“Cognosante is proud to be chosen to support this important initiative for the state of Missouri,” said Cognosante Executive Vice President Mark Shishida. “Our company began its existence as a developer of program integrity solutions for Medicaid programs. Over the past 25 years, we’ve developed a comprehensive set of services, through our Fraud, Waste and Abuse practice, to assist states across the full spectrum of Medicaid and other healthcare systems projects.”

“The mission of the MO HealthNet Division is to purchase and monitor health care services for the low income and vulnerable citizens of Missouri in a fiscally accountable manner,” said Markus Cicka, Director MMAC. “We are pleased to select Cognosante to help us achieve this objective through their leading program integrity solutions that enable enhanced provider and supplier screening and fraud-detection capabilities.”

Cognosante will utilize its configurable audit and recovery case management system, eSante™ ARMS™, for the MO HealthNet Recovery Audit Contractor (RAC) project. The system provides audit and compliance teams with the ability to effectively manage investigation caseload, track actions and activities against audit cases, and supply secure access to providers for case status purposes.

MCLEAN, Va. – February 3, 2012 – Cognosante, a leading provider of IT services to healthcare organizations, announces the addition of John Calabro, most recently the Health Information Technology (HIT) Coordinator for the state of Oklahoma Health Information Exchange (HIE) Trust, as managing director of the company’s HIT offerings for state and federal clients. In this position, Mr. Calabro, a 25-year health industry veteran, is leading the development of the next generation of modular Medicaid and HIE solutions.

“John was truly an innovator for the state of Oklahoma and we are privileged to have him join Cognosante,” said Michele Kang, Cognosante’s CEO. “Leveraging his deep experience in state Medicaid programs will be a tremendous asset to our clients. John provides the leadership necessary to help bridge the gap between state and federal programs.”

“Cognosante’s contributions to the Medicaid Information Technology Architecture and accomplishments over the past two decades in the state Medicaid environment have positioned them well to lead the industry in a transition to the modular age,” added John Calabro. “I look forward to working with executives at both the state and federal level to bring agile enterprise solutions and services for the benefit of better efficiency and improved outcomes for healthcare entitlement programs.”

In Mr. Calabro’s prior role, he provided leadership, direction, management and coordination of HIT strategy, including oversight of the implementation of federal and state requirements for HIT and HIE, for the Oklahoma HIE Trust. He also provided health informatics leadership, vision and direction to the HIT office in collaboration with the Oklahoma State HIE Governance Committee. Previously, Mr. Calabro served as Chief Information Officer for the Oklahoma Health Care Authority and Director of Information Services for the University of Oklahoma Family Medicine Health Sciences Center. He holds an MBA from the University of Central Oklahoma and a BA in mathematics from Wilkes University.

The American Medical Association (AMA) drew headlines with their recent appeal to House Speaker John Boehner to block the October 1, 2013 implementation of the ICD-10 standard for diagnosis and inpatient procedure codes.

The opposition of the AMA to the sea change that is ICD-10 is, to some degree, understandable. As James L. Madara, MD, Executive Vice President and CEO notes in his letter, there are many more codes − and all of them start with a medically-trained person assigning detailed attributes to a patient or procedure. The task of recording and assessing these attributes largely starts with doctors, and the new coding is a lot more specific than the archaic ICD-9 system it replaces.

The AMA letter cites “a high risk for claims processing and payment disruptions” – the same concern that has been voiced for virtually every improvement in administrative transaction processing since the original HIPAA legislation was passed in 1996.

What’s In Your Wallet?

Underlying these administrative anxieties, though not mentioned in the AMA letter, are providers’ very real concerns about potential impacts on revenue. Doctors know that more detailed reporting will lead to differential reimbursement – lower payments for less complex problems, for instance. The industry as a whole has been emphasizing a “revenue-neutral” approach to the ICD-10 transition, but docs know that one of the ultimate goals of ICD-10 is improved cost control.

Whose wallet will those savings come out of?  Given an opportunity, the good doctors are likely to tell you in no uncertain terms.

But the answer, surprisingly, might be: “Nobody’s.”

Bigger Pie, Fewer Crumbs

How could that be? Over time, ICD-10 could create cost savings and revenue management opportunities for providers that more than offset its implicit costs, even as it enables differential pricing and actuarial data mines for payers. Providers stand to gain through improvements in payment accuracy, the ability to manage anticipated higher patient volumes without increasing staff, and the inherent efficiencies of better quality of care.

