Niam Yarhagi’s THCB piece, Congress Can’t Solve the EHR Interoperability Problem (March 21, 2015) raises excellent points with which I mainly agree. So why write a responding blog? Because I don’t agree with his solution.
To review: Dr. Yarhagi discusses a draft congressional bill that calls for the creation of a “Charter Organization” that “shall consist of one member from each of the standard development organizations accredited by the American National Standards Institute and representatives that include healthcare providers, EHR vendors, and health insurers.”
Four agreements: I agree with Dr. Yarhagi’s conclusion that the proposed charter organization will not succeed; I agree with his prediction that it won’t be able to develop useful interoperability measures (hint: these are the same vendors that have refused to cooperate for the past 30 years); I agree that the ONC or CMS will not decertify an EHR vendor that has over 50% of all American patients and providers; and I agree that there are some medical providers who intentionally refuse to share patient information (because they think it gives them a competitive advantage over their local rivals).
One disagreement: But I disagree strongly with Dr. Yarhagi’s faith in the market to ensure that healthcare information technology (HIT) vendors will be obliged to “develop sustainable revenue stream through reasonable exchange fees negotiated with the medical providers.” That is, he asserts that if there were a real market without federal subsidies and requirements that all healthcare providers buy the HIT, then providers and the HIT vendors would agree on reasonable fees for exchanging patient records. Continue reading “Why the Market Can’t Solve the EHR Interoperability Problem”
Filed Under: Tech, THCB
Tagged: American National Standards Intstitute, Congress, Interoperability, Vendors, Yarhagi
Apr 9, 2015
Late last week, House Republican leaders declared their intention to bring H.R. 4015, the bipartisan, bicameral SGR repeal measure, to the floor for a vote.
Good news, you’d think, for doctors and the broader healthcare system, that we might finally be rid of the SGR’s broken machinations and perverse cycle of congressional intervention.
But House leaders added a footnote: the measure would be paid for by delaying the individual mandate, which CBO opined last week would save money through reduced enrollment in Exchanges and Medicaid. To cover the approximate $150 billion cost of the SGR measure, the mandate would probably need to be delayed by at least 10 years.
While sparing us a rehash of the individual mandate debate here, suffice it to say that the Obama Administration, the authors of the Affordable Care Act, and most healthcare insurers and providers consider it to be a linchpin of the health reform regime.
Without it, most agree, the consumer protections established by the ACA would precipitate spiraling premiums that would quickly destroy the market.
In other words, the House measure is DOA in the Democrat-controlled Senate and White House, which House leaders know all too well. In a move whose political deftness is hard to quibble with, they are coupling two very popular measures into a single package that they know the vast majority of Democrats can’t support.
Good politics? Probably. Good for enactment of SGR repeal? More like the opposite.
But don’t blame House leaders for the demise of SGR repeal. This move is a symptom, not a cause, of its end. As previously reported, the well-intentioned negotiators were having difficulty finding common ground on the so-called extenders package that would be included, and were miles apart on the offsets that would be used to fund it.
This train had already come off the tracks.
Continue reading “The Death of SGR Reform”
Filed Under: Physicians, THCB
Tagged: Billy Wynne, Congress, Obama administration, sustainable growth rate (SGR)
Mar 9, 2014
Congress just had an uncharacteristically big week – with significant implications for healthcare policy. It flew by fast and furious, so here we pause to unpack the most significant developments and what they teach us about the future.
1. The Permanent Doc Fix Effort is Real. You have to hand it to the committees of jurisdiction, they have kept their heads down and plugged away all year at permanently repealing the broken Sustainable Growth Rate (SGR) formula that dictates Medicare payments to doctors. They’ve floated new payment methodologies, added policy addressing the package of “extenders” that perennially travels with the “doc fix,” and now all three have successfully completed bipartisan mark-ups of their respective approaches. Furthermore, the three month SGR patch that was included in the budget deal is an implicit endorsement by congressional leadership that there’s actually a chance this could happen in the first quarter of next year.
