Author Archives

Matthew Holt

Ghosts of Health Reform Past

Jan 10, 2011• 3

By DAVID DRANOVE, PhD

I have not blogged for several weeks, mainly because I have been making sense of the curious events that transpired over the Christmas holiday. If you a regular reader of my blog, you know that I have had some harsh things to say about health reform. To criticize a law that brings joy to so many people, it must make me seem like a scrooge. But I really thought that most of the legislation was humbug. And then, in the days leading up to Christmas, I had a series of strange dreams that changed everything. I must tell you about them.

In my first dream, I was visited by a shriveled up old man who seemed to have already passed through death’s door.

I shuddered to see him. “Who are you? What do you want with me?” There was no response. He came closer and closer. I tried to move away but I was paralyzed with fear. Suddenly, he reached out and took me by his cold, clammy hand. As he held me tight we seemed to fly through space and time. Just as suddenly I seemed to be back in the real world. Only I wasn’t in my bedroom; instead I found myself in a conference room in a dreary office building. There was one window and if you craned your neck you could just make out the U.S. Capitol. Everyone attending the meeting wore the same uniform – gray dress slacks and powder blue dress shirts. But what I noticed most of all about their attire was that they all had pocket protectors filled with mechanical pens and pencils.

Then it occurred to me that I recognized a lot of those in attendance. I had seen them at healthcare conferences talking about the latest government initiatives to hold down healthcare spending. And here they were, hard at work. I listened closely and could hear them going on and on about diagnostic codes and relative values, and making exceptions for this drug and that hospital. They talked for hour after hour; it was becoming so excruciatingly boring that I begged my guide to leave. I wanted to go home. He refused and insisted that I listen carefully, for there were lessons to be learned. “Who are you,” I asked my guide again. “Why am I here?”

Healthcare Insurance Future: Brokers, Consultants, Agents

Jan 10, 2011• 2

By JOE FLOWER

When people and companies buy healthcare insurance, they usually go through a broker, a consultant, or an agent.

Agents sell insurance from one company, brokers from many companies; both make a commission—a percentage of the premium. Consultants take a fee from the client to help them set up their insurance situation, then typically turn around and hand the business to a broker or agent to handle the actual sale.

As premiums have skyrocketed, that’s been good for brokers and agents, since they get a percentage of that. As health insurance offerings have gotten both more expensive and complex, that’s been good for consultants; employers increasingly feel that they need a professional helping them sort out their choices.

How will their situation change under the looming reform—not to mention the deep reorganization that healthcare is going through at the same time? It’s a “Good News/Bad News” story.

There are five key factors here:

1. Market expansion: It’s got to be a good thing when your market gets tax credits for buying your product—let alone when everyone has to buy what you’re selling or get fined, right?

2. Less risk: One reason why people go to professionals for their insurance is that the consequences of making a mistake about what’s covered, can you get covered, or will you get kicked out “rescinded,” can be huge. If everyone can get covered for everything and you can’t get kicked out of the plan, signing up for healthcare insurance is less risky—so buyers may feel less need to involve a broker or consultant.

Definition of HIE: What‚Äôs Yours?

Jan 10, 2011

By JOHN MOORE

Trying something new here ‚Äì soliciting your collective input, the proverbial wisdom of the crowd.

As you may have read in yesterday‚Äôs post, Chilmark is quickly approaching publication of the Health Information Exchange (HIE) report. One of the last tasks is final editing/polishing of report. Am now in the process of creating a definition for HIE that clearly articulates what the primary purpose of an HIE is, but also keeping that definition loose enough to reflect what a market that is evolving so quickly that in five years time, there will not be an HIE market as we know it today.

So, with that in mind, here‚Äôs the HIE definition for the report.

Definition of an HIE:
A Health Information Exchange (HIE) is a technology network infrastructure whose primary purpose is to insure the secure, digital exchange of clinical information among all stakeholders that are engaged in the care of a patient to promote collaborative care models that improve the quality and value of care provided.