The AMA’s own research reinforces this principle.

Currently, the health care system spends as much as $210 billion annually on claims processing. One recent study estimated physicians spend the equivalent of five weeks annually on health insurer red tape. To keep up with the administrative tasks required by health plans, physicians divert as much as 14 percent of their revenue to ensure accurate payments from insurers.

(“New AMA Health Insurer Report Card Finds Need for More Accuracy”)

One of the cost-saving measures that ICD-10’s specificity will enable is automated review and approval of routine charges that are currently subject to manual review and requests for proof of medical necessity – zero-value paperwork that creates costly delays and disputes on both sides of the payment fence.  Providers and payers will still have issues over charges, but far fewer of them will require manual intervention, and each will pocket a portion of the savings.

And while payers will look at the growing repository of rich ICD-10 data for targeted health management analysis and population health trends, providers will mine their own payment data with revenue management tools to ensure they are being paid according to contract – another flaw in the current payment puzzle, according to the AMA report.

Did Someone Say Pie?

And such a reduction in administrative costs cannot be seen as a nice-to-have. In the very near future, the Affordable Care Act will be adding an estimated 34 million new patients to the insurance rolls, with no comparable increase in providers to serve them. We have to get faster, smarter, more efficient – and we don’t have a decade to come up with a new and better code set. Numerous large-scale studies, not to mention the financial results of top-tier provider systems like the Mayo and Cleveland Clinics, show that high quality care is not inconsistent with lower cost and provider prosperity.

The Quality Debate

Other than the AMA’s regrettable attempt to politicize an initiative that has flown under the radar and enjoyed bipartisan support through four administrations(*), the most troubling statement in their letter is that better, more precise coding will somehow have “no direct benefit to individual patient care.” Even John Halamka, MD and healthcare IT Übergeek, fails to see the benefit (though one suspects for different reasons – Halamka wants to “go big” – convert everything to the more granular SNOMED coding system, a change that would require a far more drastic genetic transformation of healthcare IT systems).

The American Health Information Management Association (AHIMA), the group that represents medical records professionals, is of a different opinion.  Dan Rode, AHIMA vice president for advocacy and policy went public with a rebuttal to the AMA position: “Without ICD-10 data, there will be serious gaps in our ability to extract important patient health information that will give physicians and the healthcare industry measures for quality of care, provide important public health surveillance, support modern-day research, and move to a payment system based on quality and outcomes.”

Cheryl Clark, for HealthLeaders Media, offers a list of ten ways that ICD-10 will improve quality of care.  Carl Natale, of ICD10Watch, offers a specific example of ICD-10 improving patient care.

Seeing Around Corners

I think even these thoughtful perspectives fall short of the ultimate benefits that will accrue from ICD-10, both in terms of population health and individual case management.  ICD-10 codes largely do away with the old coding system’s clusters of oblique subcodes, which were often characterized by two or three examples of common manifestations, followed by a “not-otherwise-specified” subcode for everything else.

In isolation, ICD-10 codes give a far more accurate picture of the patient’s current state or treatment. Which side of the body? Which bone? Which part of the bone? In large aggregates, they can provide a “color map” of disease or injury severity associated with, say, demographic information, pointing toward specific causes of very specific problems. (“Let’s put some helmets on the passengers of those four-wheelers out in West Texas!”)

Similarly, with just a small sampling of data mapped over time, a patient can see how changes in treatment or behavior caused her condition to improve or worsen. Further, as Health Information Exchanges continue to proliferate, ICD-10 enables the coordination of care across providers, wresting answers to the “how sick is she?” question from the file folder.

Unfortunately, most of the tools to provide these life-giving insights remain yet to be built. Because, until the data is there, there is no reason to build them.

—

(*) Louis Sullivan, Secretary of Health and Human Services under the first President Bush, is widely credited as the architect of the standards-driven principles that were enshrined in HIPAA Administrative Simplification, of which ICD-10 is but the latest manifestation.

Cognosante was honored to sponsor a breakfast roundtable with Todd Park, Chief Technology Officer and “entrepreneur-in-residence” of the U.S. Department of Health and Human Services (HHS) on Tuesday, January 31, 2012, in McLean, Virginia. Todd enlightened the audience on his innovative work at HHS and how it translates to opportunities in the private sector. Click hereto read more about the event.

