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TECHNOLOGY: We’re all agreed about motherhood and apple pie

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Information Week (via iHealthbeat) reports on the World Health Congress in which lots of important political people agreed that IT is the way forward to fix the health care mess. Those saying this included not just the usual suspects from the industry but Bill Frist, Tommy Thompson and even briefly in the State of the Union address, Bush himself.

On the one hand, while it’s good that we’re agreeing on the solution, we’re not seeing even the modest kind of Federal leadership that Molly Coye suggested a while back in terms of dollars. On the other hand I suppose that this is an improvement on Clinton holding up a sheet of paper in his 1994 speech and saying that we were going to solve the administrative crisis by having one standard paper form. But it’s 10 years and counting and we haven’t got that far . . . and I don’t honestly think that Wellpoint handing out a few freebies is going to make up the difference even though it’s a noble effort.

POLICY: Health care becomes like foreign policy

You might note that today in the UK the Hutton report on the Blair government, Iraq and "sexing up" was released. More on that later (although it exonerates the UK government from the "sexing up" allegation).

Over at The Businessword Don, Ross and I have been having an interesting back and forth in these comments regarding the uninsurance issue. In a nutshell, if you want a universal insurance system, in some way those who are working and have decent insurance will have to subsidize those who are working and don’t, as they make up 75% of the uninsured. Don, Ross and I agree on that, but disagree about whether we should do it and also how we should do it.  But that is the rational place to start.  We also agree that it’s not a situation that will change any time soon, and that it’s an important part of health care that deserves regular comment. As Limbaugh might say, that, my friends, is an honest platform for debate. But remember that not everything you read in the health care world is quite as honest.

In my in-box today I got a very curious missive from the Foundation for Health Coverage Education a new organization that I’d never heard of (and I tend to follow Foundations in California out of egregious self-interest!).  But OK, these folks say they want to promote education about the many federal and state health care coverage programs in California, which all sounds very worthy, and they have a press release about their new online tool that does that. Wa-hoozlle! 

However, on slightly closer reading I noticed that this Foundation is run by an insurance broker:

    Philip Lebherz has been working to help Californians obtain health coverage since 1977. Although Lebherz is president and CEO of LISI health care insurance brokers, he is strongly opposed to not only tax penalties on individuals or employers who choose not to purchase insurance but also any government mandates to buy insurance.

So I’m already a little suspicious, and then it continues

    Although many journalists have reported between 6-7 million uninsured in California, the real number appears to be less than one million according to the Foundation’s interpretation of a Blue Cross Blue Shield Association analysis of the 2002 Census Bureau (news – web sites). Of the 6.17 million classified as "uninsured," 2.97 million are eligible for public insurance benefits but are not yet enrolled, an additional 2.16 million have annual household incomes of more than $50,000 per year, and 652,000 are temporarily uninsured, primarily due to changes in employment. That leaves approximately 938,000 who would be characterized as truly uninsured.

The Foundation claims that 90% of bills incurred by the uninsured are eventually paid off, and therefore forcing them to buy insurance would deprive them of the ability to buy housing, cars, food etc.  This is indeed beautiful voodoo economics.

So half the uninsured are voluntarily uninsured? Lebherz may not have noticed but the public programs that he thinks are just waiting to take in 3 million Californians have no money–all over the country they are cutting rolls rather than adding to them. Has he heard of our little budget problem and the consequent Medi-Cal cuts?

As for the rest, well the numbers are pretty dubious.  According to Kaiser Family Foundation 64% of the nation’s uninsured come from households with incomes less that 200% of poverty (~$26,000) (go to page 8 in the link for more), and only 19% make 300% or more, which equates to about $39,000.  Somehow in the Lebherz analysis this equates to 35% of uninsured Californians are in households making more than $50,000. But even if that’s right a good chunk of these folks would love to have health insurance but cannot find affordable insurance in the individual market. As I’ve posted before, I know because I’ve tried as have my friends–and I think that paying $4,000 to $12,000 a year for health insurance coverage with a $2,000 deductible and many exclusions is not realistic for many households even those with incomes more than $50,000 a year.

