National Committee on Vital & Health Statistics
June 17, 1998
Health Care Financing Administration
Department of Health and Human Services
P.O. Box 26585
Baltimore, MD 21207-0519
To Whom It May Concern:
The National Committee on Vital and Health Statistics (NCVHS) is pleased to submit the following comments on the Notice of Proposed Rule Making (NPRM) labeled HCFA-0045-P.
This proposal for a National Provider Identifier (NPI) includes an eight-position alphanumeric identifier that would be assigned to all providers, along with essential identifying information. The identifier includes a check digit and contains no embedded intelligence. To reiterate the NCVHS position taken in our recommendations to the Secretary last year, we have found broad support for the proposal in general and have no disagreement with the nature of the proposed health care provider identifier. We are pleased to contribute the following comments on the selected issues on which comments were requested specifically in the NPRM.
Many of the issues raised for comment do not have obvious solutions. In order to meet the objectives of administrative simplification, we may need to simplify the approach to issues such as how to assign and administer the national health care provider identifier. In many instances, the choices among options in this NPRM are quite complex. This is due in large part to the fact that this is a substantial undertaking for which there is no funding. But the choices are also complex because several of the issues have become complicated and interrelated. These include: (a) whether individuals, groups, and organizations (and whether groups are organizations) need to be distinguished, enumerated, and tracked; (b) the amount of information on providers that needs to be collected, maintained, updated, and disseminated; and (c) what kind of registry option is possible, given the lack of funding.
The NCVHS believes that the goal should be to derive a policy that is practical, affordable, and acceptable to the Government and to the industry. To do this, the functions that are essential for enumeration of health care providers need to be isolated from those functions that are proposed for other purposes. To assist in this process, we offer the following two principles:
- A. There are only two types of health care providers: (1) human beings (e.g., physicians) who provide health care services and (2) institutions (e.g., hospitals) that deliver health care services. Human beings may be affiliated with groups, partnerships, corporations, or each other in various contractual relationships, but these relationships do not provide care. Similarly, institutions may belong to chains or corporations, but these holding entities do not provide care. By this principle, groups, partnerships, and corporations need not be enumerated as providers, although they may serve other functions in the billing or payment chain and may need to be identified in other ways. The NCVHS recognizes that identifiers for these other entities or other functions may be necessary and urges the Department of Health and Human Services (HHS) to explore the need for a standard health care electronic data interchange (EDI) identifier for transaction routing.
- B. Only essential information should be collected for enumeration, and because that information is essential, it is essential that it be kept up to date. Enumeration of health care providers and enrollment of health care providers in Medicare and other health plans appears to have become intertwined. To determine what information is essential requires that the enumeration function be carefully dissected away from the enrollment function. Enrollment offers a myriad of opportunities to authenticate provider identities and check their credentials. Enumeration should not envelop or duplicate these efforts. However, we also recognize that data in the National Provider System (NPS) may be useful for purposes other than enumeration, and we encourage HHS to examine the costs and benefits associated with maintaining data elements in the NPS for these other purposes.
The NCVHS recognizes the need throughout this enterprise to balance costs and utility. In both instances, translating these principles into policy should help not only simplify the processes, but also reduce their costs.
In addition, specific comments applicable to specific sections of the NPRM are provided below.
On the issue of whether group providers need to be distinguished from organization providers in enumeration:
The first principle noted above suggests another approach to simplify the requirement for enumerating providers. Organizations would only need to enumerated when they are institutions providing care. There may be very good reasons for groups or corporations to be involved in EDI transactions for other purposes, such as billing or payment receipt. However, those are not purposes for which a national provider identifier is needed or should be issued. As noted above, the NCVHS recognizes that identifiers for these other entities or other functions may be necessary and urges HHS to explore the need for a standard health care EDI identifier for transaction routing.
On the issue of rules to be applied for issuing new NPIs in response to changes in ownership, changes in the nature of the provider, and other circumstances:
We suggest a re-assessment of whether new NPIs would need to be issued for the types of changes cited. If, based on the principles above, a health care provider is an individual or an institution that provides health care services, it would seem practical for that individual or institution to obtain an NPI and carry it throughout its life cycle. One of the reasons for having no embedded intelligence in the identifier is for it to be durable. Therefore, if an institution that is a hospital becomes a rehabilitation center, is there a compelling reason for it to obtain a new NPI? By the same token, an individual who is a nurse may become a physician. Here again, the need for a different identifier is not apparent.
