Public Policy with Mari Savickis and Leslie Krigstein at the CHIME Fall Forum 2019
Episode 1468th November 2019 • This Week Health: Conference • This Week Health
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 Welcome to this Week in Health IT events where we amplify great ideas with interviews from the floor. My name is Bill Russell Healthcare, CIO, coach and creator of this week in Health. It a set of podcasts and videos dedicated to developing the next generation of health leaders. We wanna thank our founding channel sponsors who make this content possible, health Lyrics and VMware.

If you want to be a part of our mission to develop health leaders, go to this week, health.com/sponsor for more information. This episode is sponsored by Health Lyrics. When I became a ccio, I was really overwhelmed at first, and one of the first things I did was to sign ACIO coach to walk with me through the journey.

This was someone who had wisdom that can only be gained through years of experience. It was invaluable to my success in the role, and I now coach CIOs through health lyrics. If you wanna learn more, visit health lyrics.com or drop me a note at Bill at this week in health it.com. Over the next three weeks, we have a real treat for you.

d them to take a look back at:

I asked each of them the same eight questions, and I think you're gonna be as fascinated as I was to hear the similarities and the differences from CIOs. Each of these interviews is around 10 minutes long, so you can really listen to 'em quickly, especially if you listen to 'em at one and a half times speed, as I know some of you do, and we're gonna publish one a day with a few Newsday episodes sprinkled in through the end of November.

So check back every day for the next episode and look back to see if you missed any. That is all gonna start on Monday. Today we have an interview from the floor with Leslie Kriegstein and, uh, Marie Veka, the Chime, congressional and Federal Affairs liaisons on Capitol Hill. Uh, they're working on so many things, it's really amazing.

We hit a, we hit on, uh,:

Uh, Leslie and Mari. And actually, why, why don't you, why don't you, uh, give your roles 'cause you're congressional and you're more a different area, but, uh, introduce yourself to the Yeah. So Leslie Christine, I'm chance Vice President of Congressional Affairs and I am responsible for trying to stay on top of all of the dysfunction going on on.

Capitol Hill for, uh, the Chime membership. So, um, keeps me busy. Uh, there's lots of excitement these days and, uh, lots of challenges cutting through the noise. So, so, uh, really dysfunction. Dysfunction. We, you know, are hoping to just keep the government funded through Thanksgiving, um, let alone, uh, tackle some of the bigger policy issues like surprise billing and drug costs.

And, um, as we sit and wait for some of the forthcoming . Health it rules and see where we may need to have Congress engage there. So, um, there's some big policy conversations happening along with some of the headline news that you're seeing, uh, each and every night. So you are federal affairs. So can you introduce yourself?

Sure. Hi, I'm Ma Vickis. I'm chimes Vice President for Federal Affairs, and I have the flip side of the coin with Leslie, where I basically read and digest the thousands of pages of government regulation on any given day. And try to translate into what that means for practical realities for our members.

And there's no day off for the agencies. They don't take recesses. There's always something coming out on any given day. So it's just trying to keep pace with what's happening. And that's really fun reading. It's very, I mean, it takes a certain kind of individual that wanna read government regulation and I happen to be that crazy person.

Well, that's great. So we're, we're gonna talk about a lot of, uh, we're gonna try to get really pragmatic here, and you guys send out a, a great, uh, to the Chime membership. Great things and, and so I'm not, I'm I'm actually just gonna walk through this 'cause there's, there's so much here. Um, so stark anti, uh, anti-kickback, uh, where are we at on that and, and what, what is that about?

And where are we at? And it's a big deal to open up stark and anti kickback role. So these are issues that govern, uh, the healthcare sector of our particular interest to our members. As providers, you don't wanna be inducing referrals and appropriately. And so one of the things that we've been advocating for the past several years, knowing that there's only

A few ways to really incent financially good cyber hygiene through government incentives is to look at ways that we can leverage existing revenue streams. And one of the ways that we went about doing this was looking at start getting a kickback. So we finally saw in the proposed rule and the ability for a provider who say, uh, better resource to donate sec, uh, cybersecurity technology and services to a lesser resource provider.

And it's not mandatory, it's voluntary. So we know that there are some of our members who . Would have a strong desire to take care, to take advantage of this and others that have no desire, but it nonetheless is a recourse. Um, it's not final. So this is proposed. We'll be commenting and, um, engaging our members for feedback and input.

'cause the comments are due the end of the year. But, but this is huge. I mean, 'cause the Stark laws allowed us to, uh, to digitize a lot of these physician practices, individual physician practices that were out there. Um, but we didn't really do much after that. And without cyber cybersecurity's changing.

