HHS Secretary Kathleen Sebelius (who sat in front of me at a meeting last month–my brush with fame) is in the HuffPo writing about the benefits of the (coming) health insurance exchanges. I’m deeply disappointed that we ended up with state-based exchanges rather than the national exchange that was in the House version of the ACA, but I’ll spare you my diatribe on what States and the Senate are good for….Instead let’s focus on what the exchanges will need to do. Deliver accurate information about insurance choices to their users. That means real apples to apples comparisons of benefits, networks, out of pocket costs, etc, etc. This is all still buried on most private markets (e.g. HealthInsurance still doesn’t clearly explain max out of pocket costs–the most important number for most policies). The good news is that there won’t be any distinction between the polices sold to different business sizes and to sick and healthy people. The bad news is that when people see how little their subsidy will buy them, and that most plans will have high deductibles, the good news may get lost. But the exchanges are important advances–even if in some states they may get subverted.
The Prevention Paradox
In the last month, the Obama administration announced programs to reduce racial disparities and increase prevention in health care. Neither program was funded with actual money, so they are about political showmanship as much as any real desire to tackle the worthy causes. After all, who would oppose such programs? I half-expect the administration to follow-up these announcements with one focusing on moms and apple pie.
But have a closer look at what Iowa Democrat Tom Harkin said at the press conference introducing the latter initiative. “For every dollar we invest in prevention, we save $6. We need to provide an approach that makes it easier to be healthy and harder to be unhealthy.”
I haven’t found the report on which Harkin bases his assertion about the returns on health prevention efforts, but my sense is its more complicated than Harkin would have us believe. Some screening and prevention programs are not effective at all. Others are effective, but prohibitively expensive. Any national program to improve prevention needs to evaluate each potential component to assure it reflects Harkin’s focus on cost-effectiveness.
HIT Trends Summary for June 2011
This is a summary of the HIT Trends report for June 2011. You can get the current issue or subscribe here.
EMRs in the cloud. There is additional validation this month by MarketsandMarkets that the EMR market has heated with compound annual growth rates over the next couple of years pegged at nearly 20%. Analysts report that EMRs delivered over the Internet are a fast growing segment appealing to small practices. One new example is the Allscripts’ MyWay EMR is being offered by Costco in a hosted version for as low at $499 per physician per month. This could be an emerging market price now-a-days for a low-end hosted or web-based solution. This leaves some room for disrupters underneath to position at a lower price or premium pricing with differentiating services. We saw a similar idea pursued by Sam’s Club and Dell last year without much success.
The AMA also clarified one of its ideas for this Internet EMR market by marrying e-prescribing and registry functions to meet stage 1 meaningful use. DrFirst is the e-prescribing app. DocSite and WellCentive are participating registry-oriented EMRs. It is a welcome new alternative that should get significant market attention.
EMRs and care coordination. Care plans have become the foundation for care coordination. This is one of the lessons learned from a report by eHI. Yet it finds that additional EMR functional support is needed. Oncology patients report they want to collaborate with their physicians. The report tracks two detailed case studies at Taconic IPA and Community Health Center in CT. The EMRs are useful but insufficient to support care coordination. Workarounds are available through increased staffing.
Stepping in Where Google Health Left Off
A little over a week ago Google stated that it was putting a stake through the heart of their personal health platform (PHP) Google Health. We at Chilmark had been expecting this for some time, it was just a manner of when it would become official. Thus, we were somewhat taken aback by all the publicity surrounding this final chapter with our own post on the topic receiving well over 40 comments and link-backs (that may be a record – thanks everyone for contributing to the story). With the closing of Google Health, we postulated in that post that Microsoft really had no other worthy competitor that will challenge them to continuously make enhancements to HealthVault. We may have spoken prematurely.
Stepping in to take the place of Google, is none other than an ol’school EHR company (and one of the largest), Cerner, who provided their own commentaryon the demise of Google Health and their future intentions. Last week we had the opportunity to talk with the Cerner Health and learn more about those intentions but before getting to that, some quick background.
