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Secret Shoppers: Needing A Weatherman To Know Which Way The Wind Blows

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By BRIAN KLEPPER

Every now and then, a well-intentioned administration does something relatively harmless but so hare-brained and openly foolish that it takes our breath away. The Obama Administration’s primary care “secret shopper” plan fit this bill, and has already been shelved due to the withering criticism. My inbox a couple days ago was filled with rants by physicians of all political persuasions marveling at the lameness of the idea.

Here’s a short description from Robert Pear’s article in Sunday’s New York Times.

The administration says the survey will address a “critical public policy problem”: the increasing shortage of primary care doctors, including specialists in internal medicine and family practice. It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.

http://careandcost.wordpress.com/wp-includes/js/tinymce/plugins/wordpress/img/trans.gifThat primary care access has been squeezed is hardly in question. Undervalue a critically important resource, make it a financially undesirable choice for young professionalsand – Voila! – capacity drops. Having too few primary care physicians is the result of 20 years of systematic effort by the specialist-dominated American Medical Association, with the seeming oblivious complicity of both Democratic and Republican administrations.

Ironically, a new study answering a question related to the Administration’s project’s question was released last week. Writing in New England Journal of Medicine, Bisgaier and Rhodes had research assistants pose as mothers trying to make pediatric specialty care appointments, with type of insurance as the only variable. Two-thirds (66%) of those who mentioned Medicaid/CHIP were denied appointments, compared with 11% of those who mentioned private insurance. In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was 22.1 days longer, on average, than for those who said they had private insurance.

 

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Creating Value-Based Incentives For Primary Care

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By BRIAN KLEPPER & DAVID KIBBE, MD

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.

This description probably resonates with most health care professionals as a better approach than the current paradigm’s fragmentation and lack of continuity of care. But as with many things in health care, it won’t be easy getting to a value-based health care approach in Medicare and Medicaid. Despite wide acknowledgement that fee-for-service perpetuates our health system’s most undesirable characteristics, the mainstream of American health care seems stuck. One wonders whether CMS can rise above the special interest lobbying, get beyond the interminable pilots and decisively act on payment reform with the conviction required to help save health care from itself.

Still, the idea of value-based reimbursement begs questions. What payment methodology will incentivize the best quality and most efficient care? What path can take us there?Continue reading…

Stifling Primary Care: Why Does CMS Continue To Support The RUC?

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By BRIAN KLEPPER, PAUL FISCHER, MD, & KATHLEEN ANNE BEHAN

Last October, the Wall Street Journal ran a damning expose about the Relative Value Scale Update Committee (RUC), a secretive, specialist-dominated panel within the American Medical Association (AMA) that, for the past two decades, has been the Centers for Medicare and Medicaid Services’ (CMS’) primary advisor on valuation of medical services. Then, in December, Princeton economist Uwe Reinhardt followed up with a description of the RUC’s mechanics on the New York Times’ Economix blog. We saw this re-raising of the issue as an opportunity to undertake an action-oriented campaign against the RUC that builds on many professionals’ work – see here and here – over many years.

We have focused on rallying the primary care and business communities to pressure CMS for change, and are contemplating a legal challenge. But the obvious question is why these steps are necessary. Why doesn’t CMS address the problem directly? Why does it continue to nurture the relationship?

The Negative Consequences Of The RUC

There is overwhelming evidence that the RUC has used flawed and capricious methodologies. It has systematically under-valued primary care and operated without regard for financial conflicts of interest. Its influence has compromised care quality and facilitated the primary care labor shortage. The Chair of the Medicare Payment Advisory Commission (MedPAC) is on record before a Congressional Committee describing its harmful characteristics. We know that the valuations it recommends – and CMS accepts – are major contributors to unnecessary utilization and cost. Former CMS Secretary Tom Scully has publicly condemned it as “indefensible.”

