What was controversial four years ago, but not anymore? How about the following three statements: (1) More chiropractors will adopt electronic documentation in the near future. (2) Medicare will increase audits of chiropractors.
I believe it's up to us to decide whether we change with the times or face the possibility of being left behind. Let's go through each of the above-mentioned formerly controversial statements one at time, and see how they've come true. To set the scene, I want to start in a place that seems as far away from your practice as you can get: the criminal forensics lab.
Crime Scene Investigation and the Chiropractic Practice
Ever watch the TV show "CSI" and get caught up in the story by the production alone? The gadgets, the science and the music can mesmerize us and hold our attention. Now imagine the show, but not with million-dollar labs and walls of computers, but with walls of filing cabinets. Not very exciting, is it? Somehow, it just isn't the same.
Today, it's hard to imagine a forensics lab without any high-tech wizardry; the thought of doing science without a computer seems impossible. But if "CSI" had been on 20 years ago, you would have seen filing cabinets, fingerprint dust, and the occasional microscope - much more reminiscent of a show like "Diagnosis Murder" or even "Quincy, M.E." (remember them?). What has made the "CSI" franchise so successful is the way they take the classic "who-dunnit" mystery and anchor it to technology that pushes the limits of science.
Now imagine a scene from a show about your practice. Is the background more suitable for the "CSI" detectives or the county coroner on "Quincy, M.E.," a show that went off the air in 1983? If you look around and you see more filing cabinets than anything else, then it's only a matter of time before you lose prime-time position - in chiropractic specifically and in health care in general. Let's see why.
Prediction #1: More DCs Will Adopt Electronic Documentation
I started this column in the spring of 2006 when the dust over the 2005 Office of the Inspector General (OIG) report was starting to settle. I am active in both my state association and the ACA; I also happen to be the president of a company that has developed chiropractic management software. I say that in order to say this: I am acutely aware of the pulse of chiropractors' opinions when it comes to electronic health records because it's my job and because my service in our state and national associations means I get to talk to a lot of our colleagues.
I don't have peer-reviewed research that covers chiropractic opinion on EHRs, but I have seen surveys, as well as my own first-hand observation indicating a growing openness to adopting electronic documentation. First, there's the evidence of our chiropractic colleges; many of them have already switched to digital clinic management or have started the process. Second, there's our company research. We have internal data showing that back in 2005, less than half of the profession we surveyed believed that adoption of EHRs was going to be necessary in the next five years. Today, about 80 percent believe adoption will be mandatory within three years. That's quite a leap.
Finally, there's evidence that more chiropractors are open to EHR in the way the chiropractic software industry is marketing its products. More and more companies are bundling software, creating suites that aim to integrate the many aspects of practice together with some form of digital documentation and the technology necessary to support it, like electronic data transfer and offsite storage. In 2005, the phrase electronic health records was not in the vocabulary of most chiropractors. Today, it is rapidly moving to the forefront of people's minds.
Prediction #2: Medicare Will Increase Audits of Chiropractors
What is driving this new openness to EHR adoption? One part excitement, one part worry. When chiropractors get a chance to experience what a digitally integrated clinic feels like, most have an "ah-ha" moment, at which point they finally understand the efficiency that's possible. But underlying this need for speed is a real desire to be able to manage a case without any holes; relying on the technology to help prevent the case from ending in low patient outcomes, decreased reimbursement, or increased chance of failing an audit. And we have Medicare to thank for that last item.
Ever since the 2005 OIG report, I have been predicting that CMS administrators would see an opportunity to recoup even more Medicare dollars from us. You may remember that the 2005 report noted, among other problems, that the government paid out 280 million dollars per year for chiropractic care that was not properly documented or was improperly coded to bill non-covered services under spinal manipulation. The report also concluded that 92 percent of records reviewed failed to create a legitimate treatment plan.
With a subtitle of "Payment Vulnerability Analysis," I don't think it takes a psychic to see that audits were on the horizon. Call your state association and the associations of the neighboring states and ask them about audits. I am certain they will report back that the number of audits ending in Medicare recoupment are on the rise and have been since 2006. That is certainly what I am seeing.
With the release of the 2009 OIG report a few months ago, I see no reason to predict a decrease in CMS post-payment reviews. In fact, many states are reporting mass audits. While the profession showed a marked improvement in treatment plans, Medicare still classified half of the records as maintenance care.
Remember, in an age of health care reform, squeezing dollars out of the system is a high priority to maintain costs. Labeling undocumented care as "maintenance care" makes care vulnerable for recoupment, regardless how problematic we may think Medicare's classification of "necessary care" might be. It is still the intention of Congress to not add any burden to the budget with a health care bill. Streamlining Medicare by rejecting or recouping improperly documented visits is one way costs will be saved. Poor documentation makes it easy pickings.
Prediction #3: EHRs Will Be Mandated
Have we seen the appearance of national legislation requiring EHRs in all health care offices? Not yet, so I can't say this prediction has been completely fulfilled. However, even if such a law is never passed, there are plenty of reasons why most providers will adopt EHR through indirect pressure from the government and third-party payers, creating an unofficial mandate.
First, let's recognize that both state governments and the federal government see the cost savings provided by EHR technology, and they are starting to pass laws mandating EHR adoption. This is separate from any national health care debate. In 2008, Minnesota signed a law that requires all health care providers and hospitals to have an interoperable EHR by 2015. Another part of the bill, requiring all providers to submit claims electronically, has already been made effective.
Second, Medicare itself is moving toward a form of submission that intends to recoup money before audits. How does CMS intend to do this in the future? By requiring the attachment of an electronic note with the submission of every electronic claim. Call it a pre-payment requirement. No, it hasn't gone into effect yet. But this plan is published on the CMS Web site under its long-range plans. It's not on the docket for next year, but I'll say that it's going to be possible in five years.
Such a plan will essentially create an unofficial mandate. Any provider who wishes to see Medicare patients will need to have an interoperable EHR system in order to submit with any efficiency. I've already written about the incentive payments in prior columns. CMS is actually paying you to adopt EHR and rewarding you now, but later they will penalize and I predict that eventually it will be mandated. As goes Medicare, so goes the rest of the third-party-pay industry.
Third, EHR systems are absolutely necessary to gain control over health care costs, and this is a fact that has been publicized and recognized long before the 2008 election cycle. As I've written here before, regardless of politics, all major candidates for president had at least a cursory mention of expanding EHR technology to save at least 77 billion dollars a year in health care spending. Republicans and Democrats agree on this almost 100 percent. In the debate over the health care overhaul, there hasn't been any dissention over EHRs being an integral part of reforming the system. Public option or just insurance reform, the question is simply how they are going to be implemented (or mandated).
Predicting the Future
In a recent episode of "CSI Miami," the story takes us back in time to see the crime lab before the age of computer forensics. We see nothing but filing cabinets. The lead characters are discussing the use of technology in detective work, and the resistance to high-tech forensics. Horatio Caine (played by David Caruso) offers one inspiring line: "The times are changing. If we don't change with them, we'll be left behind."
It's been more than years since the release of the 2005 OIG report, and the predictions it has inspired in me (and others) have just about been fulfilled. Chiropractors have opened to EHR adoption, Medicare has increased its audits, and while EHRs haven't been mandated across the board as yet, the writing is on the wall. If we don't want our services to be made obsolete, and if we want to be part of the health care community utilizing health information exchange and proving the quality of our care, then we have to free our offices of filing cabinets and get plugged into the future. It is here, right now.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.