June 25, 2019

The Honorable Suzan DelBene
2330 Rayburn House Office Building
Washington, DC 20515

Dear Representative DelBene,

We the undersigned organizations are writing to offer our strong endorsement of your legislation to ensure that more chronically ill Medicare patients receive access to the best care. By removing the costsharing obligations from the Chronic Care Management (CCM) code, more chronically ill Medicare beneficiaries will benefit from the care coordination and case management services the code supports.

CCM is a critical part of coordinated care, and as a result, Medicare began reimbursing physicians for CCM under a separate code in the Medicare Physician Fee Schedule. This code is designed to reimburse providers for non-face-to-face care management. We support this initiative to further manage chronic care conditions to improve the health of patients.

The creation of a separately billable code, however, created a beneficiary cost-sharing obligation for care management services. Under current policy, Medicare beneficiaries are subject to a 20% coinsurance requirement to receive the service. This cost-sharing requirement creates a barrier to care, as
beneficiaries are not accustomed to cost-sharing for care management services. Consequently, only 684,000 patients out of 35 million Medicare beneficiaries with two or more chronic conditions benefitted from CCM services over the first two years of the payment policy.

We support your legislation to waive the beneficiary co-insurance amount to facilitate further managing chronic care conditions to improve the health of patients. Providers and care managers report several positive outcomes for beneficiaries who receive CCM services, including improved patient satisfaction
and adherence to recommended therapies, improved clinician efficiency, and decreased hospitalizations and emergency department visits.

We appreciate your leadership on this issue. Please let us know how we can be a resource to ensure that this co-insurance requirement is repealed so that more Medicare beneficiaries gain access to providers who prioritize and coordinate care of the chronically ill.

Sincerely,

American Academy of Family Physicians
American College of Physicians
American Diabetes Association
American Medical Association
AMGA
American Osteopathic Association
America’s Physician Groups
Association of American Medical Colleges
Health Care Transformation Task Force
Healthcare Leadership Council
Medical Group Management Association
National Association of ACOs
Patient-Centered Primary Care Collaborative
Premier healthcare alliance

June 3, 2019

The Honorable Richard Shelby, Chairman
Senate Committee on Appropriations
Room S-128, The Capitol
Washington, D.C. 20510

The Honorable Roy Blunt, Chairman
Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
Senate Committee on Appropriations
131 Dirksen Senate Office Building
Washington, DC 20510

The Honorable Patrick Leahy, Vice Chairman
Senate Committee on Appropriations
S-146A, The Capitol
Washington, DC 20510

The Honorable Patty Murray, Ranking Member
Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
Senate Committee on Appropriations
156 Dirksen Senate Office Building
Washington, DC 20510

Dear Chairman Shelby, Vice Chairman Leahy, Chairman Blunt and Ranking Member Murray:

On behalf of the undersigned organizations, we wish to urge inclusion of report language that seeks to end patient safety issues related to patient matching in the Senate Fiscal Year 2020 Labor, Health and Human Services, and Education and Related Agencies (Labor-HHS) Appropriations Bills.
For nearly two decades, innovation and industry progress has been stifled due to a narrow interpretation of the language included in Labor-HHS bills since FY1999, prohibiting the U.S. Department of Health and Human Services (HHS) from adopting or implementing a unique patient identifier. More than that, without the ability for clinicians to correctly connect a patient with their medical record, lives have been lost and medical errors have needlessly occurred. These are situations that could have been entirely avoidable had patients been able to have been accurately identified and matched with their records. This problem is so dire that one of the nation’s leading patient safety organization, the ECRI Institute, named patient identification among the top ten threats to patient safety.1

Importantly, recently proposed rulemakings by both the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have referenced the existing funding prohibition and have cited the patient matching strategy appropriation report language included in previous Labor-HHS bills to explore new and innovative ways that the Administration can work with industry stakeholders on this critical patient safety and care issue. Moreover, the ability to accurately match patients to their records across the care continuum is an imperative for achieving greater value and better outcomes in our healthcare system and a critical piece of the interoperability puzzle.