In studying the RUC closely, we have come to believe that the structure of CMS’ relationship with the RUC has violated the management and reporting requirements of a “de facto” Federal Advisory Committee. Meanwhile, the nation generally and publicly funded health care programs specifically are under intense fiscal pressures that have resulted, at least in part, from the runaway health care costs associated with the RUC’s influence.Continue reading…

Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT

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By DAVID C. KIBBE, MD and BRIAN KLEPPERDavid Kibbe, PhD

Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment. Doctors who get three-quarters of the way there won’t receive a dime. And a lot of uncertainty remains about dependent processes that CMS and ONC must quickly put in place, like accreditation of “testing and certifying bodies,” and the testing schemas for certification. All in all, we expect most physicians in small practices to sit on the sidelines until the dust settles, likely in 2012 or 2013.

Nevertheless, while it is good to get Meaningful Use behind us, it may be better still seeing beyond it. After all, the incentive payments for becoming a “meaningful user of certified EHR technology” are merely a small down payment on the savings that could be realized if health care supply, delivery and payment are affected by the changing policy and market environments over the next 5 years. The EHR incentive programs are meant to prime the pump by putting approximately $25 billion, give or take a few billion, into the hands of physicians and hospitals who adopt EHR technology during the 5 years between 2011 and 2016.

During that same time, by comparison, reductions in waste, duplication, and unnecessary procedures might mean savings of $100 billion to Medicare alone,# depending on whose estimate you believe and how effective you think the reforms will be in replacing payment for volume with payment for value. It might be a lot more. Conservative estimates are that 30% of our total national health care expenditure of $2.5 trillion, or over $800 million, is unnecessary and could be eliminated through real reforms. Some authoritative estimates argue that half or more of care costs are unnecessary, so the target jumps to $1.25 trillion a year.

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The Health Industry’s Achilles Heel

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By BRIAN KLEPPER and DAVID C. KIBBE

“You never want a serious
crisis to go to waste.”

– Rahm Emanuel, White House Chief of Staff

ALP_H_BK_0010 Timing matters. The health industry has demonstrated steadfast
resistance to reforms, but its recently diminished fortunes offer the Obama
Administration an unprecedented opportunity to achieve meaningful change. The
stakes are high, though. The Administration’s health team must not miscalculate
the industry’s goals, or waver from goals that are in the nation’s interest.
The two are very different.

Aligning the forces of reform will be the first challenge. The White House and Congressional Democrats appear to be
collaborating to develop a unified reform design. Even so,
the effort is hardly pure. Lawmakers have been receptive to industry influence.
The non-partisan Center for Responsive Politics
reports that, in 2009, health care interests have already spent $128 million on
Congressional lobbying contributions, more than any other sector.
The tide now turned, most of that largess has gone to Democrats.

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Bringing Patients into the Health IT Conversation About “Meaningful Use”

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6a00d8341c909d53ef01157025976b970b-pi By DAVID C. KIBBE and BRIAN KLEPPER

The Obama health team at HHS and ONC are gradually establishing the rules that will determine how approximately $34 billion in ARRA/HITECH funds are spent on health IT over the next several years. But there is a “missing link” in these deliberations that, so far, has not been addressed by Congress or the Administration: how the patient’s voice can be “meaningfully used” in health IT. After all, we, the taxpayers, will pay for all this hardware, software, and associated training. There are many more consumers of health care than doctors or health care professionals. Shouldn’t we have a say in what matters – in what is meaningful – to us?

It may have been an oversight, but patients and consumers have been left very much on HITECH’s sidelines. The attention and the money is squarely aimed at the health care providers – doctors, clinics, and hospitals. The Act’s intention is to create “interoperable” electronic health records that, in the future, will be more accessible to them: doctors, clinics, and hospitals.  This is a policy that is tied unnecessarily to an outdated vision. It is provider-centered, paternalistic and top-down. But it could be re-imagined to take advantage of the new ways millions of consumers, patients, and care giving families are using information and communications technologies to solve problems, form online communities, and share information and knowledge.

