36 months, combined with clarity about where the process is headed and an education process. Organizations such as his can facilitate the transition by educating their members. HFMA has also suggested incentives, such as tax incentives. Mr. Arges noted that Mr. Scanlon's question goes back to the issue of defining the data content associated with each transaction.
Dr. Starfield asked Mr. Arges to explain his thinking about distinguishing between administrative and clinical data -- noting her own view that there is increasingly little distinction between the two. This generated a wide-ranging discussion about the varied uses and overlaps of the two categories of information. Panelists seemed not to agree with Mr. Arges' assertion that administrative data is for external reporting and information exchange, while clinical data is for internal use; they cited the use of clinical data for external reporting, such as in HEDIS. He explained that his major point is that many clinical elements still need work, and progress on administrative data standardization should not be held up in a wait for a better clinical information system.
Mr. Beatty cited CDC's work on a national children's immunizations data base and ANSI's work on resolving issues of overlap, both processes that are working well. Mr. Rode agreed that some clinical standards are merging into the administrative, but he stressed the need to move rapidly where possible because of the pace of the industry. It is important that whatever standards are built are then able to handle clinical data.
Asked about the home health and nursing home arena, he said it is primarily composed of small shops using PC-based software, or even paper and an out-sourced business office. That industry must use two applicable data sets because of different ownership and other factors. Like hospitals and university facilities, they are faced with the need to keep separate financial transactions because of a lack of commonality of data. Smaller members will be able to shift to EDI for under $5,000, while large members have more costly transition issues to resolve because of past investments. He stressed that the technology will follow what the Department does.
Asked about how to deal with extra payer requirements even after standardization of claims, Mr. Arges suggested taking away the leverage of the payment by requiring that the provider is entitled to payment upon providing the information deemed complete for the standardized transaction.
Returning to the subject of new uses of clinical data, Ms. Coltin asked about trends among managed care organizations in asking for clinical data sets rather than transaction data sets, in order to look at service delivery. Panelists agreed that there is a trend in this direction, although it varies around the country. Institutions are getting as much information as possible in an electronic format, but much of this kind of analysis is done through short ad hoc studies. Mr. Arges agreed that the dynamics and incentives of managed care do change the uses of information.
Noting the current uses of billing systems as "de facto clinical systems," Dr. Schultz expressed hope that the emerging standards will form the basis for evaluating care. The most important issue for his members is assuring that even with the current focus on administrative and financial issues, that the "harvest of cost" will level off and be followed by reforms in the delivery of care as "the next wave," with the right data system to collect those data. "That is really where the prize is," he said.
The meeting then recessed until the following day.
Before resuming its discussion of administrative simplification, Subcommittee members discussed how they would use the testimony, the Subcommittee's role in the HHS process, and in general what they hope to accomplish. Noting that the process is less straightforward than the drafters may have anticipated, Mr. Scanlon stressed the Committee's role as a forum for external perspectives on standardization. Mr. Moore said the SDOs are so collegial that "there is no standard"; moreover, a very few people are setting a standard that everyone is to use, based on "what they need to do their business." He suggested the possible need for a more directive intervention to get past this point and to achieve the kind of goals that the AHA and AMA want. Dr. Lumpkin noted that in the current environment, "any standard is better than no standard," and the Committee and the Department need to listen to other groups to develop a sense of what standard will be most useful and acceptable to the broadest number.
Returning to the original question, Dr. Starfield urged the Subcommittee to develop a clear work plan regarding its objectives from the hearings in terms of information gathering and synthesis. Mr. Scanlon suggested feeding information into the HHS work process and then responding to its draft positions with advice, all in the light of broad information policy. In this vein, Ms. Greenberg noted that six HHS implementation teams (AKA "work groups") are forming to address each of the transactions; she suggested that the Subcommittee designate a liaison to each of them. Mr. Moore offered to supply a list of the work teams.
This led to a discussion of the Subcommittee's working relationship to the six workgroups and how it might realistically inform and influence their recommendations based on these hearings, within the constraints of time and other factors. Dr. Lumpkin described his view of "two parallel processes that will intersect," in which the Subcommittee synthesizes what it is hearing from the outside world and what it knows from its own experience and evaluates the Department's work product on that basis. The Subcommittee is thus a sounding board, as well as being "immersed in the people whose lives are being changed."
Agreeing with this, members also expressed a strong desire to be proactive, and the sense that (in Dr. Cohn's words) "the public at large would be served if at the end ... we come away with the statement that we agree with everything that HHS has done, because we've been able to work in the process and affect things as they occur."