The patient matching report language below, which has been included in the House FY20 Labor-HHS bill, clarifies Congress’ intent while ensuring that the federal government does not impede private-sector efforts to solve this serious problem. The language enables HHS, acting through ONC and CMS, to provide technical assistance to private-sector led initiatives that support a coordinated national strategy to promote patient safety by accurately identifying patients and matching them to their health information. Allowing ONC and CMS to offer this type of technical assistance will help accelerate and scale safe and effective patient matching solutions.
The absence of a consistent approach to accurately identifying patients has resulted in significant costs to hospitals, health systems, physician practices, long-term post-acute care (LTPAC) facilities, and other providers, as well as hindered efforts to facilitate health information exchange. According to a 2016 study of healthcare executives, misidentification costs the average healthcare facility $17.4 million per year in denied claims and potential lost revenue. More importantly, there are patient safety implications when data is matched to the wrong patient and when essential data is lacking from a patient’s record due to identity issues. The 2016 National Patient Misidentification Report cites that 86 percent of respondents said they have witnessed or know of a medical error that was the result of patient misidentification.

Patient identification errors often begin during the registration process and can initiate a cascade of errors, including wrong site surgery, delayed or lost diagnoses, and wrong patient orders, among others. These errors not only impact care in hospitals, medical practices, LTPAC facilities, and other healthcare organizations, but incorrect or ineffective patient matching can have ramifications well beyond a healthcare organization’s four walls. As data exchange increases among providers, patient identification and data matching errors will become exponentially more problematic and dangerous. Precision medicine and disease research will continue to be hindered if records are incomplete or duplicative. Further, as our nation combats a growing opioid epidemic, successfully matching patients with their records is critical. Accurately identifying patients and matching them to their data is essential to coordination of care and is a requirement for health system transformation and the continuation of our substantial progress towards nationwide interoperability, a goal of the landmark 21st Century Cures Act.

The ability to identify patients across the care continuum is critical in our efforts to fight the opioid epidemic. Patients being treated for opioid use disorder and patients who have experienced an opioid overdose, for example, may be especially vulnerable and need careful monitoring to help them continue in their recovery and avoid new overdose episodes, both of which hinge in part on the ability to link patients with their complete health data. Appropriately-obtained accurate and complete health data can improve prescribing decisions and help clinicians avoid inadvertently prescribing opioid analgesics to patients with these risk factors. Risk factors could be identified and tracked over time and could enable clinicians to take steps to reduce overdose risks, such as prescribing naloxone, as well as to ensure timely follow-up and save lives.

The quality, safety and cost-effectiveness of healthcare across the nation will improve if a national strategy to accurately identify patients and match those patients to their health information is achieved. Clarifying Congress’ commitment to ensuring patients are consistently matched to their healthcare data is a key barrier that needs to be addressed if we are to solve this problem, but not the only one. We the undersigned are committed to working together to identify and address, the various barriers that prevent patient matching today.

We respectfully request that you include the report language below in any FY20 appropriations bill:

Clarifying the Unique Patient Identifier Ban to Enable Patient Matching
The Committee is aware that one of the most significant challenges inhibiting the safe and secure electronic exchange of health information is the lack of a consistent patient data matching strategy. With the passage of the HITECH Act, a clear mandate was placed on the Nation’s healthcare community to adopt electronic health records and health exchange capability. Although the Committee continues to carry a prohibition against HHS using funds to promulgate or adopt any final standard providing for the assignment of a unique health identifier for an individual until such activity is authorized, the Committee notes that this limitation does not prohibit HHS from examining the issues around patient matching. Accordingly, the Committee encourages the Secretary, acting through the Office of the National Coordinator for Health Information Technology and CMS, to provide technical assistance to private-sector led initiatives in support of a coordinated national strategy for industry and the federal government that promote patient safety by accurately identifying patients to their health information.