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An Open Letter to the New National Coordinator for Health IT: Part 3 — Certification As The Elephant in Health IT’s Living Room

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By DAVID C. KIBBE and BRIAN KLEPPER

6a00d8341c909d53ef01157012476e970b-pi In the first and second parts of this series we talked about how and why there is no universal definition for the term “EHR.” Instead there is a legitimate, growing debate about the features and functions that “EHR technologies” should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that federal regulators should “separate the data from the applications.”

We also argued that there is much to learn from development platforms, recently and in the distant past, that have used standards to open the aperture of innovation. The best of these standards have reflected the experience of what works rather than specifying how to make it work. Defining the standards for data, devices, and network technologies too restrictively could choke off innovation, rendering HITECH’s offerings whose expense and complexity are a barrier to, rather than an incentive for, adoption by physicians. Incoming National Coordinator for HIT David Blumenthal, MD seems to have been considering just this concern when he recently wrote:“… [M]any certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.”

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An Open Letter to the New National Coordinator for Health IT – Untying HITECH’s Gordian Knot: Part 1

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By DAVID C. KIBBE & BRIAN KLEPPER

KibbeB&WjpgCongratulations to David Blumenthal on being named National Coordinator for Health Information  Technology (ONCHIT). Dr. Blumenthal will be the person most responsible for the rules and distribution of the American Recovery and Reinvestment Act’s (ARRA) nearly $20 billion allocation, referred to as HITECH, designated to support physician and hospital adoption of health information technologies that can improve care.

The job is fraught with difficulties, which Dr. Blumenthal has readily acknowledged. His recent New England Journal of Medicine (NEJM) Perspective, “Stimulating the Adoption of Health Information Technology,” is a concise, clear and honest appraisal of two of these challenges, namely how to interpret and act upon the key terms used in the legislation, “meaningful use” and “certified EHR technology.” Dr. Blumenthal gets to the heart of the matter by identifying the tasks on which the National Coordinator’s success will most depend, and which will foster the greatest controversy.

The country needs Dr. Blumenthal to succeed. The issues are complex and, with huge ideological and financial stakes involved, politically charged.

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An Open Letter to the New National Coordinator for Health IT: Part 2 – Opening the Aperture of Innovation

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By DAVID C. KIBBE & BRIAN KLEPPER

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One of the important decisions before Dr. Blumenthal and his colleagues at ONC and HHS is whether the national health information network will be one of closed appliances that bundle together proprietary hardware, software, and networking technology, or one of open data exchange and management platforms in which the component parts required to do medical computing can be assembled from different sources. If the former direction is chosen, power and control will be concentrated in the hands of a very few companies.  If the latter, we could see an unprecedented burst of disruptive innovation as new products and services are developed to
create the next generation of e-health services in this country.

Separating the data from the devices and applications, and maintaining a certain degree of independence of both from the networks used for transmission, is far more than a technical quibble. It can determine the economics of technology in stunning ways.

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A Self-Fulfilling Prophecy: The Continuity of Care Record Gains Ground As A Standard

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By BRIAN KLEPPER

Brian KlepperWe live in a time of such great progress in so many arenas that, too often and without a second thought, we take significant advances for granted. But, now and then, we should catalog the steps forward, and then look backward to appreciate how these steps were made possible. They sprung from grand conceptions of possibilities and, then, the persistent focused toil that is required to bring ideas to useful fruition.

We could see this in a relatively quiet announcement this week at HIMSS 09. Microsoft unveiled its “Amalga Unified Intelligence System (UIS) 2009, the next generation release of the enterprise data aggregation platform that enables hospitals to unlock patient data stored in a wide range of systems and make it easily accessible to every authorized member of the team inside and beyond the hospital – including the patient – to help them drive real-time improvements in the quality, safety and efficiency of care delivery.”

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