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Medical Reimbursement after October 16—Compliance or a ‘Train Wreck’? It now seems there won’t be the widely predicted ‘train wreck’ or ‘meltdown’ of the U.S. medical reimbursement system October 16, when HIPAA (Health Insurance Portability and Accountability Act) requirements for electronic medical claims are scheduled to go into effect. Aware that many providers and insurers, though they have had three years to make the necessary changes, are not yet ready to implement nationally standardized HIPAA payment formats and code sets, the nation’s largest insurer—Medicare--announced September 23 that it will continue to accept non-HIPAA-compliant claims after October 16 under a "contingency plan." That reprieve does not apply to Medicaid claims, which are administered by the states, but many states and private insurers are expected to adopt similar postponements of the compliance deadline. The Centers for Medicare and Medicaid Services (CMS) in the U.S. Department of Health and Human Services (HHS) is warning, however, that eventually all providers will have to adopt the new standards if they expect their claims to be paid. Among those providers are schools that file claims for Medicaid or private insurer reimbursement for medical services provided to children. That is because the preamble to HIPAA regulations published in December 2000 specifies that while schools that receive federal funds are subject to the Family Educational Rights and Privacy Act (FERPA), not HIPAA, for purposes of medical privacy, schools become subject to HIPAA regulation if they engage in "HIPAA transactions." Specifically, the preamble says, "The educational institution or agency that employs a school nurse is subject to our (HIPAA) regulation as a health care provider if the school nurse or the school engages in a HIPAA transaction." That leaves the question--What, exactly, is a "HIPAA transaction"? The Code of Federal Regulations for HIPAA provides the following definition: "Transaction means the transmission of information between two parties to carry out financial or administrative activities related to health care. It includes the following types of information transmission: (1) Health care claims or equivalent encounter information. The Centers for Medicare and Medicaid Services has made clear that there is no "shelter" from the HIPAA claims standards—in other words, providers, including schools, are subject to HIPAA even if they submit their claims to a third party for processing What Are the HIPAA Standards, and Why? In a statement to a Senate committee hearing September 23, the director of the Office of HIPAA Standards in the Centers for Medicare and Medicaid Services explained how the new formats and code sets were arrived at, and the benefits that are expected to accrue to the health care system as a whole when everyone is using the same set of rules. The widespread and increasing use of computer technology has revolutionized the way health care claims are filed, noted Jared Adair, and the transition from paper to electronic transactions has already produced a number of benefits, including less expensive processing costs and faster transactions. But problems remain, including most importantly that claims must be submitted according to the requirements of each health care payer. In that respect, Adair said, the health care industry is far behind other sectors of the economy, including banking and shipping, where standardization of transactions now makes it possible for an individual to use an ATM card anywhere in the world and for shippers to track and deliver parcels worldwide. Under the "administrative simplification" sections of HIPAA, CMS undertook the assignment of standardizing health care transactions and "code sets"—the information that must be provided for each procedure, diagnosis, place of service, etc., so the provider and the payer both know exactly what the claim covers. The transaction and code set standards were adopted by a final rule issued by the Department of Health and Human Services in August 2000, with an original compliance deadline of October 16, 2002. That deadline was later extended to October 16, 2003. Adair conceded that there will be substantial start-up costs in the transition to the new standards, but she said HIPAA is expected to create significant savings for the health care industry and the taxpayer in the first 10 years of implementation. "Health care providers will be able to submit bills in the same format to all payers and be assured the bills will be accepted. Providers will have the capability to query claims status and eligibility by computer rather than over the phone. Plans will not have to keep and store paper claims. This will reduce overhead as well as improve turnaround time for transactions, both of which should have a positive impact on cash flow." Adair pointed out that CMS has conducted extensive outreach to
explain the coming changes, and information and guidance for complying
with the transactions and code sets regulations are available on the
CMS website at www.cms.hhs.gov/hipaa/hipaa2/guidance-final.pdf.
