WEDI's 2022 National Conference (their first hybrid event) was held from October 25-27. We were very glad to have to opportunity to participate virtually. Overall, the conference had two unofficial major themes - health equity and the No Surprises Act (focused almost entirely on Good Faith Estimates (GFEs) and Advanced Explanation of Benefits (AEOBs)). There were regulatory updates throughout and also panels on other topics including the patient experience, something we've been increasingly focusing on here at MHDC.
Day 1
The first day of the conference started with some sample workgroup meetings in the morning. With two meetings running simultaneously, attendees were asked to make a choice. We ended up attending meetings on genomics, emerging technologies, and provider information. Of these, the provider information was the timeliest, focusing on the recent CMS RFI about a national provider directory. Some of the points raised were interesting including a concern about using fraudulent entries in the directory to gather PHI and other private information from unsuspecting patients and a suggestion that a national provider directory could be used move patients away from phone scheduling (we pointed out that not supporting phone scheduling may be an equity issue). There was also a push for data standardization, using address as an example. Is the address supposed to be the service location? the billing address? something else - we need to be consistent about both meaning and format.
The keynote address was by former United States CTO Aneesh Chopra. As is often the case, he was very future focused. However, early on in his talk he made a case that sometimes technology can be a barrier to policy change, using resistance to using digital quality measures as an example. We posit that his example was not about technology per se, but about the surrounding processes and resistance to change. After that he discussed the need for data and technical standardization, particularly around social needs screening and their results and in defining what specific services mean within the context of the No Surprises Act. To that end, he announced the new Project Clarity to work on setting clear, standard definitions for 10 common services for use in No Surprises and other price transparency efforts. We look forward to learning more and possibly participating in these efforts.
We expected a panel with three National Coordinators (current coordinator Micky Tripathi and former coordinators Don Rucker and Vindell Washington) to be a highlight but, unfortunately, there were technical difficulties in the online feed. We hope to watch a recording in the future and will definitely bring our takeaways to the Data Governance Collaborative (DGC). If you're a provider or payer consider joining us there.
Updates from OCR, CMS, and ONC rounded out the day. One interesting takeaway from the discussion with new OCR director Melanie Fontes Rainer was a general audience concern about victim blaming when it comes to security incidents; folks want OCR to look at ways to reduce this blame when possible and warranted.
Dr. Mary Greene of the Office of Burden Reduction and Interoperability gave the CMS update. It covered familiar ground in many ways, but there were a few key items worth mentioning here. First, she confirmed that some form of the frozen Prior Authorization rule is currently at the OMB for review, usually the last step before release to the public. So is a rule covering attachments. She also indicated that CMS has started working with ONC to improve information blocking compliance but did not provide many details. In addition, she announced a new quality measure to track whether or not an entity supports bi-directional information exchange via TEFCA (a yes/no attestation). Finally, she indicated that CMS is in the early stages of planning for ICD-11, starting with gathering feedback on what went well and what went poorly in the upgrade to ICD-10.
The ONC presentation by CMO Thomas Mason was focused on the concept of equity by design and also had a few interesting tidbits worth noting. First, ONC is actively working on aligning race, ethnicity, and language data across the entire federal government. They're also looking at using FHIR as a tool to combat inequities in several ways including by using it to connect to organizations that don't have EHRs (for example, community service organizations like food banks and homeless shelters). Finally, Dr. Mason teased us by announcing that ONC will be releasing new health equity programs before the end of the year without providing any details at all about what they are. We'll definitely keep an eye out, tweet about them, and discuss them at the DGC.
Day 2
Day 2 standouts were the keynote address from Rich Landen of NCVHS, a panel focused on the patient's view of healthcare and interoperability, and an update on TEFCA.
The NCVHS presentation spent time talking about the process for advancing HIPAA standards and specifically addressed recent requests for advancements by X12 and CAQH Core. Advancement of HIPAA standards requires approval from NCVHS. Advancement also requires that standards currently exist - since HIPAA has no standard transactions for attachments or prior authorization, related rules cannot be formally adopted by HHS.
HIPAA advancement requests are evaluated using internal review, public comments, and public listening sessions (scheduled January 18-19 for the X12 and CAQH Core requests). The internal review uses a variety of criteria including whether there's industry consensus around the requests, the expected impact of the changes (including financial), and whether it fits the planned HHS roadmap for HIPAA. In this case, they will also evaluate the impact of having multiple versions of the same standard simultaneously (for different transactions) as that's part of the X12 request. Putting aside impact, Landen notes it's not clear whether HHS has the legal authority to support multiple versions this way.
At the end of the NCVHS session we pivoted to a discussion of ICD-11 led by Jamie Ferguson of Kaiser Permanente. We didn't delve too deeply into the topic, but one key point he made was that ICD-11 is fundamentally different from ICD-10. ICD-11 is entirely digital, it uses a completely different structure from ICD-10, and will continuously update rather than use set, versioned updates. We asked a series of questions around how folks will know if their codes are currently valid, how recently invalidated ICD-11 codes should be handled given that their change of status isn't tied to a version change, and similar but the answers are still unclear at this point.
