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The Stimulus Pregame

"Drug Makers Fight Stimulus Provision"
Capital

"Lobbying War Ensues Over Digital Data"

The first was a recent and the second headline comes from the Washington Post. Both refer to what were supposed to be two already agreed on health
care reform ideas–comparative research about which treatments work
best and the creation of a nationwide system of medical records.

The lesson here is that in health care nothing is easy, simple, or widely agreed to.

The stimulus bill will include about $20 billion for computerized medical records. The problem is privacy.
Business interests want more ability to use health care data to market
their products and identify people who can be treated more effectively data mining
for example. Privacy interests want tighter control of that data. Can a
doctor or a hospital make money selling people's medical data? Could
data ultimately be used to discriminate against people? Can drug
companies pay doctors to send a letter to certain patients touting
medications? Where does a system of information that could be used to
alert patients to new treatments and used to track trends in health
care effectiveness become at cross purposes with privacy?

This is not a new debate–a health information technology bill has been bottled up in the Congress for years over these kinds of issues.

Comparative research–which drugs or medical devices work the best–makes a lot of sense. That is especially true in the wake of decades of research that continues to point to wide overuse of technology as the primary cost driver in our health care system.

So
you would think this one was a no-brainer. But wait. In the WSJ story,
"The drug industry is mobilizing to gut a provision in the stimulus
bill that would spend $1 billion on research comparing medical
treatments, portraying it as the first step to government rationing."
And you know, these guys never lose.

The rub for the drug and device industry
is that this kind of research could actually be able to call balls and
strikes–which treatments don't work well and therefore should have
their use subordinated to those that work better. Already, in the
Senate version the industry has been successful in getting language
that added the word "clinical" which has the effect of having any
studies avoid "bang for the buck" kinds of conclusions.

One
billion dollars for comparative research but we aren't allowed to know
which drug or device gives us the best return for our money?

And, these were supposed to be the easy parts of health care reform. I am again reminded of all the reports in recent months about how different the 2009 version of health care reform will be with the special interests really ready to cooperate.

Let
me say it again, there is no consensus about just what any meaningful,
or probably meaningless, health care reform bill will look like.

Can't wait for the main feature.

Robert Laszweski has been a fixture in Washington health policy circles for the better part of three decades. He currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia. Before forming HPSA in 1992, Robert served as the COO, Group Markets, for the Liberty Mutual Insurance Company. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog.

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18 replies »

  1. I was trying to post a comment on your herniated disk post but was unable to. I agree that often times surgical intervention depends on the doctor and the patients pain tolerance. I have been successful in helping people avoid surgery with the DRX9000.
    However, it too is not a ‘silver bullet’ and ultimately some patients do require surgery.
    Dr. S

  2. Robert,
    I sat in during a panel on “Wall Street, the new Administration and the Healthcare Economy”. It was a very well organized event with some heavyweight representation from leaders in the Healthcare field across Finance, clinical and policy organizations. I do not want to disclose who said what and will leave that to the WSJ reporters that hosted the conference but one thing stood out for me: “Consumerism in Healthcare” was missing in the initial panel discussions.
    These thought leaders disagreed (very politely) on a number of issues such as government-control vs. free market forces, but one thing they did agree on is the fact that it will be an uphill battle for the Obama administration and any healthcare reform, especially with Tom Daschle gone from that post.
    Next logical question arises: “So will patients continue waiting on the government to solve all the issues or will they take it in their own hands?” I rephrased my question to the panel: “Given your agreement on the difficult task ahead, what do you think the state of consumerism is in healthcare?”. I was told that it is an oxymoron and only 8% of the population is capable of making a decision about their health. Consumerism in healthcare is on the bottom of the S-curve. I actually took that as a positive sign – we – the innovators in the Health 2.0 field will wait till “the influencers”, the “thought leaders” as described in Barabasi’s book are ready to “influence a very large number of people” (p.130, Barabasi). That ride up the S-curve, in my mind, will be quick and I strongly believe that community platforms that enable the patients to share information and learn from each other will turn the 8% into a much greater number!!