The next step is to identify savings to pay the roughly $150 billion price tag, which has always of course been the biggest rub. That process is going to take center stage early next year in a “Super Committee-lite” process of negotiating various potential cuts to healthcare programs. The cynics are still betting against it, but we’re closer than we’ve ever been before to replacing the 15+ year-old SGR.
2. The Long-Term Care Hospital Sector Will Never be the Same. In a lesser-noticed component of the three month doc fix patch alluded to above, Congress eliminated the payment differential for LTCHs (pronounced el taks) and regular inpatient hospitals for patients who do not meet clinical complexity criteria. What began as an esoteric exemption for a small handful of hospitals in the early 1980′s and grew to a $6 billion Medicare benefit annually is now going to start to plateau.
The market liked the change, paradoxically, because it was gentler than some bean counters had recommended and gave plenty of time (four years) for sophisticated companies to adjust. But the hot LTCH business just got some pretty cold water poured on it.
3. The Budget Deal Helps Healthcare Programs. The Murray-Ryan agreement to set spending levels for the next two years alleviated some of the impact of the sequester on discretionary spending programs like those at the FDA, NIH and HRSA. This means that funding for new product approvals, clinical research, workforce development programs and some primary care services will be modestly improved in 2014 and 2015.
Continue reading “The Doc Fix Is Real”
Filed Under: Physicians
Tagged: Billy Wynne, Budget Deal 2013, Congress, Doc Fix, Long Term Care, Medicare
Dec 16, 2013
As we shake off the carb-coma and make our pre-resolutions, Congress and the Administration head into a sprint to the holiday recess fraught with health policy implications. Unlike every December in recent memory, there isn’t very much Congress actually has to do. Here are the top five things you need to know to follow the fun and prepare your organization for the changes afoot. A key theme to take home is that December 2013 is a month of anti-deadlines.
- The Nov. 30/Dec. 1 ”fix” to Healthcare.gov was set arbitrarily and has simply teed up another pivot point for opponents to pounce. We already know the wand hasn’t tapped the electro-synapses of the site yet to make the dang thing work like it should. Expect more incremental improvements through the month and enrollment numbers to come in above current rock-bottom expectations, with a healthy chunk coming from the proud, the few … the state-based exchanges.
- The Dec. 13 deadline for budget conferees to produce a joint resolution is similarly fictional and self-imposed. While there are some burgeoning reports that co-chairs Murray and Ryan might be able to agree to FY14 funding levels and potentially alleviate some of the sequester, the buzz-o-sphere in Washington still has deep doubts. Even if the two negotiators come to agreement, House and Senate leadership have the bigger challenge of getting a bipartisan deal through their chambers.
- Jan. 15 is the real deadline for a budget agreement and the real goal is writing a check to fund the government through Sept. 30. A budget resolution is helpful to give appropriators time to write actual spending policy, but it can be bypassed if the end-game is a continuing resolution that keeps current funding allocations in place. (Congress hasn’t passed an actual budget resolution since Democrats controlled both chambers.) At the end of the day, we’ll be back to the all-too-familiar roundtable of congressional leaders and Obama reps hatching a last-minute deal to avert a shutdown.
Continue reading “The Month of Anti-Deadlines”
Filed Under: THCB
Tagged: Billy Wynne, Congress, December 2013, federal budget deficit, Medicare, Obamacare Fix, physician payment reform, sustainable growth rate (SGR), The ACA
Nov 30, 2013
A minority of the Members of Congress are threatening to cause the United States government to default on its debts, unless the majority members agree to repeal or defund the Affordable Care Act, which Congress passed just a few years ago. There will presumably be some sort of negotiated solution. I worry that the negotiation range is being defined in a skewed way, between one pole and a moderate status quo, which is already the result of a prior negotiation. Seems like we have a one-way ratchet here.