Taking a different tack:
Cerner has been in the HIT business now for 31+ years having grown to one of the leading EHR vendors in the market. You’ll usually find their systems (EHR: Millenium) in large healthcare organizations. This sector of the EHR market is seeing fierce competition as Epic seems to pick up one win after another at the expense of others, including Cerner. While continuing to go head-to-head with Epic, it appears that Cerner has also chosen to take a different tack, adopting a philosophy of: if you can’t beat them straight up, change the rules of the game.
The Awful Dichotomy Between Health Care Politics and Policy
Amy Goldstein has an important article in today’s Washington Post detailing the place Don Berwick, the Medicare and Medicaid administrator finds himself in.
It is all but certain he will have to leave his post at year’s end, when his recess appointment expires, because the Senate will not confirm him for a lack of Republican support.
Berwick is one of the most respected health care experts in the country—his career has been dedicated to improving quality first and with that the cost of care. With the new law giving his agency more opportunities to experiment with new approaches and the ability to more quickly implement the things that work, he was the ideal choice.
But with the Democrats ramming the law through without a political consensus to support it, Berwick also became the political whipping boy for opponents to pile on. That he has been willing to point to the things that work in places like Britain only gave the political opportunists plenty of red meat to throw into an already red hot ideological debate.
Process Centered Medical Home
A new study on Patient Centered Medical Homes has been published in Health Affairs and we have a new, but predictable, indictment against small independent primary care practice. The study authored by Rittenhouse, Casalino, Shortell et all, is descriptively titled“Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes”, and follows an earlier 2008 studythat surveyed large medical groups. The study is surveying practices with 1 to 19 physicians, and in a nutshell, small practices, particularly those owned by physicians, are less likely to have medical home processes incorporated in their workflows. On average, the bigger the practice, the more likely it is that medical home processes are used, and the likelihood increases if the practice is owned by a hospital or an HMO. Hardly surprising, but the enlightenment is, as usual, in the details.
The patient centered medical home model is based on the seven joint principles stated by the various primary care associations as follows: personal physician, whole person orientation, physician led care team, coordinated care, quality and safety focus, increased access and payment reform. Both studies quoted above were restricted to measurement of processes indicative of only four out of the seven principles. Personal physician for each patient and whole person orientation were left out, and so was the payment reform principle, although some measures of external incentives in support of medical home processes were considered.
The existence of physician led care teams was ascertained based on the existence of “a group of physicians and other staff who meet with each other regularly to discuss the care of a defined group of patients and who share responsibility for their care”. Not sure why, but solo and 2 doc practices were not even asked this particular question.
Myths About Medical Malpractice
A few days ago, I found myself involved in a debate over malpractice suits on The Heath Care Blog. One reader on the thread explained why, in his view, we need some type of tort reform: “What drives physicians to practice defensive medicine is the total lack of objectivity, fairness and consistency both across jurisdictions and even within a jurisdiction as to how medical disputes are decided. Juries of lay people who cannot understand the often conflicting scientific claims in these cases can be easily swayed by emotion and sympathy for injured plaintiffs.
“The inclination to practice defensively is especially prevalent in ER’s when the doctor and the patient often don’t know each other and there is time pressure to determine a diagnosis and send the patient on his or her way,” he added. “I’ve heard from plenty of doctors who work in inner city ER’s that even poor people are not shy about suing when there is a bad outcome if they can find a lawyer to take their case which they often can.”
This comment pretty well sums up the conventional wisdom about medical malpractice cases: Juries are not objective, don’t understand the evidence, and tend to sympathize with the patient. Meanwhile, doctors should be wary of those low-income patients in ERs. Americans are litigious by nature and if patients are not entirely happy with the outcome, they’ll jump at an opportunity to turn misfortune into a payday. Poor people, who need the money, are even more likely to try to “score.”
Those are the fictions.Continue reading…
Is Medicare A Good Deal?
Think about everything you will pay to support Medicare: the payroll taxes while you are working, the premiums during retirement, and your share of the income taxes that subsidize the system. Then compare that to the benefits of Medicare insurance, say, from age 65 until the day you die.