  3. CJ—read (obviously) your posting. Wow. Will plan to explore your comments further. Have you ever read Ken Silverstein’s “Turkmeniscam”? Your comment represents a generic microcosm of realpolitik…

  4. On December 6, 2008, President-elect Obama mentioned in a weekly address that a key part of his Economic Recovery Plan would: “ensure that our hospitals are connected to each other through the internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year”.
    Recent reports indicate Obama is considering a 50 billion dollar infusion of tax monies to implement these Health Information Technology initiatives which would include the ubiquitous electronic medical records mentioned. If one wishes to gain a brief overview of this subject, I highly recommend the Congressional Budget Office’s 46 page, relatively easy reading primer entitled “Evidence on the Costs and Benefits of Health Information Technology”.
    What I fail to understand is why already established software and frameworks are not being considered as templates for the future needs of our broken health care system. I am referring to the VA and DoD computerized systems that do rather effectively integrate the essential needs of each organization. As with any IT program, both respective vistA and AHLTA systems do have their detractors from a clinical and administrator perspective. Yet, speaking as an Army Reservist clinician who has used the various forms over the last decade, I can speak quite candidly that my experience with the DoD programs of CHCS and AHLTA allowed me to see the future of civilian healthcare. Access to a patient’s entire medical record from across the globe to having an up to date medication listing to being able to correspond with and immediately refer to consultants for any given problem seems, to my simplistic world view, that the nature and evolution of a similar civilian-based application should be quite easy to adapt from applications already in use. Essentially, why invent the wheel? Why not “tweak” an established product and save potentially billions of dollars?
    I found it interesting given my train of thought that on January 15, 2009, Peter Neupert of Microsoft Corporation’s Health Solutions Group testified before the Senate Committee on Health, Education, Labor, and Pensions Hearing on “Investing in Health IT: A Stimulus for a Healthier America”. I read his testimony and he and I do agree that proper applications of IT offer great benefits for the future of US health care in general.
    A very good friend of mine at the Foreign Military Studies Office, Ft Leavenworth once admonished me that the key to analyzing another country’s domestic and foreign agenda and subsequent policy is to “follow the money”. As a clinician not in uniform and a prospective US Senate candidate in 2010, I have to wonder whether our taxpayer monies will truly be spent effectively and in good stewardship in this particular agenda of health care. It seems that billions of dollars are up for grabs in this case. I suspect that Microsoft’s representation at the aforementioned Senate hearing is more than just an altruistic affirmation that our health system is in trouble. Corporate interests for some reason tend not to be in sync with either patient or provider interests and I can share 20 years of experience acknowledging that reality

  5. Robert Laszweski says- “The lesson here (referring to the lobbying battles preciptated by the medical provisions in the Obama economic stimulus plan) is that in health care nothing is easy, simple, or widely agreed to”
    Au contraire-I would argue there is very wide consensus that the US health care system is terribly broken to the point of crisis?
    I would also posit that there is at least public consensus that Big PhRMA- a true miracle industry gone sour- has duped and swindled us at best-harmed us at worst.
    Can we all agree?
    Dr. Rick Lippin
    Southampton,Pa

  6. CJ,
    That was as comprehensive a BURNING of a group as I have read in 15 years in Healthcare IT!
    My lap top is still smoking! Nice!
    T