We appreciate your consideration and inclusion of this report language and we look forward to working with you to pursue an appropriate solution to enable accurate patient identification and data matching in our nation’s healthcare system.

Sincerely,

American Health Information Management Association (AHIMA)
America’s Health Insurance Plans (AHIP)
American Medical Association (AMA)
American Medical Informatics Association (AMIA)
Blue Cross Blue Shield Association (BCBSA)
College of Healthcare Information Management Executives (CHIME)
eHealth Initiative (eHI)
EP3 Foundation
Federation of American Hospitals (FAH)
Health Innovation Alliance
Healthcare Information and Management Systems Society (HIMSS)
Healthcare Leadership Council (HLC)
himagine solutions, Inc.
Imprivata
Intermountain Healthcare
Just Associates, Inc.
LTPAC Health IT Collaborative
4medica
Medical Group Management Association (MGMA)
Nemours Children’s Health System
NextGate
Patient-Centered Primary Care Collaborative
Premier healthcare alliance
The Sequoia Project
Strategic Health Information Exchange Collaborative (SHIEC)
Trinity Health
Verato
WebShield

UPDATE:  On July 11, many of the same organizations came together to support an amendment being offered by Representative Bill Foster (IL) and Representative Mike Kelly (PA) to HR 2740.  The Amendment strikes Section 510 of the Labor-HHS Appropriations bill which currently prohibits the US Department of Health and Human Services from spending any federal dollars to promulgate or adopt a national patient identifier.

June 3, 2019

Submitted via www.regulations.gov
Ms. Seema Verma
Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

RE: CMS–9115–P; Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability and Patient Access for Medicare Advantage Organization and Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans in the Federally Facilitated Exchanges and Health Care Providers

Dear Administrator Verma,

We write to express strong support for CMS’ proposal to require hospitals participating in Medicare and Medicaid to send event notifications – also known as admission/discharge/transfer or ADT feeds – to community practitioners. These notifications are critical to improving patient safety through better care transitions and are key to enabling value-based care at scale.

Although our organizations play different roles in the health care system, we are united in a common commitment to realizing the promise of health care data through increased information sharing. We believe that advancing regulations that lead hospitals to share information with community practitioners is a transformative step toward greater data liquidity that will enable better decision-making, reduce waste, and improve outcomes for patients. The benefits of such notifications are evident in states and localities where this information is shared today, and CMS’ proposal will ensure that they are experienced by all patients regardless of where they live.

Below we put forth several recommendations designed to further strengthen and refine CMS’ approach based on our real-world experience.

1. Hospitals are able to send ADT notifications today without any new standards or use of certified EHRs to collect data.
While there are many hospitals that have chosen not to share ADT feed alerts with community providers for competitive or other reasons, states such as Connecticut, Iowa, Wisconsin, Florida, Tennessee, Maryland and New York have already taken steps to encourage hospitals to share ADT feeds with community providers. In other localities, many hospitals are sharing alerts with accountable care organizations (ACOs) and other providers, on their own or through intermediaries.
We stress that hospitals are able to share ADT notifications today using their existing systems, and by working with a health information exchange (HIE) or health information network (HIN), contracting with a vendor that can send the alerts on their behalf, or building their own interfaces. As evidenced by the widescale adoption of this use case today, new standards efforts are not needed for the successful, immediate implementation of the proposed requirements. In numerous conversations with HIEs, other intermediaries and providers, we were unable to find a single example where a hospital was unable to send an ADT notification today due to lack of standards. For the future, further development of ADT messaging standards could be useful to support inclusion of new data elements and/or types of notifications.