MCLEAN, Va. – January 11, 2012 – Cognosante, a leading provider of IT services to healthcare organizations, has been awarded a contract with the state of New Mexico to provide independent verification and validation (IV&V) services for the Integrated Service Delivery 2 System Replacement (ISD2R) Project. The replacement system, also known as the Automated System Program and Eligibility Network (ASPEN), will determine eligibility, benefit delivery and case management in support of Human Services Department public assistance programs.

“The ISD2R project supports a fundamental component of New Mexico’s low-income and medical assistance program,” said Cognosante Managing Director Jarred Clark. “Cognosante brings a long history of performing IV&V services in the Medicaid arena to the effort. This coupled with our extensive experience supporting large, complex eligibility systems, will help to ensure the best outcome for the project.”

“ASPEN will bring New Mexico into the 21^st century by replacing our nearly 25-year-old eligibility system that is so important to the thousands of New Mexicans who are in need of our services, as well as our caseworkers who process those cases,” said Charissa Saavedra, Human Services Department Deputy Secretary. “The integrity of implementing this new eligibility system is of utmost importance to the Human Services Department and must be done efficiently and effectively. We are looking to Cognosante to assist in this effort.”

MCLEAN, Va. – January 4, 2012 – Cognosante, a leading provider of IT services to healthcare organizations, has been awarded a contract with the state of Utah to assist in designing an IT blueprint for future development of the current Utah Health Exchange. “Cognosante is proud to be selected to support this market leader,” said Michele Kang, Cognosante’s CEO. “As an innovator and leader of defined contribution-based exchanges for small employers, Utah has laid the foundation for the future health insurance exchange model. The new framework will expand capabilities and empower consumers with the information they need to make informed choices in the purchase of their health insurance. Cognosante’s deep and unique expertise in health insurance exchanges, Medicaid and federal systems will support the design of a flexible, modular and robust system to accomplish this goal.” “In collaboration with Cognosante, we will incorporate the best working models available in the marketplace to broaden the scope of our current Health Exchange,” said Dr. Norman Thurston, Health Policy and Reform Initiatives Coordinator, Utah Department of Health. “Our mission is to provide an intuitive healthcare system for consumers that provides the best value and facilitates future reform elements of the state health system. Cognosante brings industry-leading skills and subject matter expertise to help us achieve this result.” Under this effort, Cognosante will work with Utah’s team to develop a technology framework for the current Health Exchange system that provides a single point of access to Utah consumers for comparing insurance coverage options. The framework will provide the infrastructure needed for all users, including citizens, small businesses, health plans and government agencies. The system will allow consumers to enroll in private or public insurance and obtain cost and quality information on health plans, health care providers and treatment options.

MCLEAN, Va. – December 21, 2011 – Cognosante, a leading provider of IT services to healthcare organizations, has added Stephen Gantz as Vice President of Health Reform. In this role, Mr. Gantz provides solution architecture development, strategic planning, business development and sales support. “Steve brings a wealth of knowledge and experience to this position,” said Michele Kang, Cognosante’s CEO. “He possesses deep subject-matter expertise in security and privacy, and is a thought leader and frequent author and industry event speaker on security and privacy, health IT, HIPAA, regulatory compliance and enterprise architecture. He will work in close collaboration with our federal and state clients to understand and respond to provisions in major legislation, and oversee the implementation and management of our corresponding health IT solutions.” “Healthcare transformation is arguably the most pressing challenge facing the country today,” added Steve Gantz. “Health IT adoption and health care reform promise enormous benefits in service delivery improvements and cost efficiencies, but realizing this potential will require an unprecedented level of cooperation among health care providers, insurers and individuals, and between federal and state agencies. Given our experience and close working relationships with key government stakeholders, Cognosante is uniquely positioned to take on the current challenges. I am excited to contribute to our efforts toward making healthcare transformation successful.” Prior to joining Cognosante, Mr. Gantz held the position of SVP and chief security officer at Evolvent, a federal healthcare systems integrator, where he was responsible for the development and implementation of security-related services and solutions. Before Evolvent, Mr. Gantz led the delivery of enterprise architecture and health IT services for multiple federal agencies, working in the Health Solutions Division of Vangent, an IT consulting and business process outsourcing firm. Mr. Gantz holds both a master’s degree in public policy and bachelor’s degree from Harvard University.