Ms. Greenberg stressed the need for quick turnaround in response to Departmental recommendations, and others agreed on the need for efficiency. Mr. Moore urged the Subcommittee to be as clear and specific as possible in its input. Mr. Scanlon added that the timing is good because the development process is in a very early stage, except for the Provider and Payer Ids.
Dr. Starfield suggested that the Subcommittee call attention to possible placeholders for which standards need to be developed later, in the light of NCVHS recommendations about core data elements. Dr. Lumpkin said it could ask the HHS work groups to analyze the inclusion of the core data sets and a map of where they are in standard sets under development.
Dr. Cohn observed that the Committee can, and perhaps should, build on its past consensus development activity around the core data elements project, in which it identified where consensus exists or is possible. In this way, it can help narrow down the choices and move the field toward consensus. This could be moved forward by asking HHS to identify where there is consistency or inconsistency among the data element and code sets on requisite standards. He added that this is "not a small task," having tried it himself.
Ultimately, the Subcommittee agreed to do the following:
· to ask Dr. Lumpkin to outline a process and rationale whereby the Subcommittee will process and synthesize the perspectives it is exposed to through these hearings and make it available to the Department, and subsequently react to its recommendations;
· to designate a liaison to each of the HHS work groups (see list at end of minutes and in Executive Summary)
· to formulate and circulate follow-up questions for "all players" about the vision and cost questions raised earlier.
The group then turned to the matter of questions for past and future panelists. They agreed that in addition to a set of follow-up questions for people who have already presented, they would refine the questions to be asked of future panelists. SDO representatives may be given a different set than other panelists. Dr. Lumpkin and Dr. Braithwaite will work on all questions and circulate them to other members. The follow-up questions will focus on how the respondent distinguishes between standards and simplification, and how their constituents will know when simplification has been achieved. A related question is how much variability is appropriate.
These issues generated some discussion of "how far out" in the standards the Subcommittee should set its scope. Using the analogy of the IRS 1040, the options for the outer limit would be the 1040 EZ, the regular 1040, or the optional forms.
It was also agreed that the Subcommittee would consider contracting for production of a background document compiling the papers received and a summary of the transcript.
The Subcommittee's discussion of its process and work plan continued following two more panel discussions. Dr. Starfield turned the floor over to Dr. Lumpkin, Chair of the K2 Work Group, and he introduced the next panel.
Blue Cross and Blue Shield plans have used standardized and automated processes for decades at the national and local levels. Both the Association and individual member plans continue to be active participants in national standards development, notably ANSI ASC X12N and WEDI. Mr. Pokorny noted that today's comments are preliminary to a forthcoming meeting of Blue Cross/Blue Shield representatives on the administrative simplifications of HIPAA and their effect on plan operations and practices. That meeting will be followed by a meeting with the Department in late January. Mr. Pokorny also referred the Subcommittee to a letter to HCFA and WEDI, which accompanies his testimony, that provides extensive comment on the unique identifiers, NPI and PAYERID.
AFHO is an association of federal employee health benefit (FEHB) fee-for-service plans sponsored by employee organization carriers. AFHO plans hope HIPAA's procedures will catalyze the conversion to a paperless claims processing environment.
Mr. Decker is also Chair-Elect for the WEDI Board of Directors. He noted that his remarks do not necessarily represent official AARP positions, and also that AARP is not a health plan. However, his organizations have an interest in the goals of administrative simplification, especially that of enhanced quality of care.
Discussion with these panelists focused primarily on the need for variability, but also touched on the implications of NCVHS's core data element recommendations, the potential for getting data for evaluating quality of care, opportunities for future panel input, confidentiality issues, and state requirements.
Dr. Cohn asked a question about how much variability is needed, prompting a wide- ranging discussion to which the group returned several times. Panelists agreed that standardization should focus on the core areas, and they noted specific ways in which flexibility is needed, e.g., requiring only a percentage of the data elements and allowing the addition of data elements for internal uses. Mr. Pokorny suggested a broader standard that does not preclude such modifications, and Mr. Decker agreed, adding that the idea is to "aim for the middle, with flexibility on the edges." Mr. Pokorny noted that NUCC is trying to cull its data set down through a consensual process.