On a daily basis. Absolutely. And we've been, we've been busy trying to hit reboot on the sector collectively, and many of our members are actively engaged with an industry-wide effort to try and improve the cyber posture of the healthcare sector. So it's a volunteer effort. It's free. We, we do a lot of work with them and we're very engaged.

der that was set to sunset in:

And then there's also a series of of changes that they've made that would promote value in care coordination. Wow. We, we probably camp on that. It's a lot to unpack. . Yeah, we probably camp on that, but I want to talk 21st century cares. So which one of you is like the expert on 21st Century cares? Is that in your case?

It depends what way it's coming through. So, I mean, this was landmark legislation for the entire . Our healthcare industry, right? It had a number of, um, efforts to speed biomedical research and bring cures to patients. Um, but then there were about 40 pages of health it, uh, statute that really will dictate our industry moving forward.

And, um, it came on the heels of years of hearings and stakeholder round tables and meetings. And, um, one of the things that was kind of became the buzz phrase was information blocking. And so, uh, the rule dictated to . O and C, that they need to start promulgating rules on how to spur interoperability, how to create this network of networks, but also how to stop information blocking.

And so, you know, Congress, to the extent that, uh, health it is getting attention has kind of taken a step back because we do have the rules that are currently pending. So I think we will see congressional action kind of once we've seen those rules and see if they're actually going to mimic, uh, what congressional.

Was for, um, the various provisions, uh, that call for action. But that's really, you know, where my side of the house is right now, it's in limbo because, uh, 21st Century Cures was the last administration. Do you see a lot of continuity in healthcare across administrations? Um, in some, in the broadest sense, no, of course not.

Um, but in, in the health IT space, I think, you know, naturally, even as national coordinators changed and as . Frankly, um, leadership on Capitol Hill changed. You saw folks prioritizing different it, um, issues or opportunities. So I think there has been a commitment to interoperability. We had the interoperability roadmap that dated back year, so the last administration that really took off on the hill and where folks became very passionate about all of the different things that we could do to spur interoperability.

signed into, um, into law in:

And now this is like, there's several year lag time. And so to Leslie's point, the rules are now coming out and they're gonna be operationalized very shortly. We're waiting on the final rule for CMS and ONC concerning the interoperability rule as a dual companion rule that will govern what I've been calling the next decade of our industry.

So we're of . Or on pins and needles waiting for that to happen. Um, and to Leslie's point, there is like a bit of the, been the ball carrying forward from the last administration. I would say the name of the game in the next era is gonna be the consumer. And so it's all about engaging the consumer and making sure that the consumer has access to their data as quickly and as securely as possible.

Well, I mean too, so we've, uh, at hams last year, we had a niche chopper on the, on the thing on the show. And he talked about, you know, how this in, in healthcare, it's been relatively consistent drive towards. Operability towards, um, transparency, data sharing, uh, in the best interest of the patient because almost it doesn't matter what your political background, do we want to do what's in the best interest of the patient?

Yes. Do we wanna share the data with the patient? Yes. And so there's been consistency. Um, and I also have Don Rocker on the show recently, and we were talking about this, but one of the things that's probably more, that feels like it's more pronounced in this administration is Don just came out and said, we

Of 'em make healthcare a market. And in every market it's, you know, transparency, price, uh, so you don't have surprise bills. It's, um, choice and it's access to data around the services, the quality of the services you're gonna receive. And then I recently, I was at the health conference in her, uh, sea Chema, Ima talk and she just drove that home.

And it seems to be, that seems to be the, the whole push right now. Is that what you're feeling? I think that is, and there's a counterweight to this. So on the one hand, this is all like moving in the right direction. Patients should be engaged. Consumers, there should be transparency about cost and like, and they should have access to their data.

But on the flip side of this one issue that's been emerging is making sure that their data is not used in a way that they didn't intend it to be used, such as the commoditization and data aggregation of it. And so there needs to be, um, some protections that are put into place around how say, uh, uh, uh, healthcare data is married with like other consumer data.

So there's . Two different regulatory schematics that govern these spaces. There's HIPAA that governs the providers and payers, and then there's, um, the FTC that governs third party apps. So we've been trying to wrestle that dragon down and try to figure out how best to ensure that patients are informed about how their information could be used, while at the same time facilitating quick and seamless access.

And that also marries well with the broader conversations happening on Capitol Hill with, you're seeing Tech giant after Tech giant brought up set before a congressional committee and the . Dawn of what is privacy, um, with CCPA and GDPR, I think there's, um, a call to action for a national privacy, standard law.