For information about Medicaid claims, the web address is www.cms.hhs.gov/medicaid/hipaa/addminism/
GAO Calls for Better Monitoring of Drugs for Racial and Ethnic Minority Children African-American children and children from other racial and ethnic groups aren’t included in sufficient numbers in clinical trials of medications that will be given to children, even though they may have genetic predispositions that make certain drugs ineffective or even dangerous, according to a report released in September by the General Accounting Office (GAO). "FDA officials are concerned that drug effectiveness and adverse effects can vary among children from different racial and ethnic groups," the report noted, but "no formal evaluations have assessed the extent to which children of different racial and ethnic groups are represented in clinical studies of new drugs." Pediatric testing of drugs, once almost non-existent, has speeded up since Congress enacted legislation to make it profitable for pharmaceutical companies to conduct such tests, but no one so far can pinpoint whether the clinical trials now under way include minority children in appropriate numbers, the GAO said. The federal Food and Drug Administration (FDA) has taken one positive step, the report notes, by requesting studies of drugs that may be used to treat conditions or diseases that disproportionately affect minority children, including hypertension, type II diabetes, and sickle cell anemia. Between January 2002 and March 2003, the FDA granted exclusive marketing rights to four drugs that may be used for those conditions and issued written requests for six more studies. Here are the GAO’s estimates of prevalence rates for some of the diseases that may affect ethnic and racial minority children disproportionately:
The report, "Food and Drug Administration Should More Efficiently Monitor Inclusion of Minority Children," GAO-03-950, is available on website www.GAO.gov. ----------------------------------------------------------------
Underage Drinking Gets National Attention Underage drinking, including by children still in elementary school, is getting major national attention following a strongly worded report released September 9 by the Institute of Medicine (IOM) of the National Academy of Sciences. The congressionally mandated study called for heightened adult supervision of children’s behavior and for the alcohol and beverage industries to shield young people from advertising that makes alcohol seem desirable and glamorous. Calling its report a "national wake-up call," the Institute of Medicine also urged Congress and state legislatures to raise the excise tax on alcohol, particularly beer, which studies show is the beverage most young people prefer. Noting that after adjusting for inflation, alcohol is actually cheaper today than it was 30 or 40 years ago, the report said, "Increasing the cost of alcohol has well-documented deterrent effects on underage drinkers." The report also made very specific recommendations for educational and law enforcement measures, including rigorous evaluation of all intervention and education programs. On the whole, however, the report concluded that adults, especially parents, consistently under-estimate or even condone the extent of alcohol consumption by their children and other young people, and often defy the age-21 drinking age by providing teens with alcohol at parties. At a September 30 congressional hearing following release of the IOM report, the Beer Institute strongly defended its position on underage drinking, noting "the long-standing commitment of American brewers" to address the problem. The Institute’s testimony also pointed out that 82 percent of today’s adolescents do not drink. Speaking for 34 spouses of state governors who focus on the 9-to-15 age group in an effort to make childhood drinking prevention a national priority, Patricia Kempthorne of Idaho said, "While it is unsettling to think that we have to consider elementary students when we think about drinking prevention, we do." Drinking initiation most often begins at the age of 13, she noted. Kempthorne urged that the United States Surgeon General issue an independent evaluation and "Call to Action on Childhood Drinking," and that alcohol-use surveys begin to collect data on children as young as 9. Possibly the most compelling testimony at the hearing came not from adults but from a student who is a senior at North Haven High School in North Haven, Connecticut, the state with the highest rate of underage drinking. "When I read the NAS report, especially the committee’s proposal for a national adult-oriented media campaign, the words ‘adult oriented’ jumped out at me," said David DeAngelis. "Targeting adults is necessary to effectively address underage drinking. Many parents not only condone the use of alcohol but also provide liquor to their children and their children’s friends." He also pointed out that high school students who do not drink are affected by underage drinking, often being ostracized by students in the popular drinking circles and pressured daily to join. The Institute of Medicine report, "Reducing Underage Drinking: A Collective Responsibility," is available on the Internet at www.nap.edu. ---------------------------------------------------------------- IN CONGRESS The following school health-related bills have been introduced in recent sessions of the United States Senate or House of Representatives. All of the bills have been referred to committees, but none has yet been reported or passed. Student Self-Treatment of Diabetes Representative Ruben Hinojosa (D-TX) introduced legislation September 25 that would require all schools that receive federal funds to allow students to treat their diabetes with physician-prescribed and over-the-counter medications and devices, including insulin pumps, glucagons injections, insulin syringes, insulin pens, blood glucose