2. CMS should strike language limiting proposed requirements to hospitals with EHR systems, recognizing that many facilities use other types of systems to send notifications.
While CMS proposed to limit the new requirements to hospitals that currently possess an EHR system with the capacity to generate the basic information needed for the notification, it is not necessary to use an EHR to gather the required information or send the notification. In fact, many hospitals use administrative IT systems for this purpose. We encourage CMS to strike this language and instead allow hospitals the flexibility to choose how to comply with the new requirement.

3. Event notifications should be shared for patients who present in the ED regardless of whether they are subsequently admitted as an inpatient, and the minimum information included in the notification should be expanded to include discharge disposition.
We strongly encourage CMS to expand the patient population to whom this requirement applies to include patients who present in the ED and are subsequently discharged without being admitted, as well as those patients who are admitted in observational status. Planning for a safe care transition begins when a patient presents in the ED regardless of whether they are admitted to the facility. In addition, notifying the community practitioner when a patient visits the ED enables them to intervene immediately which can improve outcomes for the patient and result in better coordination that reduces costs and prevents waste.
We also recommend that CMS expand the minimum information in the notification to include the discharge disposition data field. This information is critical for community providers because it gives insight into the outpatient care recommended to the patient and better enables the provider to follow-up with the patient on their hospital visit and coordinate any additional care.

4. CMS should consider other policy options for replacing and/or augmenting what constitutes “reasonable certainty” with respect to receipt of notifications.
We appreciate the need for CMS to establish parameters around a hospital’s responsibility for sharing information with community practitioner. While we agree that an exception may be needed when technical issues beyond a hospital’s control prevent successful receipt and use of a notification, we are concerned that the “reasonable certainty” standard may not be specific enough to ensure the requirement has the intended effect on information sharing.

Accordingly, we recommend that CMS consider other policy options for replacing and/or augmenting the “reasonable certainty” standard included in the proposed regulation. For example, we encourage CMS to deem a hospital compliant if they send the required information to an intermediary for distribution to their provider networks if the intermediary is covered by the prohibition on information blocking. A hospital would be compliant with the new requirement if they: 1) attest that they are not information blocking through the Promoting Interoperability Program; and 2) generate a notification and share it with the intermediary, but it is not ultimately sent because there is no subscribing provider.

This is an important clarification that ensures hospitals receive credit if they are unable to comply through no fault of their own. It also reinforces that hospitals have discretion in determining the technological mechanism through which they will share notifications; we urge CMS to further clarify this point in the final rule.

5. CMS should implement a feedback mechanism for community providers to report issues receiving ADT notifications.

We encourage CMS to consider creating a feedback mechanism for community providers that have the ability to receive notifications yet get incomplete, unreasonably delayed, or no data at all to log or report these issues.

Conclusion

Advancing regulatory levers to promote Medicare and Medicaid-participating hospitals to share ADT feeds has the potential to significantly improve care for patients across the country. CMS’ proposed rule is a significant first step on the path to greater information sharing and interoperability. We encourage CMS to implement this new requirement expeditiously (e.g., within months) given that there are no technical barriers to doing so.

Sincerely,

Aledade
American Academy of Home Care Medicine
Audacious Inquiry
Beth Israel Deaconess Care Organization
Biden Cancer Initiative
Blue Shield of California
Caregiver Action Network
Community Care Collaborative of Pennsylvania and New Jersey
Elation Health
Florida Association of ACOs
Greater Houston Healthconnect
Healthix
Iora Health
Keystone ACO
Lahey Clinical Performance ACO
Lahey Clinical Performance Network
MaineHealth Accountable Care Organization
Manifest Medex
Mental Health America
Missouri Health Connection
National Association of Accountable Care Organizations
National Council for Behavioral Health
National Partnership for Women & Families
NEQCA Accountable Care, Inc.
Network ACO
OneHealth Nebraska
Partnership to Empower Physician-Led Care
Patient-Centered Primary Care Collaborative
PatientPing
Rhode Island Quality Institute
RGV ACO Health Providers, LLC
Saint Francis Healthcare Partners
The Health Collaborative