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The Promise of Electronic Healthcare Records

• 18

By JOHN HALAMKA, MD

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should frustrated that he was never confirmed.

In his parting interview with the press,  he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

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2011 EHR Adoption Rates

• 19

By MARGALIT GUR-ARIE

On Wednesday the Centers for Disease Control and Prevention (CDC) released the results of its yearly survey on Electronic Health Records (EHR) adoption for office-based physicians. No surprises. Generally speaking, the majority of physicians in ambulatory practice are now using an EHR, and over half of surveyed doctors say that they intend to seek Meaningful Use incentives. The report is also presenting results broken down by state, so you can learn what folks are doing in your immediate vicinity. The more instructive exercise is to compare last year’s survey results [Fig. 1] to this year’s estimated EHR adoption numbers [Fig. 2].

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MedPAC’s SGR Solution: Bad Medicine For A Chronic Problem

• 16

By JEFF GOLDSMITH

The Medicare Payment Advisory Commission (MedPAC) is the closest thing Congress has to adult supervision on important health policy questions. The Commission commands bipartisan respect both for its record of sound policy advice and for its leadership.

With its October recommendations, MedPac attempted to solve the sustainable growth rate (SGR) physician payment formula budget crisis by spreading its more than $300 billion cost beyond the physician community.  More than two-thirds of the burden would fall on hospitals, pharmaceutical and device manufacturers and, significantly, on Medicare beneficiaries themselves. Clearly MedPac’s intent was to widen the circle of pain.

However, a significant portion of the burden, over $100 billion, would still be borne by the physician community through 17 percent reductions in specialists’ fees and a ten-year freeze on primary care fees.    If implemented, MedPac’s policies will give rise to a festival of unintended consequences: weakening multi-specialty group practices (which rely upon specialist comp to cross-subsidize their primary care services); winding down private practice-based primary care medicine; accelerating the hospital roll-up of medical practices while widening hospitals’ losses on the practices they already own; and triggering a further wave of ill-timed cost shifting to private insurers.

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Appellate Court Upholds ACA In Opinion By Prominent Conservative Judge

• 8

By TIMOTHY JOST

Yesterday, November 8, the United States Court of Appeals for the District of Columbia became the second federal court of appeals to uphold the constitutionality of the minimum coverage requirement of the Affordable Care Act.

To date, one federal appellate court has held the minimum coverage  requirement to be unconstitutional (although severable from the remainder of the ACA), while five other appellate court decisions have held that the courts lacked jurisdiction to consider the challenge brought to them, either because the plaintiffs in the particular case had not been injured by the minimum coverage requirement or because a federal statute, the Anti-Injunction Act, denies jurisdiction.

This is a very important decision.  Judge Laurence Silberman, who wrote the majority opinion upholding the statute, is a highly-respected conservative judge, appointed by President Reagan.  Judge Harry T. Edwards, a Carter appointee, joined Judge Silberman in the majority.  Judge Brett M. Kavanaugh, another well known conservative judge appointed by George W. Bush, dissented in an opinion that was much longer than the majority opinion, but on jurisdictional grounds rather than on the merits.  Kavanaugh would have held, as the Fourth Circuit did in the Liberty University case, that the Anti-Injunction Act deprives the federal courts of jurisdiction.  In the course of his lengthy opinion, Judge Kavanaugh suggests that there may be prudential as well as legal reasons why the courts may want to stay out of this fight, and suggests that if there is in fact a constitutional defect with the ACA (which he does not decide), it could be easily fixed by Congress.

This decision comes down two days before the Supreme Court will consider, and quite possibly decide, whether or not to take certiorari in one or more of four other appellate court cases that have been decided in ACA challenges.  Although a grant of certiorari is almost certain at this point, the D.C. Circuit’s decision, as well as the earlier opinion of Judge Jeffrey Sutton, another prominent conservative who sided with the constitutionality of the ACA in a Sixth Circuit case, will certainly be noted by the Supreme Court justices.  Moreover, the media narrative that seemed to explain the district court opinions—Republican appointees strike down the law while Democratic appointees uphold it—seems again not to work for appellate court judges.  It may not work for predicting the Supreme Court vote either.

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The Fine Line Between Shared and Manipulated Medical Decisions

• 7

By MICHAEL MILLENSON

Spend some time with the Society for Medical Decision Making, and “shared decisions” starts to seem less a clinical ideal and more an offshoot of picking a monthly cell phone plan. The fine line between “motivating” and “manipulating” behavior (albeit sometimes unintentionally) starts to blur.

At the group’s recent annual meeting in Chicago, the differing sensibilities of medical and marketplace ethics were in plain view on a panel entitled (with a nod to the Richard Thaler and Cass Sunstein behavioral economics best-seller), “From a Nudge to a Shove: How Big a Role for Shared Decision Making?”

Peter Ubel, a physician and a professor of marketing and public policy at Duke University, told how some free-market theorists have defined away, “overweight.” Since people know what causes them to put on pounds, goes this reasoning, the weight they are must be the weight they rationally decided to be. (Shades of Dr. Pangloss!)

Unfortunately, eating decisions are not purely rational. Eat in a large group, said Ubel, and lingering at lunch could boost your calorie count by 25 percent. Choose the large plate at the buffet table over the small one and bump up calories another 25 percent. Our brains even seek out the bad: give us two identical crackers, but label one as having a more “unhealthy fat,” and we’ll consistently pick it over the healthier-labeled cracker in a taste test.

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Crowd-sourcing Medical Bills

• 7

By KATIE VAHLE

What if everyday purchases were priced and consumed like healthcare services?