The problem is of course twofold. 1) We end up with very little contribution into the insurance pool from the uninsured, and it’s clear that they could probably come up with at least half of the balance required for the nation to get to universal coverage. And 2) more importantly from the point of view of the safety net system, dealing with the uninsured is a hugely inefficient financial train wreck.

However, the real point of this new "Foundation" is that no rational system would need a huge amount of waste motion otherwise know as the health insurance brokerage market–so any attempt to sell the current system as being "not in any real trouble" is all Lebherz and his ilk care about. So you can just lie and keep repeating the lies and maybe someone will believe you, or as in the UK focus on the irrelevance of whether a single claim was "sexed-up" or not. Oh yes and there really were WMDs, WMD programs, Al-Quaeda terrorists, a bad guy called Saddam in Iraq, and health care’s getting more and more like foreign policy everyday

POLICY: California docs ambivalent about SB2

The poor CMA apparently can’t get it right. It finally gets a quasi-universal insurance bill passed in California that should reduce the number of uninsured showing up at the doctor’s office and yet a bunch of its members (like the LA and San Diego Medical Societies) have noticed that they might have to buy insurance for their employees when the bill becomes law.  So of course the squawking has begun. 

But the math skills of the southern Cal docs may be lacking. Lets say that 25% of their patients are uninsured (which is about the ratio down there). Presumably if that number fell dramamtically, many of the uninsured they are treating will now be insured, and so will be paying so revenues will go up–presumably by up to 25%.  Costs may rise as the office staff need insurance, but insurance does not cost more than 10-12% of payroll. So they should come out ahead. 

And of course if they bothered to read the fine print they might notice that SB2 doesn’t apply to employers with less than 50 employees, and not many solo or small group practices have that many.

PHARMA: Price controls and foreign imports–European style

Although drug prices are generally set by the government in Europe, there is significant price variation between different countries.  Savvy European entrepreneurs have therefore gone to wholesalers in the cheapers countries (like Greece) and imported drugs to be resold to pharmacists. As you might expect the drug companies are not happy about this importing of cheaper drugs (sound familiar to my North American readers?) and have successfully gone to court to enable themselves to limit their sales to wholesalers in any country to enough for that country only. Now the EU is calling on national licensing associations to make it easier for these traders that exploit price differences to buy and sell in new markets.  To American pharmas and patients dismayed (for different reasons) at the overall lower prices outside the US, this might all seem like a storm in a teacup, but it does go to show that these days maintaining high prices for drugs is not easy.

POLICY: France faces health budget crunch

Just to follow up on the news from the UK last week, there’s a report out from the French government suggesting that they might both charge more for prescriptions and increase the payroll tax that supports health care.  The government’s fear is that it may end up with a yearly deficit of 29 billion Euros (apprx. $35 bill) by 2010.  France is supposed to be keeping its budget deficit to a specified amount as part of a wider EU agreement (although neither it nor Germany has managed that so far!) and health care accounts for 20% of the overall deficit. 

In France drugs account for more than 20% of health care spending (compared to less than 10% in the US) and so reducing Rx consumption is a likely target of cost cutting.  Incidentally the only place that uses more prescription drugs per capita than France is Japan, where doctors traditionally make most of their incomes dispensing drugs–a little like oncologists in the US, who are now finding that source of income being switched off.

TECHNOLOGY: Pew reports on wired Californians

(…and I don’t mean because of too many espressos)

Pew reports that poorer Californians use the Internet at high rates. For households with less than $30,000 in annual income 45% of Californians have Internet access versus 36% nationally, and  of those, 83% have searched for online health info versus 77% nationally.  This gives backing to some private data I have from Harris that indicates that poorer Americans who have Internet access are substituting looking online for physician visits.

If you have an online strategy you might think about what you can do for this underserved group.

QUALITY QUICKIE: Letter from England, (with UPDATE Tues)

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UPDATE: Don Johnson and I are having a friendly spat about the real cost of health care in Europe and another about the uninsured in the new comments section of The Business Word.  I hope that Don keeps support for his comments section up and that you’ll join me in commenting there. (I’m barely able to keep my blogging up, so no comments here for a while yet).