Dr. Cohn pressed the panelists by noting that providers find the kind of variability deemed necessary by health plans to be burdensome and costly; he asked what the reaction would be to the imposition of a single standard. Mr. Decker noted that the point is to standardize the transactions between the trading partners and the business, in order to smooth out interactions among 20 or 30 partners. Mr. Ramey agreed, and noted that much progress has already been made in that direction. He predicted that all payers could endorse a standardized form for major information processes.
Mr. Pokorny pointed out that the process is already in place for dealing with these questions. It is assumed that the law will result in the necessity of change; the objective is to integrate the change into the business environment of plans. Knowing the transaction data set for the business purpose would help. He added that a bigger question may be whether the law will allow separate trading partner agreements. Dr. Lumpkin responded that at present these agreements, nominally entered into freely, can in fact be unavoidable and can have very complicated ramifications for providers. He suggested that standardization can be a two-step process that begins with internal arrival at common data definitions, and Mr. Pokorny said that Blue Cross/Blue Shield has already come up internally with a standard and recognizes the value of that effort, which has saved hundreds of millions of dollars.
Later in the discussion, Mr. Cohn asked the panelists to speculate on the extent to which variations are a function of different data requirements for the same or similar offerings. Mr. Pokorny doubted that the variability in requirements is as great as the number of offerings, and he suggested getting the perspective of employers into these standardization discussions. Dr. Lumpkin asked for feedback on the degree to which variability is due to payer versus employer requirements.
Noting the many mentions of paring down to a minimum core, Dr. Starfield asked whether the NCVHS recommendations on core data elements were known in the field and might aid decisions about medical information as it is standardized. Mr. Pokorny offered to investigate this and send an answer in writing. Mr. Ramey said federal plans are aware of general efforts in this area, but not necessarily of the Committee's recent report. He noted that as the largest employer-based plan in the country, OPM should have a seat at the table in discussions of this question. Mr. Decker reiterated his point that although his organization and WEDI members have been very involved in standardization efforts, other health care entities are not aware of the implications of the HIPAA. Several panelists responded affirmatively to Dr. Starfield's query as to whether the core data elements could help them in their thinking about the basic core that needs to be standardized. Mr. Decker added that these hearings will help focus attention on that process.
Dr. Iezzoni observed that the data already under discussion are also used to evaluate quality of care; she wondered whether in the current standardization effort the field is taking quality of care priorities into consideration as well. Mr. Decker commented that the goal of the work is to improve access and quality, and administrative efficiency should help achieve it although it does not assure it; he assured the panel that WEDI's members do have quality of care in mind. However, he and Mr. Pokorny also observed that getting clinical care data elements is not what administrative transactions are about, and they are separate information functions. They agreed that the clinical information needs are critical. Dr. Iezzoni suggested a focus on the inclusion of specific, sometimes simple data elements to permit a look at quality of care -- e.g., data on whether a discharge diagnosis code was for a preexisting condition or one that occurred subsequent to entering the hospital.
Dr. Starfield noted the move away from generation of a bill from transactions, and the possibility that data will be increasingly used for quality of care purposes. Mr. Pokorny acknowledged that his thinking may be conditioned by a billing context, and he offered to think through these questions and send a response to the Subcommittee. Dr. Lumpkin stressed the Subcommittee's eagerness for continued input from those who are testifying, and its plan to send out additional questions to those at this meeting and those who were invited but did not testify.
Mr. Ramey said OPM has a contract with all federal plans to collect data to begin outcomes measurement, starting with breast cancer and asthma. He suggested that outcomes measurement data collection should be a separate issue in the context of standardization.
Returning to Mr. Ramey's comments about confidentiality, Mr. Gellman called attention to problems with use of the social security number. He also cited OPM confidentiality requirements that he characterized as "not a particularly good model at all from a patient perspective."
It was noted that multiple state requirements resulting from current standardization efforts may prove to be a significant issue.
Dr. Lumpkin thanked the panelists and introduced the next group.
PCS is the nation's oldest and largest prescription benefit management company. It hopes the HIPAA requirements will build on the accomplishments of the prescription benefit management industry in regard to electronic point-of-service claims. Pharmacy is the most automated sector of health care related to claims payment. Its three major areas of interest are the transaction standard, transaction content standards, and security standards.
Mr. Sheldon noted that his is probably the smallest company the Subcommittee will hear from. It is fairly representative of the roughly 1,000 third-party administrators (TPAs) in the U.S., who provide administrative services to providers operating their own health plans and to employers and insurance companies.