monitors, and blood glucose monitoring supplies. Hinojosa’s bill, H.R. 3178, which has more than 50 co-sponsors, would "prohibit interference" with student self-medication by schools if the treatment has been prescribed or recommended by a physician. Mental Health Screening H.R. 3063, the Children’s Mental Health Screening and Prevention Act of 2003, introduced September 10 by Connecticut Representative Rosa DeLauro (D), would authorize10 grants to schools or other facilities to implement evidence-based preventive-screening tools to detect mental illness and suicidal tendencies in school-age youth and to refer those in need of assessment or treatment. The term "evidence-based preventive screening tool" is defined to mean a method that has been shown to be valid and effective through independent research, is determined by well-regarded scientists to be of high quality, and meets standards for publication in peer-reviewed journals. Reimbursement for Health Screening in Schools The Healthy Children Learn Act, S. 1004, was introduced in May by Senators Richard Durbin (D-IL) and Susan Collins (R-ME), with co-sponsorship by Senator Hillary Clinton (D-NY). Noting that "Many schools have found that the health of a child can significantly affect his or her ability to learn," Durbin cited asthma and impaired vision and hearing as health problems that can be discovered by health screening in schools. The legislation calls for removing barriers that prevent school systems from receiving reimbursement for screening services by assuring that reimbursement would be available under both Medicaid and SCHIP. Obesity Prevention Schools could benefit indirectly, by partnering with other community groups, under a bill, S. 1172, the Improved Nutrition and Physical Activity Act (IMPACT), introduced by Senate Majority Leader Bill Frist (R-TN) "to help Americans make healthy decisions about nutrition and physical activity to prevent obesity," with an emphasis on youth education. Frist noted that obesity is increasing at an alarming rate among young people and is now second only to smoking as the nation’s leading cause of preventable death. These and other bills can be tracked on website http://thomas.loc.gov. ---------------------------------------------------------------- WORTH NOTING Many More Americans Lack Health Insurance The Census Bureau reported September 30 that in 2002, 43.6 million Americans had no health insurance, an increase of 5.7 percent over the previous year. Primarily because of government programs such as Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP), children and the elderly had the highest rates of coverage; currently, one in four children receives coverage under Medicaid or SCHIP. Influenza Vaccine Plentiful, CDC Says Supplies of influenza vaccine are expected to be plentiful this fall, and no staggering of vaccination is recommended, the Centers for Disease Control and Prevention (CDC) said September 26. That means influenza vaccination can proceed for all persons, whether healthy or at high risk, either individually or through mass campaigns, as soon as vaccine is available. The optimal time for flu vaccination is during October and November. In June of this year, the Food and Drug Administration approved live, attenuated vaccine for use among healthy persons 5 to 49 years of age; this vaccine is administered intranasally rather than by intramuscular injection and offers another option for preventing influenza, particularly in high-risk groups such as health care workers. Campaign Will Educate about Antibiotics A campaign aimed at reducing inappropriate use of antibiotics will try to convince American health care consumers that "Antibiotics don’t cure everything," including viral infections. According to the Centers for Disease Control and Prevention, doctors prescribe "tens of millions" of antibiotics for viral infections that are not treatable with antibiotics, with the doctors citing diagnostic uncertainty, time pressure, and patient demand as their primary reasons. A coalition of the CDC, the Food and Drug Administration, and many professional organizations will use television, radio, and print public service announcements to better inform Americans about when antibiotic use is warranted and when it is not. The campaign is sparked by concerns about increasing resistance to antibiotics caused by inappropriate overuse. Information is available at www.cdc.gov/drugresistance/community. RWJF Funds New Approaches to Drug Treatment Ten substance abuse treatment sites have been selected by the Robert Wood Johnson Foundation to redesign processes such as client intake, assessment, scheduling, outreach, and family involvement, with the aim of creating more efficient and accessible drug treatments that clients are more likely to complete. Information about the program, "Paths to Recovery," is available at www.pathstorecovery.org. Six States Now Include Unborns in SCHIP Washington State is the sixth state to avail itself of an option offered by the U.S. Department of Health and Human Services to offer prenatal care under the State Children’s Health Insurance Program (SCHIP) to pregnant women and their unborn children who would not otherwise be eligible for Medicaid or SCHIP coverage until after they were born. Illinois, Massachusetts, Michigan, Minnesota, and Rhode Island are the other states offering this coverage. September News Alerts The following information appeared during the month of September in the News Alerts section of this website. Candidate Lieberman Calls for Federal Aid to School-Based Health Centers As part of comprehensive plan to provide health care to all children, from birth to age 25, presidential candidate Senator Joseph Lieberman said September 3 that as president he would seek federal funding for school-based health centers. Speaking at Broad Acres Elementary School in Silver Spring, Maryland, where he