These days you’d have to try hard not to know the price of a product or service before you buy it. So imagine booking an airline ticket with zero knowledge of the cost, only to return home to a bunch of outstanding bills for the trip. One statement may cover the seat rental and fuel used. Another bill may itemize each time the flight attendant handed out drinks. A few weeks later a bill for the pilot’s flying time may roll in. Can you imagine the resulting confusion, stress and angst?

I know it sounds absurd but this is the nightmare patients face every time they use the healthcare system. And it isn’t uncommon for these confusing medical bills to spiral out of control. Last year, the Commonwealth Fund (a non-profit healthcare research group) reported that 20% of US adults had medical debt or faced problems paying medical bills and only 58% of Americans felt confident they would be able to afford the care they needed.

So what options do consumers have when faced with the reality of paying for their healthcare?

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Getting the Patient’s POV

• 1

By JESSIE GRUMAN

One major challenge for the new Patient Centered Outcomes Research Institute (PCORI) is to make good on its stated mission to improve health care by producing evidence “that comes from research guided by patients, caregivers and the broader health care community.”

In order to “guide” that research, patients will offer their time and their experience to serve on various panels alongside scientists and other stakeholders, many of whom have competing agendas. This means that representing the patient perspective in research governance, priority-setting, design, execution and dissemination is not a good task for the shy or the ill-prepared.  Not only do you have to have reflected on your own experience as a patient, but you have to have a good sense of how much you can generalize from that experience. This is, after all, not about you. It is about us – all of us patients.

Sometimes this means gathering information from others who have a similar diagnosis and who have been treated with similar approaches. What was getting chemotherapy for breast cancer like for you?

Sometimes it means learning about how people with different kinds of heart conditions or kinds of cancer experience their diagnoses and treatments or health care in general. What happened when you were discharged from the hospital?

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CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment

• 1

By BRIAN KLEPPER & DAVID KIBBE, MD

By mid-November, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) must respond to the legal complaint filed in a Maryland federal court by six Augusta, Georgia family physicians.

These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.

In a sense, the suit reflects the larger concerns of America’s increasing unrest: a general frustration with a system rigged to benefit the few at the expense of the many, privatizing profits while socializing losses. It calls into question an incentive structure that has resulted in half or more of all health spending providing no utility and translating to exorbitant cost but debatable value. In other words, the case is accompanied by a sense that the system, as it is currently constituted, is failing the American people.

Any simple examination of medical services payment reveals the systematic under-valuing of primary care services relative to procedural services, the direct result of the RUC’s valuation process. For example, in an earlier Health Affairs Blog post we compared a 99214 moderately complex established office visit with a routine cataract extraction and intraocular lens implant. The first has all of medicine as it’s palette. The second is a highly refined, low risk, repetitive procedure that is valued, on an hourly basis, at 12.5 times the first.

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More Explanation of the Explanation of Benefits (EOB)

• 1

By DAVID E. WILLIAMS

A few weeks ago I parsed an Explanation of Benefits (EOB) I received from Blue Cross Blue Shield of Massachusetts after a visit to Sports & Physical Therapy Associates, an excellent physical therapy center with 14 locations in Greater Boston. The post (What does an Explanation of Benefits (EOB) actually explain?) generated a number of comments and questions on the Health Business Blog itself and when it was cross-posted at KevinMD. In particular:

  • What would a cash paying patient be asked to pay?
  • How is the $225 in “charges” derived? Is it determined by Medicare?
  • Does the provider lose money on the Blue Cross contracted rate?

I’m not a billing expert so I sent an email to Sports & PT to ask them to respond directly. I was impressed with their informative and thorough response, which I am posting here with their permission.

Mr. Williams,

We would be happy to provide you with some insight into how insurance claims are processed.  Please find your questions with the corresponding answers below.

When a patient first comes to our clinics, we provide them our Policy Disclosure document.  I think you will find it valuable in understanding the relationship between patient and provider, patient and insurance carrier, and lastly, provider and insurance carrier.  Here is the first paragraph:

“Sports and Physical Therapy Associates (SPTA) is pleased to participate in your health care and we look forward to establishing a lasting relationship as your physical therapy provider. As part of this relationship, we wish to establish our expectations of your financial responsibility as outlined in our Financial Policy. Letting you know in advance of our Financial Policy allows for a good flow of communication and enables us to better satisfy you. Your medical insurance is a contract between you and your insurance company; we are not a party to that contract. We can often help with providing information about your benefits, but you are primarily responsible for knowing what type of coverage you have and for any charges that you have incurred as a patient with us. Please review and sign the following Financial Policy prior to your first visit.”

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Are Health Apps the Cure for Anything That Ails You?

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By ROCHELLE SHARPE

With about 9,000 consumer health apps currently available in the iTunes store, it seems like almost all smart phone users can download their way to better health these days.

The store offers a mindboggling array of creative apps, including ones that calculate calories burned during exercise, create soundtracks to help people fall asleep, and display pictures that can elicit memories from Alzheimer’s patients. If the store doesn’t offer something for what ails you now, it probably will soon. The selections will proliferate within the next year, with an additional 4,000 consumer apps expected by next summer, industry experts say.

But all this innovation creates a bewildering set of problems. It’s hard to figure out what apps are available, let alone which work best. Health apps may have the potential to dramatically improve people’s lives, but those based on misleading or bogus information can cause serious harm.

“Apple isn’t testing apps for their scientific validity,” said Dan Cohen, a social worker who has reviewed apps for their effectiveness.

Given the stakes, it’s no surprise that the government is starting to regulate these smart phone applications. Just last month, the Federal Trade Commission brought its first cases against the makers of two health apps. Each claimed to cure acne with colored lights emitted from cell phones.

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