  7. Why not pack CCHIT EHR certifications in Cracker Jack Boxes? If folks think CCHIT is a real organization and the certification is anything more then a stamp of approval from the HIMSS Circus they need to think again after looking at the facts.
    Some facts are known about the Certification Commission for Health Information Technology.
    The Certification Commission for Health Information Technology (CCHIT) is a defunct Illinois Not-For-Profit 501(c) 3, which operates to take money from the Office of the National Coordinator and Vendors by offering to sell a “Certification”.
    DID I say DEFUNCT? Yes I said DEFUNCT…please read on.
    The Not-For-Profit 501(c) 3, Certification Commission for Health Information Technology (CCHIT), operates a “Front” office located at 200 S. Wacker Drive, Chicago, Illinois.
    CCHIT, as it is known, represents itself as a government recognized organization for certifying electronic health records. CCHIT has received monies from the United States Government (estimated over $2.5 million to date) and monies from vendors of electronic health records.
    CCHIT was formed as a NFP in the State of Illinois and is an entity spawned by none other , HIMSS.org. CCHIT is no longer a legal entity existing within the State of Illinois effective April 11, 2008, but continues to engage business as a 501(c) 3 accepting payments as reported by J. Morrisey, Director of CCHIT Communications (February 3, 2009).
    CCHIT continues to hold itself out to take money for the sale of “Certification” (a rubber stamp device the buyer can display on his product if the fee is paid), a contrived performance standards product label developed by its parent organization, Healthcare Information and Management Systems Society (HIMSS), a lobbyist, with headquarters at 230 E. Ohio St., Chicago, Illinois. CCHIT was also located within the HIMSS Headquarters at 230 E. Ohio Street in Chicago but moved to Wacker Drive apparently due to appearances of being too close to the lobbyist parent organization.
    CCHIT, through the organization that spawned them—HIMSS.org, a lobbyist organization—recently asked for $25 Billion additional funds in an open letter to the Obama administration (http://www.himss.org/advocacy/). HIMSS, through its agent H. Stephen Lieber, provided CCHT with $300,000 seed money in 2006 with which to fund a startup operation. HIMSS receives money from CCHIT as a subcontractor, as the payoff for seeding the startup. HIMSS provides public commentary through the use of its own members for certification criteria back to CCHIT. HIMSS is also the parent company for the Electronics Health Record Vendor Association (EHRVA), another Not-For-Profit housed at 230 E. Ohio St., Chicago, Illinois.
    The Facts:
    1. The Chairman of CCHIT is Mark Leavitt, MD, PhD. Mark Leavitt is also Chief Medical Officer with HIMSS.org. It is believed Mark Leavitt may be a relative of Mike Leavitt, former HHS Secretary.
    2. CCHIT takes federal money, and money from vendors, in exchange for the sale of “certification”. CCHIT does not have a legitimate physical address where it conducts its testing. CCHIT has a “front” office at 200 S. Wacker Drive, Chicago, Illinois, with previous headquarters at 230 E. Ohio St., Chicago, Illinois. CCHIT is, in fact, now defunct.
    3. CCHIT has no legitimate registration certificate of good standing with the State of Illinois, the state in which it is purportedly chartered as a 501(c) 3. It is, in fact, listed as “involuntarily dissolved” effective April 11, 2008, file# 65254336. Illinois State listing here: http://www.ilsos.gov/corporatellc/
    4. CCHIT does not provide independent inspections of its facility or 3rd party reviews of its findings. “Certification” status of vendor products granted by CCHIT after the Illinois State’s involuntary dissolution date of April 11, 2008 appears to be without merit or bogus, and CCHIT operates deceptively to convey legitimacy.
    5. CCHIT operates fraudulently within the State of Illinois and in the United States to take money from vendors of electronic health record systems and from taxpayers; the CCHIT business practice presents as a Pay-For-Play scheme; if the vendor pays, CCHIT certifies the product conveying a competitive advantage in the marketplace. There is no transparent certification testing for 3rd party review. The costs to certify are in the many tens of thousands per vendor. Officers and Directors of CCHIT have taken money in exchange for “Certification“, knowing its 501(c) 3 operational status to be defunct.
    6. CCHIT, a dissolved entity and defunct 501(c) 3 Not-For-Profit, receives funding from the Office of the National Coordinator (ONCHIT) and is tied to a lobbyist organization that claims to be a Not-For-Profit, HIMSS.org—the organization that spawned CCHIT and which formerly housed the entity in its corporate headquarters located at 230 E. Ohio St., Chicago, Illinois.
    Why does CCHIT continue to certify vendor products when its own corporation has been involuntarily dissolved? Does the word “MONEY” ring a bell?
    CCHIT continues to hold itself out as certifying entity when it can’t even certify to the state of its incorporation that it does in fact exist.
    Closing thoughts:
    The certification process and testing should be reviewed carefully, and those vendor companies whose products were certified after CCHIT’s involuntary dissolution should be contacted. Money should be returned to the vendors and the taxpayers- CCHIT is a bogus operation.
    CCHIT should NOT be allowed to receive future Federal grants and monies from the United States Government as part of the stimulus package. CCHIT is defunct , moreover the cozy relationships between CCHIT, ONC, CMS, HITSP and others are bankrolled with taxpayer money and money from HIMSS.org and its others.
    Through all the smoke and mirrors we the people are supposed to trust these Bozo’s and they actually think we are buying it?
    There is no point in CCHIT holding itself out as a legitimate entity at HIMSS Annual Conference either, CCHIT is a defunct organization and has been since the beginning of 2008…DUH!
    CCHIT has flown under the radar for a year and a half, the jig is up and the whistle has been blown.
    CJ

  8. “The lesson here is that in health care nothing is easy, simple, or widely agreed to.”
    The corollary is that *even* if something is widely agreed to, there are vested interests with enough clout to scuttle a good idea, or at least mutate the concept.
    I’m not saying there aren’t philosophical opponents to evidence based medicine or comparative research, but if polled, I imagine it would hit 75% or higher. Despite this, PhRMA, medical device makers and others will have something to say about whether we get there.