Does this make sense to you? Does this definition resonate with your own view of the market? Any and all comments welcomed, but please be quick to get them in as we are on a fast track to have this report done within the week.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

Definition of HIE: What’s Yours?

Jan 10, 2011• 6

By JOHN MOORE

Trying something new here – soliciting your collective input, the proverbial wisdom of the crowd.

As you may have read in yesterday’s post, Chilmark is quickly approaching publication of the Health Information Exchange (HIE) report. One of the last tasks is final editing/polishing of report. Am now in the process of creating a definition for HIE that clearly articulates what the primary purpose of an HIE is, but also keeping that definition loose enough to reflect what a market that is evolving so quickly that in five years time, there will not be an HIE market as we know it today.

So, with that in mind, here’s the HIE definition for the report.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

Early Experiences with Hospital Certification

Jan 10, 2011

By JOHN HALAMKA, MD

As one of the pilot sites for CCHIT’s EHR Alternative Certification for Hospitals (EACH), I promised the industry an overview of my experience.

It’s going very well. Here’s what has happened thus far.

1. Recognizing that security and interoperability are some of the more challenging aspects of certification, we started with the CCHIT ONC-ATCB Certified Security Self Attestation Form to document all the details of the hashing and encryption we use to protect data in transit via the New England Healthcare Exchange Network.

Next, I had my staff prepare samples of all the interoperability messages we send to patients, providers, public health, and CMS. Specifically, we created

CCD v.2.5 used to fulfill the Discharge summary criterion
HL7 2.51 Reportable lab
HL7 2.51 Syndromic surveillance
HL7 2.51 Immunizations
PQRI XML 2009 for hospital quality measures

We validated them with the HL7 NIST test site

and the HITSP C32 version 2.5 NIST test site.

CCHIT validated the PQRI XML as conforming.Continue reading…

(Limited) Sympathy for the Blue Devil(s)

Jan 10, 2011• 5

By Matthew Holt

A year on from Wellpoint’s ju-jistu move of announcing a 39% rate increase in California, therefore re-invigorating the health care bill and guaranteeing themselves billions in government subsidies, Blue Shield of California, the non-profit rival to Wellpoint’s Anthem Blue Cross, announced a 59% increase! In the annals of THCB, Blue Shield has a mixed record. CEO Bruce Bodaken was a big supporter of the ACA and consistently called for universal coverage, but at the same time the behavior of Blue Shield after the revelations about the insurance recissions was worse than any other insurer. It actually fought much harder for the right to continue them than Wellpoint, Healthnet and the rest. The most recent rate increases also concern the individual market—you know, that segment of the insurance market that Mark Pauly thinks works pretty well.

Blue Shield is saying that the rates really are only a 15% average increase, and that for some individuals they’re getting a delayed increase—in other words they should have been charged more last year—which is where that 59% number comes from. Why are rates going up? Blue Shield put out a handy press release giving its side of the story. Blue Shield is pretty explicit that the extra costs of the abolition of life-time maximums and the addition of kids up to 26 on family policies was only around 4% over 2 years. The big factor was that utilization went up 7%, unit costs (prices) went up 5% and the rest of the increase (3%) is due to lower overall out of pocket costs relative to what the insurer was covering (because of overall cost increases).

Translated into “where the money went,” hospital payments went up 15%, drugs up 12% and doctor payments went up 9%. In addition, although Blue Shield doesn’t state it, the pooled risk profile of everyone in a particular individual market product gets worse as while they all get charged the same at “entry”, and then more healthy people drop out as prices go up than sick ones. This is the insurance death spiral we used to hear so much about.

However, it’s not just Blue Shield and it’s not just the individual market.

The Moral Component to Transparency

Jan 9, 2011• 1

By PAUL LEVY

Many of you have asked if I intend to continue this blog, now that I am stepping down as CEO of BIDMC. Yes. (I’ll have to change the name. How about “The blog formerly known as . . . ” or just a simple “Not Running a Hospital”?)