Are you likely to come out ahead? That depends in part on how old you are. If you are a typical 85-year-old, for example, you can expect about $55,000 of insurance benefits over and above everything you have been paying into the system. If you’re a typical 25-year-old, however, you will pay an extra $111,000 into the system, over and above any benefits you can expect to receive.
By the way, this is not the sort of calculations you want to try at home on a pocket calculator. It’s too complicated. Fortunately the heavy lifting has already been done by Andrew Rettenmaier and Courtney Collins in a report for the National Center for Policy Analysis and summarized in this chart.
In terms of dollars in and dollars out, Medicare breaks down this way:
- A typical 85-year-old is going to get back $2.69 in benefits for every dollar paid into the system in the form of premiums and taxes—a good deal by any measure.
- People turning 65 today don’t do nearly as well — they get back $1.25 for every dollar they pay in.
- The average worker under age 50 loses under the system — with a 45-year-old getting back only 95 cents on the dollar.
- That’s better than the deal 25-year-olds get, however; they can expect to get back 75 cents for every dollar they contribute.Continue reading…
Real Reform For Medicare Advantage
Medicare Advantage (MA) is stuck in a cycle in which the government wants to micromanage MA plans and cut their reimbursement to satisfy deficit hawks, while the health plan industry lobbies for exactly the opposite. The result is a negative-sum game, a stalemate that benefits nobody.
It turns out that this stalemate would be remarkably easy to overcome, in a way that makes money for the government, gives seniors a visibly better deal, reinvigorates the Medicare ACO, and entices many more members into MA. Since MA plans are held to quality standards far beyond what Medicare fee-for-service requires (remember, straight Medicare is a payment system, not an insurance plan), I am going to assert that the increasingly popular MA plan option – especially plans with high Star ratings – provides better care coordination for seniors than fee-for-service (FFS). The government recognizes this implicitly by initiating Medicare ACOs. ACOs are supposed to close that care coordination gap in FFS but it does not look like that is going to happen on a broad scale in the near future.
If one accepts the premise that more care coordination is a worthy goal, here’s a better way of addressing that care coordination gap by getting more seniors into MA, rather than by setting up a parallel universe of ACOs…and do it in a way that clearly saves money for the government and seniors.
Start with the recognition that most 64-year-olds are already in an HMO or PPO. Today’s sign-up procedure for Medicare acts as though neither innovation exists. A senior becomes eligible for Medicare and then (in competitive markets) gets deluged with offers to join one or another MA plan, which requires switching out of FFS — a model that, while called “traditional,” is totally unfamiliar to patients coming out of commercial HMOs. These enticements to seniors are quite costly for the health plans, involving brokers, salespeople, advertising etc.
How about a system in which MA becomes an opt-out instead of an opt-in for 65-year-olds, meaning people would automatically start receiving their Medicare benefit through a health plan instead of FFS? As you read what follows, assume that MA would still be totally voluntary and that people who want the old-fashioned FFS can simply opt into it.Continue reading…
Hidden Medication Costs
Always covered by an employer health plan, I had never given a thought to prescription costs – my medications had been covered by moderate copays. This changed when I retired and enrolled in Medicare (and a Medicare Part D plan).
Just prior to retirement, my eyes suddenly began tear and swell so much that it impacted my vision. The eye doctor diagnosed an allergic reaction and prescribed prednisone drops to reduce the swelling and antihistamine drops to combat the reaction. The antihistamine drops required pre-approval by my employer’s PBM, which was granted. Per my employer plan I paid a relatively small copay for each prescription.
Three weeks later, on a follow-up visit, the doctor recommended that I continue the antihistamine drops for the duration of the allergy season. But I was running out and had to refill the prescription. Now I was on Medicare so I checked the cost of the drops on the website of my Part D provider. It was $279. Could this be?? Oh indeed it could — and I had a high deductible and would have to pay all of it!! Of course, if I continued to need the drops, the plan would eventually assume more of the expense – but even then the cost would be high – to the plan, even though not as much would come from my own pocket.Continue reading…