On the issue of the impact of electronic standards on the long-term care industry:
As part of its monitoring of standards adoption for its annual report to Congress, the NCVHS will be interested in hearing from representatives of the long-term care segment of the health care industry. However, we believe that the proposed standards offer the opportunity for all segments of the health care industry to adopt automation and to benefit from such adoption. Long-term care providers may elect not to use electronic transactions, just as other providers may do. Yet, when long-term care providers elect to use electronic transactions, the standard provides them with a single method that can be exchanged with all payers. This offers much greater incentives to adopt electronic transactions than currently exist. The NCVHS believes that it would be an unfortunate precedent to exempt segments of the health care industry from these rules.
On the issue of scheduling early implementation of the standards to avoid disruptions and ease the transition:
The NCVHS concurs with the recommendations that came from the Workgroup on Electronic Data Interchange (WEDI) at their Healthcare Leadership Summit in August 1997. Under that recommendation, willing trading partners could implement any or all of the standards by mutual agreement at any time during the 2-year implementation phase (3-year implementation phase for small health plans). However, health care providers should not be required by health plans to use any of the standards during the first year after adoption of the standards, and a health plan should give its health care providers at least 6 months notice before requiring them to use a given standard. These recommendations offer a realistic and functional approach to management of the 2-year implementation schedule and, most importantly, this approach would remove many of the disincentives to early implementation. The NCVHS recommends that this implementation schedule be incorporated into the Final Rules, if there is legal authority to do so, to reduce the uncertainty and ease the transition period for all segments of the health care industry. If this goes beyond the authority accorded by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we urge HHS to identify other mechanisms to accomplish this objective.
On the issue of requiring providers to submit updates to data maintained by the NPS:
The NCVHS believes that reconsideration of the purpose of enumeration will markedly reduce the number of data elements necessary. However, if the data elements are necessary, timely updates will be important.
On the issue of which registry option to adopt, given funding constraints:
The NCVHS urges HHS to adopt an enumeration process that is not unduly burdensome on industry or the Government. Obviously, design and establishment of a registry without funding makes for some very difficult choices. Tradeoffs are inherent. Nonetheless, selection of Option 2 may represent a false economy. Option 2 is a complicated mix of Federal and State programs made more complicated by the mixing of enumeration and enrollment functions. If funding were not an issue, Option 1, which involves a single registry for enumeration of all health care providers, would be clearly superior to Option 2 for both the industry and the Government.
The NCVHS supports the concept of a single registry, which would utilize the provider data from Medicare and State Medicaid enrollment files to reduce costs and administrative burden, and we urge HHS to re-assess the costs of such an approach. The costs for the registry could be further reduced by the elimination of non-essential data elements, as suggested in the principles above.
On the issue of data elements that should be collected for enumeration:
Detailed information on health care providers is desirable for many business and research purposes. However, the fact that no funding source is available for the enumeration function dictates a more parsimonious strategy. To that end, we recommend that HHS examine the costs and benefits associated with maintaining data elements in the NPS for purposes other than enumeration.
On the issue of disseminating data from the NPS:
The need to keep costs low will dictate limits on all of these activities. First, the issue of data release needs to be reconsidered in light of reductions in the number of data elements collected. Second, limiting the number of formats for data dissemination, utilizing the Internet for frequent updates, and limiting the number of access options that need to be managed would all be consistent with a strategy to minimize costs. Third, although beneficiary education is an important function for Medicare, this programmatic function would be beyond the scope of activities for a registry.
NEW AND REVISED STANDARDS
On the issue of designing a process to handle requests for new or revised standards:
Under HIPAA, the Secretary of HHS is the final arbiter of which standards are adopted and how they are changed. However, we urge HHS to consider having the process for evaluating proposals for new standards (including requests for waivers and testing) rest with a private sector organization with public sector involvement. Such an organization could operate under guidelines set by HHS in the Final Rules. These guidelines should incorporate those principles proposed in the NPRM, including the ANSI accreditation principles for processes which are followed by accredited standards development organizations.
On the issue of the approach, assumptions, and findings of the impact analysis:
The NCVHS believes that the Government has taken a deliberately conservative approach to estimating the savings to be achieved from administrative simplification. As part of our role in monitoring the progress of administrative simplification, the NCVHS will continue to solicit information from the industry on the efficiencies, costs, and savings from implementation of the provider identifier and other standards.
On the issue of funding to support the development and operations of the NPS:
It is unfortunate that the Government has so few options available to it to cover the costs of issuing identifiers for health care providers. We encourage HHS to adopt a strategy to minimize costs for this activity and to continue to explore funding alternatives.
On the issue of tradeoffs between cost and which data elements are necessary to uniquely identify providers:
As discussed above, the NCVHS encourages HHS to adopt a limited approach to enumeration that would not duplicate efforts that will continue to be accomplished by health plans when enrolling providers.
Don E. Detmer, M.D.