My thought: perhaps the negotiations should go both ways, so that the end-result is more balanced. What if the Democrats made symmetric threats to cause default, unless:
- Medicare is expanded to cover all the poor who do not qualify for Medicaid (filling the gap the Supreme Court created in its “coercion” opinion),
- The Federal government creates a public health insurance option, to compete along with the corporate insurers (which was killed in final negotiations to pass the ACA),
- The Federal government gets explicit authority to provide insurance subsidies in the health insurance exchanges it sets up for states that have refused, oh and, as a kicker,
- Ronald Reagan International Airport (DCA) is re-named Jimmy Carter International Airport.
Ok, that last one is silly, but it might make for a fun bargaining chip, since it symbolizes the strategic game that is now being played, as we re-legislate settled questions. Positional bargaining is not pretty or enlightened, but if these chips can be traded, we might end up in the fallback position of keeping the Affordable Care Act as the negotiated compromise that it already is. Of course, the ACA is also the default rule, which has a nice double meaning in this context.
Christopher Robertson, JD, PhD is a visiting professor at Harvard Law School, an associate professor at the James E. Rogers College of Law, University of Arizona, and a research associate with the Edmond J. Safra Center for Ethics at Harvard Law School. He blogs at the Petrie-Flom Center’s Bill of Health, where this post originally appeared.
Filed Under: Uncategorized
Tagged: Christopher Robertson, Congress, GOP Repeal, The ACA
Sep 24, 2013
Congress is in recess, but you’d hardly know it. This has been the most do-nothing, gridlocked Congress in decades. But the recess at least offers a pause in the ongoing partisan fighting that’s sure to resume in a few weeks.
It also offers an opportunity to step back and ask ourselves what’s really at stake.
A society — any society —- is defined as a set of mutual benefits and duties embodied most visibly in public institutions: public schools, public libraries, public transportation, public hospitals, public parks, public museums, public recreation, public universities, and so on.
Public institutions are supported by all taxpayers, and are available to all. If the tax system is progressive, those who are better off (and who, presumably, have benefitted from many of these same public institutions) help pay for everyone else.
“Privatize” means “Pay for it yourself.” The practical consequence of this in an economy whose wealth and income are now more concentrated than at any time in the past 90 years is to make high-quality public goods available to fewer and fewer.
In fact, much of what’s called “public” is increasingly a private good paid for by users — ever-higher tolls on public highways and public bridges, higher tuitions at so-called public universities, higher admission fees at public parks and public museums.
Much of the rest of what’s considered “public” has become so shoddy that those who can afford to do so find private alternatives. As public schools deteriorate, the upper-middle class and wealthy send their kids to private ones. As public pools and playgrounds decay, the better-off buy memberships in private tennis and swimming clubs. As public hospitals decline, the well-off pay premium rates for private care.
Continue reading “The Return of the Greater Common Good”
Filed Under: OP-ED, THCB
Tagged: Congress, Economics, Privitization, public institutions, Robert Reich
Aug 27, 2013
Us and Them
And after all we’re only ordinary men
The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face. ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry. ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”
My wife grabbed my arm, restraining me from throwing the nearest object at the television. I cursed under my breath.
No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society. I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.
It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving. If only we could get rid of the bad people, we could make everything work. If only those people weren’t oppressing us. If only those people weren’t so lazy. It’s the radical religious people who are the problem. It’s the liberal atheists. It’s the corporations. It’s the government. All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.
Continue reading “Us and Them-Ism”
Filed Under: OP-ED, THCB
Tagged: 2012 Election, Congress, ideology, MD, Mitt Romney, Obamacare, Politics, President Obama, problem solving, Rob Lamberts, The ACA, us and them
Aug 5, 2012
The ink was barely dry on the PPACA when the first of many lawsuits to block the mandated health insurance provisions of the law was filed in a Florida District Court.
The pleadings, in part, read:
The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty, that all citizens and legal residents have qualifying health care coverage.