Same with, uh, breach, uh, but there still remains some significant issues to be resolved. And so how healthcare fits into that, um, and to, you know, what extent non-covered entities kind of end up under other jurisdictions. And, um, you know, how we can better empower patients from the outset. I think is something that we're tracking closely and a few bills have been introduced, and I expect that to continue, um, to be of interest to focus on that are focused on healthcare.

So let's talk cybersecurity we did a little bit earlier. It's, uh, it's interesting. When I was CIOI would have to sit in front of the board and I'd say, look, if a nation state attacked our health system, they're getting our data. And that seems so defeatist to me. And the, the analogy, uh, cybersecurity, CEO gave me and said, look, here's the deal.

Some of these nation states have, have set up attacks directly on your health system. Mm-Hmm. , they've essentially put aircraft carriers on the coast of California and they're attacking, and we're asking each individual hospital to defend their turf against that kind of attack. He goes until the federal government steps in and starts to supply some help goes, you're you're defenseless.

the Cybersecurity Act back in:

But in there there was also, uh, a specific section looking at healthcare. So that was the first time that lawmakers, you know, put a stake in the ground and said, . Healthcare is probably behind where everybody else is and is nowhere near where the industry should be. So we're still seeing, uh, I would say like reaping the benefits of that statute and, and that legislation in the sense that it created a task force and the task force created recommendations and then from the recommendations that practices and then changes to the Stark Law.

And, um, so now that those things, you know, that cycle is running the cycle of policy making. We are seeing, um, from, uh, tech leaders on Capitol Hill, interest in . Going back to the drawing board to say we need to specifically help those that are small, rural, under-resourced. And what does that look like? We know the money trees have kind of shriveled up and gone away.

It's not like we're gonna get another meaningful use for cybersecurity unfortunately, even though that might be what it takes. Or, you know, one of the suggestions in the task force report, um, for relative to medical device security was like a cash for clunkers program for outdated medical devices. You know, again, if, if we had another stimulus, that might be a great opportunity to, that would be great.

Uh. to change things, but being realistic about our, our current budget situation, that's probably not possible. But I do think there is renewed interest. I think there's commitment and I, I think there's also a recognition that, um, providers aren't actively saying, come take my data. Right? One of the CIOs I was talking to last night equated a cyber attack to, you know, if someone came in and stabbed a patient in the ed, the hospital's not going to be liable for that action.

You're gonna . Charge the person who committed the crime. How is that different than if someone came in and held your system ransom? Why is the health system being the victim? And so one of the things that we are really encouraged about in the broader healthcare cost conversation, um, there is a provision that would direct OCR, right?

of, uh, the Cybersecurity Act:

So seeing how do you st stay up with all the acronyms? It's, you know, it's a, we live in Washington. Yeah. I block off 15 minutes of my day every day to make sure that I have alphabet soup under control. So. There has been a lot of progress. I think, um, there's been progress in terms of education of lawmakers, um, but I think, you know, we're also, you know, trying to do the work of educating the provider community, right.

Um, it's challenging, it's new and um, you know, it's scary. Uh, we know resources are finite, you know, the decision between investing in IT and IT security and finding the qualified professionals to be able to do that. This is a very complex con. That unfortunately right now doesn't present with a lot of easy answers.

And you, and we've been also collaborating a lot with the sector and also the federal government. And that that's, I mean, that's part of the reboot on our sector to try and hit refresh. How are we going to work more cohesively so that we can improve this cyber, our posture overall? And so that's been, I mean, many of our members are involved in the health sector coordinating council and, um, the joint effort on cybersecurity.

We just did a podcast with HHS where we, it was, you know, locked arms and talk . About what the progress that we've made and the things that we have to look forward to. And we're still, we're still, we've got a long ways to go, but we've also made a lot of progress. We've seen a lot of good developments from the FDA.

A lot of those recommendations that Leslie referenced in the industry report on cybersecurity are now coming to fruition, just like the Stark and Kickback, which was recommended by that, that group. And so there's work that's being done to improve the posture. So I think that, you know, it's nice to acknowledge like how far we've come, but we still have a ways to go.

Yeah. So I wanna talk to telehealth. National patient id. I also wanna talk about the work that you're doing and, and, um, I, I mean, we are seeing CIOs go to Capitol Hill, have conversations. We're also seeing state engagement and those kind of things. Um, but two more, two more policy things. So Telehealth, uh, on a, uh, from a Medicare standpoint, from ACMS standpoint, they're trying to do something pretty, um, progressive, uh, with telehealth and can you give us a little bit Yeah, I mean, a lot of this, I mean, I'll let Leslie talk.

very wonky, but they call it:

And so we've been busy, you know, trying to push the needle forward on this, both from a regulatory and a statutory, um, side. And so, for example, the, the recent, the current administration has actually moved the needle forward. They now pay for, um, certain, you know, remote monitoring, uh, . Visits and, and, and our eConsults, like with a physician to physician or if a patient needs to check in with their clinician.