The Patient Advocacy panel was moderated by Samantha Holvey of WEDI and also included Anna Hyde from the Arthritis Foundation, Laura Ryan from AARP, and Nicole Braccio from the National Patient Advocate Foundation. Some key issues raised include a disconnect between the financial and clinical elements of care, the need for more care coordination and the desire of many patients for a care manager to help with this, and the need for better processes to transition patients from pediatric to adult care. There was also a discussion about the need to not just tell patients that something exists (price transparency, information blocking, etc.), but explain what they can do with it without making it an extra burden on them. Finally, the panel stressed the need to include patients of all stripes in the design and evaluation process of any program, device, or service both generally and also to ensure accessibility.
The TEFCA update from Mariann Yeager talked a bit about the ongoing application process for QHINs and the need for objective, quantifiable rules for evaluating QHINs. Applicants are required to refrain from discussing their candidacy until final adjudication, but in her mind there's a wide enough range of applicants to ensure there won't be a monopoly. When asked what sets TEFCA apart from other exchange frameworks, Yeager indicated the governance process and amount of oversight were real differentiators; there are a lot of rules QHINs and others must adopt to participate. While TEFCA will be live next year, she believes that its use will ramp up in 3-5 years. That's a long time in today's world - we'll see how things go.
Day 3
After a keynote address by Peggy O'Kane from NCQA, most of the day was focused on the price transparency components of the No Surprises Act including both a combined overview and update from CMS and breakout sessions with audience discussion of GFEs, convening providers, AEOBs, and the recent No Surprises RFI.
O'Kane talked about the need for alignment among quality measures - until this happens no amount of technology will make for a smooth process. She says that's outside of the purview of NCQA, though, and didn't discuss how to achieve better alignment (CMS is working on it, but it's unclear exactly what will come out of their work or when it will happen).
Most of the rest of her comments revolved around new NCQA programs in SDOH and equity. In particular she touted their health equity accreditation program involving existing 5 measures stratified by race and ethnicity (expanding to 8 in 2023). The program will also add a new social screening measure in 2023 incorporating food insecurity, housing insecurity, and transportation needs as well as indication of whether interventions occurred to assist with identified issues. When asked about related survey instruments, O'Kane indicated that it's too early in the process of social needs screening to standardize on a particular survey. Hopefully that will become part of the process moving forward so we don't compare apples to oranges.
The CMS presentation was interesting because they shifted back and forth between discussing the current laws, regulation, and guidance and related questions in the No Surprises Act RFI. Completely focused on GFEs and AEOBs, it was an effective way to cover the material. While none of the information was new to anyone who's been paying attention to this topic, it was interesting to see what they stressed and which RFI questions they highlighted.
Some of the points they made include:
- HIPAA security and privacy rules apply to GFEs and AEOBs
- A single GFE/AEOB pair should cover a primary service and all related services (without using the "scheduled together" criteria previously outlined by CMS, although they agreed it applied during Q&A)
- GFEs are not required for services scheduled less than 3 days in advance or for unscheduled urgent/emergency services
Providers of secondary care have 1 day to provide their information to the primary provider of care for the GFE - Diagnosis codes are not currently required for GFEs for self-pay or uninsured patients
- AEOBs must be provided in the format requested by the patient
- AEOBs must require information about the status of a patient's deductible and out of pocket maximums as of the time the AEOB was generated
All four breakout groups got together to report out. Some of the comments from other groups included complaints that X12 was not mentioned in the No Surprises Act RFI (and related concerns that it focused too much on APIs and real-time decision making), concerns about how to estimate variable factors (like whether someone will need a cane, crutches, walker, or wheelchair after orthopedic surgery or how long an appointment they need for something), and a request for clarity around whether primary/convening providers have an obligation to shop for secondary providers and select the cheapest option for their patients (this was an incredibly interesting comment; we hope to see some official guidance on it in the future). All of the folks reporting back were summarizing from much longer sets of notes; it would be extremely interesting to see the full reporting from the other sessions.
Summing Up
WEDI generally offers a mix of policy, process, and data/data exchange sessions at their multi-day events. This one was no different, but policy and process was definitely a bit more of a focus than data and data exchange which some of us at MHDC found a bit disappointing. In some areas we also felt the session participants were a bit more focused on stating the problems than on solving them than we'd have liked. This was not universally true, and questions asking about solutions were sometimes effective in mitigating it.
We continue to find a lot of value in WEDI conferences, especially the updates from CMS, ONC, OCR, and other agencies within HHS. We look forward to attending future events and bringing our thoughts back to MHDC membership both in future newsletter articles and through discussion in the DGC.