toured the school’s health center, Lieberman called for "a true national network of school-based health centers" in elementary schools. Pointing to the more than 1,500 school-based health centers currently operating in 45 states, Lieberman said, "Despite the popularity of these centers and the growing need for these services—particularly in rural and urban communities—the federal government barely provides enough funding for two school centers in every state." Under his proposal for federal support, Lieberman said, "As they typically are today," he said, "the school-based centers will be designed locally to reflect the needs and values of communities, ease the burden on busy parents, and meet the growing health needs of their children. With these centers in place, children with chronic diseases like asthma will have the help they need. Children will be screened for serious illnesses that would otherwise to undetected, like diabetes, and referred for proper care. And the centers will give schools more guidance in health promotion, nutrition, and physical activity to teach all children how to start healthy and stay healthy. School-based centers will serve as the foundation for health and nutrition education for our children." Following his visit to the Broad Acres center, which provides physical and mental health care to children and uninsured parents, Lieberman said, "I want to see if we can open thousands more school-based health centers." Study Finds Severe Illness, Deaths from Influenza in Children Although the 2002-2003 flu season was mild, many children experienced severe influenza-related illnesses, and even death, according to a Centers for Disease Control and Prevention(CDC) report in the September 5 issue of Morbidity and Mortality Weekly Report (MMWR). A study of hospitalizations and several unexplained deaths in children under 21 years of age by the Michigan Department of Community Health uncovered evidence of severe influenza-related illness, leading the CDC to suggest that influenza complications may be under-reported in the United States. Of four deaths found in the Michigan study, none were children considered to be at high risk for influenza, nor were they in the age group for which influenza vaccination is encouraged by the Advisory Committee on Immunization Practices. "The results of this ongoing investigation indicate the need for further studies to better define the frequency of serious complications from influenza in children and young adults and to incorporate such findings into evaluations of current vaccine recommendations for children," the CDC said. The report, "Severe Morbidity and Mortality Associated with Influenza in Children and Young Adults," is available at www.cdc.gov/mmwr HRSA Previews Next Year’s Grant Making In a notice published in the Federal Register September 4, the Health Resources and Services Administration (HRSA) calls attention to the grants it expects to make in fiscal year 2004, if Congress appropriates the necessary funds. Categories in which grants will be made include health professions programs, including loan repayments and scholarships; primary health care programs; HIV/AIDS programs; maternal and child health programs; and rural health policy programs. The comprehensive preview replaces individual notices of grants availability that formerly appeared in issues of the Federal Register. The preview announcement appears under "Health Resources and Services Administration" in the September 4 issue of the Federal Register. Strong Commitment to Curb Teen Drinking Urged by National Academies Curbing underage drinking is an uphill battle because alcohol is legal and readily available to adults. But the fact that more young people drink alcohol than use other drugs or smoke tobacco is costing the nation an estimated $53 billion annually in traffic fatalities, violence, and other behaviors, the Institute of Medicine and the National Research Council said in a report released today. Adopting an unusual tone of urgency, a committee appointed to look into underage drinking urged federal and state governments to enforce existing drinking-age laws, mount alcohol education campaigns, and increase excise taxes on alcoholic beverages. The committee also called on the alcohol and entertainment industries to stop making drinking look glamorous in advertising and programs aimed at teenagers. The full text of the report, "Nationwide Strategy to Combat Underage Drinking Requires Shared Responsibility; Action Also Needed to Improve Compliance with Laws," is available online at www.nationalacademies.org/news American Lung Association Calls for School Asthma Plans Based on a national survey of members of the National Association of School Nurses, the American Lung Association said in a report issued September 10 that asthma is more disruptive of school routines than any other chronic condition and many school staff lack awareness of the causes of an asthma attack. The report cited access to rescue inhalers as "one very important issue," and urged that students who are developmentally able be allowed to carry their inhalers with them. "When an asthma attack occurs, having a rescue inhaler in hand—not sitting in the nurse’s office—can mean the difference between life and death," said John Kirkwood, president and CEO of the American Lung Association. The full text of the American Lung Association report is available at www.lungusa.org Fifth State to Insure Unborn Children under SCHIP Massachusetts today became the fifth state to avail itself of an option offered by the Department of Health and Human Services (HHS) to insure unborn children and their mothers under the State Children’s Health Insurance Program (SCHIP). Illinois, Michigan, Minnesota, and Rhode Island are the other states offering this coverage. The new regulation allows states to expand prenatal care to pregnant women and their unborn children who would otherwise not be eligible for Medicaid or SCHIP until after they were born. USDA Seeks Comments on Possible Revisions of Food Pyramid The Center for Nutrition Policy and Promotion in the U.S. Department of Agriculture (USDA) is seeking public comment on possible revisions of the daily food intake patterns that serve as the technical basis for the consumer-oriented Food Guide Pyramid. The USDA says it welcomes comments on or before October 27 on such points as:
The full text of the request for public comment, which appeared in the Federal Register September 11, is available online in PDF format at www.cnpp.usda.gov/pyramid-update Study Finds Medicaid Children Often Receive Poorer Services in Managed Care Medicaid-insured children enrolled in managed care plans generally received poorer preventive health care than commercially insured children enrolled in managed care, according to research published in today’s issue of the Journal of the American Medical Association. On indicators such as immunization rates and number of well-child visits, researchers found Medicaid children received lower quality of care than commercially enrolled children, in part because of difficulties encountered by managed care organizations in serving Medicaid populations, including a lack of reliable transportation, geographic maldistribution of network providers, language barriers, inflexible parent work hours, and a lack of continuity in primary care resulting in high utilization of emergency department services. On one indicator—adolescent well visits—managed care did equally poorly for both commercial and Medicaid patients. The researchers noted that some managed plans did achieve equivalent and high-quality care for Medicaid enrollees, though they were unable to identify characteristics of the plans that accounted for this. The study by researchers from the University of Arkansas was supported with funding from The Commonwealth Fund. States Expected to Make Further Cuts in Medicaid Eligibility, Benefits With most states coping with their fourth year of fiscal stress, all 50 states and the District of Columbia have planned or implemented Medicaid cost containment actions for the coming fiscal year, according to a survey released today by the Kaiser Commission on Medicaid and the Uninsured. That will be in addition to Medicaid spending cuts already in place, the commission notes; 34 states report that they have reduced eligibility, and even more that they have cut benefits, over the past three years. "The state fiscal crisis is putting health care for low-income families and the elderly and disabled at risk. Many will get less care and others will lose it altogether," said Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured. Primary cause of the state fiscal crisis has been the sudden falloff in state tax revenues, with growth in Medicaid costs playing a much smaller role, the commission said. The report also notes that health care for individuals with disabilities and the elderly accounted for nearly 60 percent of Medicaid spending growth from fiscal 2000 to 2002. The reports released today are available online at www.kff.org/content/2003/20030922 OCR Reports on HIPAA The director of the Office for Civil Rights (OCR) in the U.S. Department of Health and Human Services told a Senate committee September 23 that since the HIPAA (Health Insurance Portability and Accountability Act) patient privacy regulations went into effect April 14 this year, OCR has received and responded to some 14,000 calls to a toll-free line for HIPAA questions. Noting that HIPAA "establishes the nation’s first-ever comprehensive standards for protecting the privacy of Americans’ medical records," Richard Campanelli cited frequent "misconceptions" that have surfaced about the regulations, including:
As evidence that confusion about these and other HIPAA issues is "dissipating" as covered entities and consumers become more familiar with the regulations, Campanelli noted that by the week ending September13, the number of calls to OCR was down to 480, only about a third of the number in the first weeks after April 14. The toll-free telephone line for HIPAA questions, maintained jointly by OCR and the Centers for Medicare and Medicaid Services, is 1-866-627-7728.
CDC Prepares for Possible Return of SARS It’s not known whether Severe Acute Respiratory Syndrome (SARS) will re-emerge in the United States and elsewhere this fall, but the Centers for Disease Control and Prevention (CDC) says it wants health care workers to be ready if it does. Satellite broadcasts scheduled for September 23 and 30 aim at the "clinical interface"—suspicion, prompt recognition, appropriate diagnosis, and rapid implementation of infection prevention measures—if a case of SARS is suspected. Following the live programs, the information presented will be available for viewing at www.phppo.cdc.gov/PHTN/webcast/SARS-return. A clinician information line for questions related to SARS is open 24 hours a day at 877-554-4625. CDC Reports on Immunization Registries Currently, approximately 44 percent of U.S. children are enrolled in immunization registries, according to the Centers for Disease Control and Prevention. The registries are databases of information about the immunization status of individuals who have given permission to be included in a registry. The national health objective for 2010 is to have 95 percent of children under six years of age enrolled in such registries. NASBE Posts State School Health Policies The National Association of State Boards of Education (NASBE) has posted on its website a comprehensive review of state school health policies, including legal codes, rules, standards, administrative orders, and other policy mechanisms. Policy profiles for individual states can be accessed at www.nasbe.org/HealthySchools/States/State_Policy.html.
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