So between, you know, between that, there's actually been a fair amount of progress. And CMS each year usually adds a few extra services to their list of telehealth, but we still need a lot more action. And that's where we go to the hill where we need to remove those statutory barriers and that work is really underway.

Yeah, there was a, a fairly comprehensive telehealth uh, uh, proposal introduced last week. Uh, bicameral, bipartisan from, uh, the telehealth caucus membership, and it really does, uh, look to at least expand CMSs capabilities to reimburse, right? So, um, there's a lot that folks are doing, uh, with private payers, right, that are thinking more creatively.

You're seeing new entrants into the marketplace that are offering these kinds of services. But unfortunately, Medicare is far behind. And so, um, in a hearing before the energy and Commerce committee. In the house a few weeks back, uh, administrator Verma was asked a few questions about telehealth and asked about, um, you know, what's the value?

What can we do to, to improve the outlook? And she said it's, it's critical, and especially as they're looking at rural health and, and addressing some of the access challenges. Uh, but unfortunately Medicare is bound by some very archaic, uh, statutory guidelines that in this political, you know, nonsense, it's really difficult to change.

Something like:

And so CBO is convinced annually that increasing telehealth services will U result not in cost savings, but additional costs. 'cause I think it's gonna result in duplicative services and over utilization. And so we continuously work with our members to try to paint the picture of, you know, how can we be more proactive?

How can we be more preventive? How can we look at keeping folks out of, you know, the high cost environments? And unfortunately, CBO has been very, very slow to, um, acknowledge, but we've seen progress in opioid and mental health. Um, I mean, there's so much, uh, so, you know, they've taken a very, um, uh, kind of stepwise approach in Mm-Hmm.

looking at different disease states or different . For in geographic locations to like slowly start adding more reimbursement opportunities. But we still have a long way to go. And speaking of costs, I mean, that's one of the things that while we have several members who are early adopters and first movers, the vast majority of our members can't afford to do telehealth because they need this spigot to be turned on by the government so they can get reimbursement or by the commercial payers so that they can start, uh, funding the actual infrastructure associated with this.

So until those two, um, . , like guess planets align. Yeah. It's very, very hard to keep moving this forward. And so that's why we work on, it's a little bit of the reimbursement piece that has to be changed in order for that, that to really like kind of take off. And I think the other thing that we've really tried to drive home with lawmakers is it won't always be telehealth.

It's just gonna be delivery of healthcare, right? And whether it's, you know, the traditional brick and mortar touch and feel and care experience, or if it's going to be delivered via a virtual platform, that's just going to be healthcare in the future. Sure. And so let's make sure that we're not hampering that evolution.

Mm-Hmm. and meeting folks who like me, very much like my ability to do a telehealth visit. How often do you have people who don't live in your world look at you and say these words? That's crazy. , I mean, telehealth, first of all, the, the, the patient satisfaction is through the roof on telehealth. And we have, we have the numbers to show, we do, um, access goes through the roof and cost gets reduced significantly.

Mm-Hmm. , I mean, who do. Need to talk to the c to say the wheels. The wheels of change in Washington are very slow. It, it's a lot of hurry up and wait. I mean, it is just, I, I liken changing public policy to rolling a boulder up a mountain sometimes. It just takes a long time. A lot of patience, a lot of conversations.

Yeah. I mean, it's telling the stories, it's having folks share the data. Um, you know, CBO likes particular sources of data. I mean, it's been a great source of frustration for I think folks in the health IT space. Because, you know, just about every CIO can probably attest to the value that it would bring to their organization and, and frankly, to patients.

Um, but challenge Medicare too. They feel like they have to be very good stewards of taxpayer dollars. So there is this underlying current of whether or not if you increase the reimbursement and the number of services that are allowed to be paid under telehealth rules, that there could be program integrity issues.

And so there's, there's that sort of in the, in the low lung in the background. Trying to overcome that has been a little challenging. Yeah. They have to constantly be cognizant of fraud. Exactly. And there is fraud. I mean, yeah, there a big announcement mean there's a lot opportunity too that, so it's, it's a balancing act, honestly.

Yeah. See that may I, you know, we can talk about a lot of things, uh, national patient id, so getting some pushback. We are, and we aren't, I mean, for this being an issue that's over two decades old and you know, when I started at Chime about five years ago, we were still very much . Afraid of the folks wearing the tinfoil hats and, you know, to see a bipartisan vote in the House of Representatives in favor of repealing the ban.