State of Florida, et al. vs. HHS
It turns out, the Founding Fathers would beg to disagree.
In July of 1798, Congress passed – and President John Adams signed - “An Act for the Relief of Sick and Disabled Seamen.” The law authorized the creation of a government operated marine hospital service and mandated that privately employed sailors be required to purchase health care insurance.
Keep in mind that the 5th Congress did not really need to struggle over the intentions of the drafters of the Constitutions in creating this Act as many of its members were the drafters of the Constitution.
And when the Bill came to the desk of President John Adams for signature, I think it’s safe to assume that the man in that chair had a pretty good grasp on what the framers had in mind.
Here’s how it happened.
Continue reading “Congress Passes Socialized Medicine and Mandates Health Insurance – In 1798″
Filed Under: THCB
Tagged: Congress, Health insurance, Individual mandate, The ACA, The Marine Hospital Service
Dec 10, 2011
Q: What’s going on with the farm bill? Any chance for improving it?
A: I wish your question had an easier answer. The farm bill has to be American special-interest politics at its worst.
As Stacy Finz has been reporting in the main news and Business sections of The Chronicle, the failure of the recent super-deficit reduction plan also brought an end to a secret committee process for writing a new farm bill. Now Congress must follow its usual legislative procedures. The farm bill is again open for debate.
Advocacy is much in order. The farm bill is so enormous, covers so many programs, costs so much money and is so deeply irrational that no one brain – certainly not mine – can make sense of the whole thing.
It is all trees, no forest. The current bill, passed in 2008, is 663 pages of mind-numbing details about programs – hundreds of them – each with its own constituency and lobbyists.
The farm bill was designed originally to protect farmers against weather and other risks. But it grew piecemeal to include programs dealing with matters such as conservation, forestry, biofuels, organic production and international food aid.
Continue reading “Farm Bill Needs a Major Overhaul”
Filed Under: OP-ED, THCB
Tagged: Congress, deficit reduction plan, farm bill, Obesity, Supplemental Nutrition Assistance Program
Dec 5, 2011
You can’t believe the play that little athenahealth gets in Washington, DC… and thank goodness for it because no one has a clue about HIT.
How could they really?
I mean, there are 535 people in our federal legislature (give or take) and there are like a million different market spaces in the nation. This is why I have such a hard time with federal control of things. It’s impossible for them to know what’s going on…there are just not enough hours in the year.
As I’ve been thinking about care coordination and the complete lack of sustainable models or entrepreneurship in that space, it occurred to me that it’s currently not clear that it is legal for RECEIVERS of electronic health information to pay senders for the value of that health information. This means that the sender has no real motivation to send useful, relevant data in a timely manner (I know I’d pay the doc who sent me exactly what I needed about a patient more than I’d pay the doc who sends over a 30-page PDF) and that our industry will take a long time to understand the true health information exchange needs of providers.
I wanted to bring the concept with me to the Hill that Meaningful Use, in my opinion, is use that is meaningful to a medical care provider in the actual doing of business. In a space with such clear demand, we’ve got to let innovators develop a way to supply information that the market (providers of care) needs, if we want to improve outcomes and reduce costs.
So I flew down to Washington and it was tons of fun… me and Lauren Fifield and the lobbyist and a full dance card on Capitol Hill.
First, we met with Sally Canfield, policy director for Sen. Marco Rubio, R-Fla.
She’s a true health policy veteran who likes getting—and will give you—the straight story. She’s also one of the only people on the Hill with whom I could speak at my normal (lightning) pace and know she can keep up. We talked about everything from the potential fall of hospitals (Need a hospital? Just scan the horizon for a construction crane)…to the alarming rate of physician employment…to making Meaningful Use really meaningful…to encouraging care coordination…to life in the cloud.
Continue reading “Mr. Bush Goes to Washington”
Filed Under: OP-ED, THCB
Tagged: athenahealth, Care coordination, Congress, HIT, Meaningful Use
Nov 18, 2011