I’ve been in the UK for a few days and thought that it would be appropriate to give you some impressions of what I’ve been hearing about the state of health care over here. One of the most noticeable factors is that we’re not in France. The BBC reported last night that the French health service was about to have a doctors’ and pharmacists’ strike because of threats to reduce government finance of the system there.  The BBC reported with some incredulity that any French person can get any operation they like any time for free, but did point out that the French pay 30% more overall for their system, and that (stop me if you’ve heard this tune before) costs were going up faster than the economy can afford it, etc, etc.

The UK is also increasing its rate of health expenditure from what used to be a very miserly 5.5% of GDP on the way to 7-ish%.  In some ways they are having capacity constraints, with the result that some GP positions in London are vacant, and some patients are being sent to France for surgery to reduce waiting lists.  That’s possible because these days funding for primary (including Rx) and secondary care is organized via Primary Care Trusts (PCTs) which buy (or "commission" in New Labour-speak) hospital services from Trust Hospitals.  Although this might seem like the basis of a competitive market, in fact a PCT tends to cover virtually all the residents of one town, and the hospitals they purchase from usually have a catchment area that’s about the same size as the PCT.  In other words there’s more or less a single buyer (that looks something like a staff-model HMO) and a single seller (the local tertiary care hospital) — and there’s not real money flowing between them. Within the PCTs, the primary care is delivered by notionally independent GP practices, who behave much as they always did — although the minority which were "fundholders" under the previous reform environment probably have less control over hospital purchasing than the used to.

The most interesting development is the move towards what might be called intermediate risk sharing for chronic disease management. Starting in April 2004, GP practices will be putting up to one third of their revenues at risk, and be able to earn 1050 points by hitting a number of targets in certain therapeutic areas.  Each point will start off being worth up to 75GBP but will go up to 120GBP.  In other words each GP may have up to 120,000 GBP at risk for their practice, which may wind up to 30-40,000 GBP per doctor in real money. There are ten chronic disease states being targeted, many of them surrounding cardiac care, with some 75 metrics being measured. The measurement of the interventions, which are all the standard things of keeping the heart patients on the right drugs, making sure the diabetics get their eye exams, etc, etc, are being done from the information systems of the GPs themselves.  But this isn’t the gong show it would be in the US as by now the vast majority of GP practices have got primary care EMRs, and most GPs are taking electronic notes during consultations.

To this point, many GPs have just been coding office visits with electronic diagnoses that are the easiest to input rather than the most accurate (i.e. coding all visits from diabetics the same).  They don’t get paid any differently for different codes (unlike the US) so convenience had been the driving factor. Most of the GPs I talked with are fairly confident that the add-ons required, such as alerts to contact patients to make sure they’ve come in for an annual exam, or alerts to remind the GP in the middle of the consult that the hypertensive patient hasn’t had a blood pressure test, can be (or already have been) added to their systems – and that’s where they’re focusing the most effort. There’s also a presumption that some of the smaller one or two doctor GP practices with only a couple of thousand patients will merge to get better IT IT and admin support. Overall there’s some optimism about the system, as reflected in this American assesment from UCLA’s Paul Shekelle.

It’s also interesting to note that in the absence of the completion of the huge EMR in the sky projects that the government just awarded contracts for, the UK is already far ahead of the US in primary care IT.  However, this doesn’t really spread over to the hospital side.  In fact frequently the communication between GP and Hospital specialist breaks down (does this sound familiar?) and a patient may be put on a drug in the hospital and the GP either not be informed about it, or take them off it when they come for the follow up visit. As the GPs currently control their own drug budget they’ve been somewhat incented to under-prescribe – any savings there can be used in the rest of the practice to buy new computers, nicer chairs for the waiting room, etc. Additionally the end points that GPs are going to be rewarded on are based on intermediate outcomes, not on hospital measures.  So for example, getting the % of at-risk patients on statins up above a certain number will be rewarded and it’s just assumed that this will reduce costs down the line and in the hospital.  But at present no one’s counting and the information systems aren’t really able to talk to each other about it. However within the PCTs there are already guidelines that many GPs (are at least trying to) follow willingly, even though they’re paper based, and there is a system of clinical consultation over local guidelines at the PCT level itself.  As well as the NICE (national institute for clinical excellence) which creates national guidelines for technology and drugs based on cost-effectiveness analysis.