  9. Conservatives have been misinforming the public about the health IT provisions of the stimulus package by falsely claiming that it would lead to the government telling the doctors what they can and cannot treat, and on whom they can and cannot treat. The Hudson Institute fellow, Betsy McCaughey, claimed that the legislation will have the government monitor treatments in order to guide your doctor’s decisions.
    The new language in the bill tasks the (already existing) National Coordinator of Health Information Technology (NCHIT) with providing appropriate information so that doctors can make better informed decisions. The NCHIT provides counsel to the Secretary of HHS and Departmental leadership for the development and nationwide implementation of health information technology.
    Contrary to Ms. McCaughey’s statements, the language in the House bill does not establish authority to monitor treatments or restrict what your doctor is doing with regard to patient care. It addresses establishing an electronic records system so that doctors can have complete, accurate information about their patients.
    The funding for health information technology in the recovery package is projected to create over 200,000 jobs and a down-payment on broader health care reform. Converting an antiquated paper system to a computer system by making the health care system more efficient.
    The Congressional Budget Office has estimated that one-third of $2 trillion spent annually on health care in America may be unnecessary due to inefficiencies in the old system such as exessive paperwork. Investing in infrastructure like health IT would help improve the quality of America’s health care.
    Currently, fewer than 25% of hospitals and fewer than 20% of doctor’s offices employ health information technology systems. Researchers have found that implementing health IT would result in a mean annual savings of $40 billion over a 15-year period by improving health outcomes through care management, increasing efficiency and reducing medical errors.
    Investing in health IT would also help primary care physicians who often bear the brunt of tech implementation without seeing immediate benefits, affording the infrastructure for expanison. Some PCPs are ahead of the IT curve but cannot afford the richness of its expansion. They need this important infrastructure.

  10. It seems to me that all this talk about change maybe creating the type of change we dont need in health care! Isn’t interesting how the legislators who have quite the deal when in comes to their own health insurance aren’t so interested in “spreading the wealth” when they are writing laws.
    Congress seems to forget that they too have families who are aging. That one day the treatment option they want for their loved one isn’t an option as it does not fall into findings of the comparative research.
    I attended one of the administrations health care reform forums. It’s attempt I guess to get that grass roots information. Many at the forum (mostly health profressionals) I attended seemed to agree that we needed to reform healthcare. At the end of the night, exactly what to reform was still a question. So maybe we do need to go back to the patients, doctors, nurses and other allied health professions and see if we can’t determine what it is that needs to be reformed. Our conculsion might be, that it is our government that needs to be reformed.

  11. Once again, Bob, a beautiful job of capturing the essence of Obama’s reform strategies, which leads inexorably to these lamentable limericks.
    Using data to create cost-tight federal controls,
    Based on comparisons and EMRs are reasonable goals.
    But I would remind our policy gurus,
    And those who share similar views,
    Those who stand to be hurt will find exploitable holes.
    In the health care world of perplexing complexities,
    Wonks know not of endless concavities and convexities.
    Health care will never be a data- or leak-proof machine,
    That can be reduced to some overall routine.
    Dominated and dictated by absolute objectivities.
    So, if you really want workable reform,
    Why not create a performable perfect storm?
    Why not listen to patients and doctors on the ground?
    Where real reform is to be found.
    Rather than to those at the top, where unreality is the norm.

  12. Yet again, we are experiencing another era of missed opportunity for meaningful health care reform. Meaningful reform is not possible without a trusted information systems with an ability to improve the lives of patients and the clinicians deserving of their trust. Congress is punting the tough decisions regarding privacy to HHS. If past performance is any measure of the future, HHS (via the ONCHIT) will enact rules that (to them) appear to be the most budget-friendly. I will leave it to others if they think HHS will consider the level of acceptance by patients and their doctors. The end result will be that they will “compromise” in a fashion that privacy will not be adequate, and the hassle factor will be enormous. This will greatly impair sharing of health information just as has been experienced in the U.K.
    Not only the flawed approach to privacy protections, but the predominant industry-proposed road maps to interoperability are so fundamentally flawed that lack of true interoperability is likely to thwart meaningful reform.
    How much evidence is necessary to prove the proposed approaches to both privacy and interoperability are unacceptable to a majority? Is there any irony that the policy wonks so prone to advocating evidenced-based medicine seem all but unwilling to take an evidence-based approach to health care reform?
    It will be interesting to see how much more evidence and pain it takes before our nation realizes the centralized, top-down decision-making and attempts to control patients, physicians and the doctor-patient relationship simply can’t succeed.
    Until the grassroots are included and more involved in the decision-making, it is ludicrous to expect meaningful reforms.
    All is not lost. At least we can expect the music to play a little louder and faster at the next Dysfunctional Health Care Reform Dance.

  13. Dear Bob: Good post. Lots to consider. It seems to me that information about treatment effectiveness goes hand and hand with a determination by payers to change payment to reward efficiency and penalize wasteful or ineffective providers. Information by itself may not be enough, but paired with payment reform, calling the “balls and strikes” as you say takes on economic heft. Kind regards, DCK

  14. First of all $20 billion for EMR is way to high. It should not be more than a billion. It speaks for the lack of efficiency/competency or lack of confidence.
    Using the data for public health purposes is good. I am already tired of telemarketers and spammers..I am not sure if I would not new sets of telemarketers calling me to sell few new ideas.
    Hey, I know you have terminal cancer and would live only 3 months – how about this great offer on coffin! That would be the height of telemarketing and I see that happening with information being made available.
    rgds
    ravi
    http://www.biproinc.com/healthcare_services.html

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