1. He outlined the list of possible benefits from administrative simplification, stressing that such measures might improve the disappointing results of his company's investment in receiving automated claims on the 837, and thereby increase productivity and competitiveness. This would also yield more comprehensive data for analyzing the health care delivery system, eliminate paper, and increase accuracy.
Possible negative outcomes include greater expense and reduced administrative options, which may drive some TPAs from the market. He also expressed concerns about the provision to allow state laws to supersede federal standards, the fact that the timing coincides with "the Year 2000 problem" (which must have priority), and plans for the electronic signature.
2. The time frame is too aggressive, as implementation is inevitably a slow process. The communication of the process and expectations is critical.
3. This industry experiences major problems in regard to provider identification. A provider ID will help greatly, but the issue of multiple locations must be addressed carefully. Also, provisions must be made for those still transmitting claims on paper. Miscoding should be addressed through education.
4. Building on the current standards requires a good planning stage, ideally followed by staggered implementation dates.
Finally, Mr. Sheldon suggested that the Subcommittee consult with "two good sources" for his industry, the Self-Insurance Institute of America and the Society of Professional Benefit Administrators.
State Farm asks the Department to design its standards for application by property casualty insurers as well as health insurers, so they may be used for all medical insurance transactions.
Discussing these presentations, the group touched on these topics: the rate of EDI and other issues for self-insured employers; the prospects for X12, including the views of the pharmacy industry; State Farm's recommendation about property and casualty insurers; the optimal time frame; state variations and other variability questions, including the feasibility of requiring one standard; the application of these issues to code sets; and the financial and other ramifications of various standardization scenarios.
Dr. Cohn expressed surprise at Mr. Sheldon's low percentage of electronic claims received ((6-8 percent), and Mr. Sheldon explained that many PPOs don't receive claims electronically. Ms. Jensson said State Farm is coming belatedly into the EDI world, but moving quickly from a paper environment. Asked about the impact of standardization on self- insured employers, Mr. Sheldon described the elementary operations of some offices, which will not be able to survive the transition.
Dr. Braithwaite noted the general favoritism on the panel for the X12 standards, and he queried Mr. Lavin about his organization's stance in this regard. Mr. Lavin explained that NCPDP is involved with X12 and accepts the X12 for transactions other than claims transactions. Moreover, X12 is trying to develop an interactive claims standard. Pressed further by David Clarke of HCFA, he said the hope is that X12 will adopt the NCPDP standard or at least have a transaction that could read the data sets. His organization wants to support the X12, but wants the claims to interact. Other panelists expressed their satisfaction with the X12.
Dr. Cohn asked Ms. Jensson to expand on her comment about property and casualty insurers, and she said State Farm is currently reviewing the implementation guides for the health care transactions. It appears that the transactions will meet the company's needs with the inclusion of a few critical data elements.
Ms. Frawley asked for comments on concerns about the aggressiveness of the time frame. Mr. Sheldon reiterated his point about the long ways his industry must evolve and the fact that few TPAs are using the 837. Mr. Lavin referred to having to roll out a standard to 54,000 pharmacies and half a million physicians. Ms. Jensson noted that her company is starting with the 837 and cannot work on all of the transactions at once.
Mr. Scanlon asked about variations imposed by different state laws and practices, and the group said they didn't know for sure but assumed this could be a problem. On the broader question of variability, Dr. Braithwaite noted the common provider complaint that ever payer has its own requirements; he asked the panelists to assess the feasibility of having a single set of required information that all payers would accept and not require additional information. Mr. Jensson said State Farm is trying to do exactly that, and she expressed doubt that variability would be "a huge issue." Mr. Sheldon said the HCFA 1500 works well for most physicians; the problem is when something doesn't make sense and more information is needed, but that doesn't happen often. Mr. Lavin suggested that one source of the problem of variability is competition among the plans; what needs to happen is for companies to work through an SDO such as ANSI to get their business interests on the table and then negotiate for them. The variability will be in the code sets, and individual business partners can work them out.
Dr. Cohn asked for more comments on variability at this level, and Mr. Lavin described the practice of using only part of a code set. Dr. Braithwaite asserted on behalf of providers that the entire standard code set should be used, and Mr. Lavin countered that if a standard is broad, it will be subject to interpretation and not all sets within it will be used. Ms. Jensson stressed working out an agreed-upon meaning and common language for the various codes -- a process that is actually underway.
For the next meeting, Dr. Cohn asked the panelists for information on the expected financial, technical and disease management ramifications of having a single standard versus having both X12 and NCPDP.