Please expect a combination of commentary on current events and issues. But also please expect an occasional lesson or two from my experience of the last nine years, all offered in the hope of being helpful to others in the field. I apologize in advance if some portions seem self-aggrandizing or self-praiseworthy. I don’t mean them that way, but sometimes, to be historically accurate, I’ll have to include a few good things about myself!

Here we go. Act 2.

In a comment on a post below, author Charles Kenney asks:

Isn’t there a compelling — perhaps even overriding — moral component to transparency?

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the “prior” against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

Clueless in Utah?

Jan 9, 2011• 16

By ROGER COLLIER

The trials and tribulations of Utah’s much-touted Health Exchange continued in December, with the announcement that yet another chief executive had quit, along with the admission that very few eligible employer groups had signed up for the exchange.

The Utah exchange differs from that of Massachusetts in that it currently focuses on coverage for small employers offering defined contribution plans, a policy that was hoped to demonstrate the effectiveness of such plans. However, so far enrollment has been far too low to test the merits of this approach.

The Salt Lake Tribune reported in late December that a new executive director had been appointed to head the exchange, which is administratively located in the Governor’s Office, making the third director in just over six months.

The Tribune went on to compare the expectations of State officials, who had anticipated enrolling 3,000 small employers with an estimated total of 40,000 employees, with the current reality. As of late December, with coverage scheduled to start on January 1, 2011, just 43 of the State’s estimated 50,000 small businesses had signed up and been determined eligible.

Back in September, when the Utah exchange started to accept coverage applications, Utah’s Governor Gary Herbert was quoted as saying: “[the exchange] is quickly becoming a model for the rest of the nation when it comes to health care reform.”

Hopefully not.

Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE.

The Study Question

Jan 8, 2011• 1

By MARYA ZILBERBERG

Let's start at the beginning. Why do we do research and write papers? No, not just to get famous, tenured or funded. The fundamental task of science is to answer questions. The big questions of all time get broken down into infinitesimally small chunks that can be answered with experimental or observational scientific methods. These answers integrated together provide the model for life as we understand it.

Clearly, the question is the most important part of the equation, and this is why in my semester-long graduate epidemiology course on the evaluative sciences we spend fully the first four to five weeks talking about how to develop a valid and answerable question. The cornerstone of this validity is its importance. Hence, the first question that we pose is: Is the study question important?

This is a bit of a loaded question, though. Important to whom? How is "important" defined? This is somewhat subjective, yet needs to be scrutinized nevertheless. In the context of an individual patient, the question may become: Is the study question important to me? So, importance is dependent on perspective. Nevertheless, there are questions upon whose importance we can all agree. For example, the importance of the question of whether our current fast-food life style promotes obesity and diabetes is hard to dispute.

That Which We Call a Rose

Jan 8, 2011• 6

By MARGALIT GUR-ARIE

What’s in a name? Sometimes nothing much.

Sometimes a shift in paradigm. The Medical Record in its current format was created over a century ago by Dr. Henry Stanley Plummer at the Mayo Clinic. When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine naturally named the new invention Computer-based Patient Record System (CPRS)

The Medical Records Institute chose the term Electronic Patient Record (EPR). Somewhere along the line the “patient” got dropped from the concept and the software used to compose and store medical records became known as Electronic Medical Record and the name EMR stuck.

As EMR software evolved and started exhibiting rudimentary information exchange abilities and some semblance of “intelligence”, it was felt that a name change was in order. To differentiate the newer and smarter software from the original EMR, the term Electronic Health Record (EHR) was introduced and is now enthusiastically supported by the Federal Government. The term EHR is used in acts of Congress, rule makings from CMS and ONC and Presidential speeches. Since EMR has been around for quite some time, most industry veterans, as well as most doctors, are a bit confused about the new terminology.