CMS can’t manage its way out of a paper bag.

While actual health care providers feel the ground shifting beneath their feet, no t to mention the cause and effect, why have we not become more vocal and asked about the relevance of HHS (United States Department of Health and Human Services) and CMS (Centers for Medicare and Medicaid Services)?

When was the last time anyone looked at the importance, objective, main outcomes and measures? Results and conclusions and relevance?

CMS has done more to add to the costs of healthcare, hurdles and regulations than they themselves could comply with. (Look up the organization charts for both HHS and CMS).

There are multiple examples, but let’s look at one big example: HealthCare.gov and follow it and some others legislation which providers have/will have to comply with that will have a major impact on the success of change and the Affordable Care Act. These pieces -- whether intended consequences and or unintended consequences -- will define success.

The first comment and criticism I have is: Both HHS/CMS rely too much on processes and not enough on outcomes.

Here are some points and other information to keep in mind:

Challenges remain; a back-end link providing payments and automated account records to insurance companies have yet to be built and might not be completed before summer. But that is mostly a headache for the insurance companies, that have to bill and process payments through spread sheets; it is not likely to affect consumers’ experience or their access to insurance. (Time, March 10, 2014)

The Obama Administration was obsessed with healthcare reform policy, but oblivious to the nitty-gritty of implementation. No one in the meetings leading up to the launch had any idea whether the technology worked. The meetings were attended by the president (sometimes), Denis McDonough, the White House Chief of Staff, Kathleen Sebelius, Secretary of HHS, CMS Administrator Marilyn Tavenner and White House health reform policy director Jeanne Lambrew. The other attendees were also policy people, pollsters or communications specialists focused largely on the marketing and political challenges of enrolling Americans. Policy director Lambrew kept Todd Park, the Chief Technology Officer off the invitation list. Chief of Staff McDonough says in meetings with the president prior to the launch, Obama always would end each session by saying, “I want to remind the team that this only works if the technology works.’”

The problem was that no one in the meetings had any idea that the technology did not work, nor did the president and his chief of staff have the inclination to dig in and find out.

The president put McDonough in charge of the launch. What McDonough was able to pry out of the crew at CMS was that even on October 17, only three out of 10 people were able to get on at all. McDonough was supposed to be attending to everything associated with the rollout, including the technology. But he and Lambrew (the person that kept the CTO out of the meetings) simply accepted the assurances from the CMS staff that everything was a go.

The president and McDonough quietly brought Jeff Zients in, when it became obvious their early explanation for the website problems was anything but the whole story. Zients, a highly regarded businessman, won high marks as a deputy director of the Office of Management and Budget.

Zients and Todd Parks led the Administration effort to fix HealthCare.gov. They brought in a team of unknowns –except in elite technology circles who dropped what they were doing in various enterprises across the county and came together to save the website. In about a tenth of the time that a crew of usual-suspect Washington contractors had spent ‘over $300 million’ building a site that didn’t work, this ad hoc team rescued it.

Remember, as you read this article, to keep in mind the pieces and the intended and unintended consequences. Three of the biggest challenges to providers in this year of all-consuming and more legislation than I have ever seen in healthcare are Meaningful Use, ICD-10, and Administrative Simplification.

This year is expected to be a watershed year in the area of health information technology (HIT). Alongside challenging HIT reporting programs such as CMS Meaningful Use EHR Incentive Program and mandates, including ICD-10, are significant administrative simplification opportunities with new standards and operating rules.

During this year, medical practices will see the start of Stage Two of Meaningful Use. This second stage includes many of the same criteria as Stage One, although several criteria now have increased thresholds that must be met by eligible professionals (EPs). EPs will also have to contend with several new difficult criteria. Particularly demanding will be two criteria that require a minimum number of patients to take certain actions. For example, one criterion states that five percent or more of an EP’s patients must be provided with:

The ability to view online, download and transmit their health information.

Secure electronic messaging to communicate with these patients about relevant health information.

Talk about lessons. Did HHS and CMS see and understand about people’s accessing sites? Is this a race to failure? Complete one before you add to it and include another.

Now if this is not an example of my comments and criticisms I mentioned earlier, I can’t think of a better one.

The Office of the National Coordinator of Health Information Technology (ONC) and the CMS, are not in the same box or even the same column together.

On October 1, 2014, the industry will move to ICD-10, a transition that represents one of the most significant challenges that practices have faced in recent history. Contrary to many of the past HIPAA requirements for practices, ICD-10 will require resources, money and training for clinical staff and the potential modification of patient workflow. Assume there will be delays and problems with your revenue cycle due to the change over, (and remember CMS says it becomes an insurance company issue). Develop an effective contingency plan to ensure that your organization has sufficient capital to meet payroll and other expenses.

The PAC included a number of administrative simplification requirements that are expected requirements that could improve operational efficiency and decrease costs for providers. In 2014, CMS is required to initiate a certification program that requires a health plan to prove it can conduct these transactions and operating rules. And there will be fines to noncompliance which can be as much as $20 per covered life. (If you believe this about simplification, particularly under the management of CMS, you are not getting much oxygen to your brain.)

Following a scathing study showing that patient-centered medical homes did not lower costs, the leading accreditation agency for patient center medical homes does not spend enough time on outcomes. (National Committee for Quality Assurance, NCQA)

In a study published in JAMA, RAND researchers compared 32 NCQA-recognized practices in southeast Pennsylvania with 29 that were not. Over three years, a significant difference was found in only one of the 11 quality measures and there was “no robust association with utilization of costs.”

The NCQA which recognizes more than 6,800 physician practices as medical homes, announced in March that the NCQA will unveil revised IT standards to show IT recognition process value.

The new standards, scheduled to begin last month, will shift their focus to align with HHS (I think that is sometimes referred to as the “fox guarding the hen house”) requirements for information technology, enhance team-based care, target high-need population and advance the triple-aim goals of increasing quality, lowering cost and improving patient experience.

Processes upon processes with a changing target, there can be no positive outcomes, the providers and the patients will most definitely know the bad unintended consequences is why the Affordable Care Act will fail. It is really not if it will fail, it is when it will fail, unless change and management within HHS/CMS changes and changes fast.

I think that providers who have to live with the consequences should be able to bring in a team of unknown (except in elite technology circles) rescuers to figure out what is going on now and during the fiasco ahead.

What is needed is a new and fresh set of eyes. And those eyes should do as the ad hoc group working on the site said, “We are taking our team outside the CAVE to solve some big problems.”

Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC.  He is a national speaker, presenter and a published author.  He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood.  For more information contact Bill at j.william.appling@outlook.com.