Dr. Lumpkin thanked the panelists for meeting with the Subcommittee.
Mr. Moore reported that the Deputy Secretary has approved a work plan developed with extensive participation from within the Department and consultation with the private sector. The process is co-chaired by himself and Dr. Braithwaite. The emphasis has been on creating an open, participatory process that is appropriate for a national standard that will apply to all of health care, not just federal agencies.
The standards identified in HIPAA were combined into five groupings to be addressed by implementation teams, worked out through a consultative process involving the private sector. A sixth team will address cross-cutting issues. (See list below.)
Although the original intent was to include private sector representatives on the teams, the Department's legal advisors advised against this, so the Department has been in consultation with the American National Standards Institute Health Informatics Standards Board. The ANSI/HISB prepared a quick inventory in the fall, and since then has developed a more thorough analysis of the status of the SDOs with respect to each of the standards identified in the legislation. This analysis will be the starting point for the HHS teams.
Mr. Moore noted that the implementation schedule is outlined in the law. The industry's appeals for more time will be taken into consideration. The process for developing the recommendations begins with the SDO input mentioned above; then the HHS teams will determine what resources are needed to complete the analysis, agree on what standard to recommend, bring this to NCVHS and the Data Council, and disseminate it widely through open meetings, the Web and other means. Then the final recommendations will be published for the community at large, including data elements, code sets, and so on.
The HHS teams (followed by the names of NCVHS Subcommittee liaisons) are:
· Claims/Encounters (Coltin)
· Enrollment/Eligibility (Van Amburg)
· Identifiers (Lumpkin)
· Systems/Security (Frawley)
· Medical Coding Classification (Iezzoni)
· Infrastructure (Cohn)
Dr. Lumpkin noted the surprising degree of agreement among the panelists, particularly in regard to the X12 standards. He called attention to an issue that arose in the Payer panel and that warrants further attention from the Subcommittee, concerning envelope issues versus content issues. He reminded the group of an early panelist's injunction not to stifle innovation, and also took note of the apparent agreement about format, content and coding systems in X12 that the Subcommittee needs to understand.
Second, he noted that the Subcommittee needs to get back to groups that have presented about their vision for administrative simplification and how they will know whether it has been achieved. He asked members to send him their thoughts about the questions. Dr. Cohn suggested that "the warnings" heard in this meeting be reflected in the questions asked of the SDOs -- e.g., in regard to envelope issues and data issues.
Ms. Greenberg added that questions are also needed on the time frames, costs and resources associated with implementation. She thanked Mr. Moore and Dr. Braithwaite for lining up very good speakers for this meeting, and asked whether there were others who still need to be heard from. An example is those who might speak to Dr. Iezzoni's point about the potential for using administrative elements for evaluating clinical issues such as quality of care.
Dr. Cohn proposed a third set of meetings to look at coding issues -- e.g., the suitability of the ICD-10 as a standard, where CPT-4 fits, information on HCPCs, and questions about procedure classification. Dr. Iezzoni observed that "we stand on a kind of precipice" in that the Department is thinking of implementing not only a new diagnostic system but a new procedure coding system; these decisions should be looked at in relation to the quest for administrative simplification, including asking whether this is the right time to implement a new procedure coding system, even if a great deal has been invested in it. She will talk with Dr. Cohn and others to plan an agenda for a meeting on these coding and classification issues.
Dr. Lumpkin noted that those discussion should also look at the links to computerized patient records and to NLM's work. Dr. Iezzoni also noted the connections to ANSI's work on a functional status placeholder and to ICIDH. She agreed with Dr. Cohn that these are not immediate priorities for the Subcommittee; nevertheless, its short-term work should be carried out within that broader context and long-term set of issues.
Turning to the question of the Subcommittee's role in respect to the HHS teams, Dr. Lumpkin suggested that it will be providing reality testing, and also preserving the broader sense of context around such values as not precluding innovation.
Dr. Cohn noted that the Subcommittee has not talked about personal identifiers; another issue is security. Dr. Iezzoni suggested identifying the overlaps with the Privacy and Confidentiality Subcommittee's work, and possibly addressing identifiers at a full Committee meeting.
Dr. Lumpkin then thanked all those responsible for this successful meeting, and declared it adjourned.
I hereby certify that, to the best of my knowledge,
the foregoing summary of minutes is accurate and complete.
/s/ Barbara Starfield December 2, 1997