Additionally there was great familiarity with the Kaiser system, and the NHS has done a series of comparisons between the two, which in part inspired the new contracting system by showing that the lower use of hospital care and greater emphasis on overall patient management at Kaiser led to better and more cost-effective care.  But many people I talked to were aghast when I described the state of IT in the typical American doctors office – they just assumed that the rich Yanks must be well ahead of them!

TECHNOLOGY: IT for EBM

Occasional contributor Matt Quinn has been on a tear this week.  He notes the following gem from a recent iHealthbeat story about the use of IT in evidence based medicine.

    According to Dr. Bob Williams, principal of Cap Gemini Ernst & Young’s health consulting division, "most physicians want to include data collection in their clinical systems, but they don’t want the guidelines that come from the data to interfere with the care they provide."

Some time back I had a blogging conversation with Robert Centor over at DB’s Medical Rants about evidence-based medicine. He said:

    Having physicians enter data on their patients is not an intelligent use of their skills and time. In order to understand quality we would need such a large and broad database that data entry would take longer than patient encounters.

I still have a longer reply to Robert stored up, but the gist of my argument is, just because systems for recording data are not perfect doesn’t mean that we should give up the prospect of using (and improving) them. The lack of the "perfect" in recording clinical data has been allowed too many physicians to drive out the "good" of recording what data they can and using it to guide their care. Regarding Bob Williams’ comments Matt asks:

    Does this mean that:
    – physicians don’t trust that the data that they’re recording (in clinical as opposed to billing/financial information systems) accurately reflects the care that they’re providing?
    – they don’t feel that they should learn (i.e. change behavior) based on what works and what doesn’t work for them and their colleagues (i.e. evidence-based guidelines are so valid/established that one should not deviate from them even based on personal/group evidence)? or that
    – it’s OK to collect data but it’s not OK to measure their performance against it (and other docs)?

Like Matt I’m a little puzzled by what Bob means but I suspect it’s the inverse of Matt’s second point in that many physicians don’t want to know about the guidelines because, for want of a better term, "they know better". That’s OK in one of the three methods that Michael Millenson told me are how physicians practise medicine . Millenson’s three ways are:

a) Follow the best evidence based guidelines
b) Innovate by doing something different and record that innovation so that it can be compared to the guideline. Then you can see whether it was worse than the guideline, or better than the guideline and should thus be used to change the guideline, or
c) Ignore the guideline because you just "know" that your way is better.

Millenson tends to think that way too many physicians are in category c), and I suspect that Bob Williams agrees with him. As I’ve posted about before, following the EBM guidelines is not easy, but it should be second nature amongst physicians to figure out what they are, ensure that they are widely understood by the clinicians and patients they are working with, and to check their own practice patterns against them.  With no information systems to record what was done, the last part is almost impossible.  It seems that the physicians Bob Williams was talking about are not so interested in completing that piece of the puzzle.  As I commented earlier this week, this is one area where physicians have a real opportunity to show great leadership. Millenson doesn’t think that they have done so far.

But there is hope and activity here. Fellow blogger Alwin Hawkins sent me an example from his hospital Providence in Oregon (Thanks Al!)

    One project was the tracking of myocardial infarction patients. A nurse goes through all charts on the telemetry and coronary care units, checking to see whether patients are being started on the medications recommended by the American College of Cardiology. We placed on all the pre-printed admission order sheets spaces for beta blockers, ACE-I’s, statins, and aspirin, along with. Just that little reminder alone got the docs improved compliance in writing the orders, along with the parameters for holding the medications.

So there you have it. A little hint of the guideline via the information system (in this case a paper order sheet) and the guideline begins to get followed. Similar examples are all over the country, and have been for some time.  But the question is when does the tipping point occur?

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