Um, it wasn't something that just got tucked into a, it is not a ban on national patient. It's a ban on funding research for a national patient. Correct. And so, um, you know what, the industry, and I think a way that we really haven't seen over the last 20 years is, you know, there are 50 plus organizations that we're working with that are all saying in unison, we've gotta address this once and for all.

Folks are generally solution agnostic. So you know, if the government wants to go down the route of an identifier, if they wanna go down the route of expanding the Medicare beneficiary identifier, if they wanna look at biometrics or, you know, I think folks are open. It's just a matter of the time has come.

And if we really do believe that we need to be interoperable, which we all do, until we address this foundational element of data exchange, we're not gonna accomplish the goals that High tech set out, that cure set out. And that, you know, we hear Administrator Verma and folks in . Administration saying is, you know, a top priority for them.

So yes, we know, uh, where Senator Paul stands. He's very much carrying forth, um, where his father is. And, and we did see some opposition from the ACLU. Um, but I'm optimistic given the industry support, um, given the fact that, you know, a new day has dawned also in privacy and patient expectations, that I think we'll see some level of progress.

n even funded for fiscal year:

Wow. So, well, an election, I'm sort curious what it's like for you guys to do your job well, an election year really ratchet this up and make it more challenging, I think. Know, on Capitol Hill, we're already starting to see kind of the political gamesmanship with, um, of course the house is moving forward with impeachment and the, the leadership of the house is saying, we've gotta kind of show our worth.

So let's look at some of these other healthcare packages. 'cause they heard voters loud and clear in the last election. That healthcare's a big priority. So you're seeing a lot of those like messaging bills. So that sort of thing will pick up. Um, but, and then you'll start to see like, we can't give that candidate a win or we can't let the president get a win.

So . You know, and things will come to a halt on the Congressional front. Um, but after the election in Lame Duck, I think it's going to be a complete free for all with an immense amount of opportunity. So it's definitely, you know, the tension is going to be ramping up. Um, you know, I don't anticipate a lot of productive conversation, but in my world health it has been bipartisan.

Um, republicans, democrats have commitments for different reasons about, you know, recognizing the need. To do better with our federal investment. So from that vantage point, we've been able to stay out of the fray. There's just a lot of noise that we're cutting through. There's something, election years, there's so much noise trying to elevate.

But the great thing about an election year is the year after an election year, everyone's trying to mm-hmm to move the needle fair quickly in that first year, especially the first a hundred days. Right? So this is really setting the foundation for, for what's gonna happen. I mean, you asked about telehealth.

I think, you know, five or six of the Democratic candidates have included . Some kind of reference to telehealth and their healthcare platform. So I think tracking what that looks like and kind of seeing what the president might unveil in, in the healthcare space, um, as well will be, you know, worth watching.

Um, a lot on the regulatory side too. But as you lead up to an election, what they're gonna do is they're just gonna start pushing things out very quickly because they have to get that out the door before the election. And so we're already seeing pressure on the administration to get the ONC rule out ACMS rule.

And then, you know, there's a HIPAA that is gonna be . They just got the start getting kickback. It's gonna be just like a steady stream. And then probably the closer you get to the election, things will start to peter off. And as people really focus in on that, you guys have already stayed longer, but is there anything you want to get out to people who are listening in terms of, uh, the work you're doing, how they can participate?

What, what role? The membership playing? You know, there's really, uh, countless ways that you can engage in policy. Um, whether it's working with us directly for responding to, you know, . Comments and, and those sorts of formal opportunities. We also get members with a lot of questions. You know, I saw this in a bill.

What does that mean for my health system? Or, Mm-Hmm , I don't understand this measure. And we're happy to kind of do those one-on-one, um, you know, office hour kind of things. Um, but we also, the last few years have done advocacy summits in DC and have been able to bring lawmakers and policymakers to have those one-on-one conversations.

And we took about 30 members up to Capitol Hill to do hill visits. So, you know, I . Think our opportunities for engagement are growing. There's always opportunities to engage lawmakers at home when often our members are the biggest employers in the district. We've got a story to tell. So it's really a choose your own adventure, uh, kind of interaction with policy and, you know, the more the merrier are approached.

And we also have a phantom mailbox, which we will staff, but it's policy@chimecentral.org. And we are happy to talk to both members and industry. We, you know, we routinely do both. And so to Leslie's point, there's really like a . Lot of different ways to interact with us, so we would certainly encourage anyone to reach out to us.

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