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Tag: Policy

Frances Dare explains HITECH, really well

Frances Dare from Cisco is a buddy of mine who has more and more been their student of what's going on in Washington. Given that we just saw the biggest piece of health care IT legislation ever pass, I thought I'd check in with her. Frances, has really done her homework about exactly what's in that $19.2 billion pot and more (yes there's more than that) and how it's going to be spent.

This is a long(ish) and detailed interview, but if you care about IT in health care, I highly suggest you listen!

Reform? Marginal, I fear…

Matthew HoltToday’s news is that there is now a double header running health care with the addition of the 
(notably all-female) team of Sebelius & DeParle joining Orzsag, Zeke Emmanuel and a host of others with influence on the health care policy tiller. We await a CMS leader, and probably multiple other appointments quickly down through the ranks.

However, I remain convinced that not much is going to happen, and that even if Obama’s “plan” gets enacted, it’s a limited reform that is not the big bang we need to do the job.

Thankfully rather than me having to explain why, Bob Laszewski (who makes me feel like an inadequate noobie every time I read his stuff) details the problems over at Health Affairs blog. The Bob L summary?

  1. Obama’s team has not aggressively gone after the hard cost problems as part of Medicare & Medicaid, preferring to trifle around the edges with modest cuts 
  2. For the (these days relatively modest!) $120 billion a year the reforms are going to cost it’s only looking to the health care system to pony up around half of it—the rest (c. $65bn a year) will come from the taxpayer.
  3. The details of the plan are being left to the Congress which means that it’ll be watered down.

As I said in the looooong comment thread on Maggie Mahar’s piece on THCB yesterday—BTW Maggie’s comment on her own piece may be the longest comment I have ever seen on any blog!—there’s no reason that the rest of the economy should contribute more to the health care system. As John McCain might say (albeit with disapproval), we need to redistribute the wealth within the system.

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Health 2.0 more interesting than porn!

Last Thursday I gave a talk to a very high powered group, the National Committee on Vital and Health Statistics. My old colleague Matt Quinn is now working for the soon to be very rich Agency for Health Research and Quality (another HHS agency), and he lined up a series of talks for the committee on non-traditional data sources. Non-traditional, by the way, means about anything that isn’t from one of the huge Federal government household surveys (like MEPS) that’s used by HHS to analyze health care spending and consumption. John Halamka, CIO of BIDMC and Chair of HITSP, gave an excellent summary talk about data sources that are being collated and integrated in Massachusetts. It’s available on his blog here. Bear in mind that a LOT of work has already gone into putting various patient data sets together in that part of the country. The most encouraging thing was how relatively easy it was for BIDMC to interface with Google Health and Microsoft HealthVault, and how problem free those interfaces have been.

My talk was about Health 2.0, and given that it was less familiar to the committee I both introduced the concept of social networking and consumer tools, and discussed how it might be integrated into a national data capture strategy to improve quality reporting and hopefully spur improvements in medical care processes. Both talks are available here. You need to go to 4.48.00 or so to catch where I start. John’s talk is after the discussion

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Getting “the CCHIT question” wrong

Matthew Holt

There’s been a lot of blather from one commenter (who may or may not be a front for a group of  malcontents) on the WSJ Health Blog and lots of other blogs about CCHIT and whether it was doing business without a license in Chicago, and/or was a front organization for HIMSS or EHRA. All summarized on Neil Versel’s blog. Indeed I did get a call from one well known blogger telling me that HIMSS’ lawyers had asked for him to take those comments down—not too bright a piece of PR on HIMSS’ part IMHO.

MrHISTalk thankfully did what I certainly could not be bothered to and actually looked into the “CCHIT is not a licensed corporation” situation and figured out that it’s basically being run legitimately. I myself cracked the joke privately that if CCHIT/HIMSS/EHVRA/Leavitt et al had only managed to get $2m (or $7m for that matter) out of the Bush Administration, they needed to go to the Haliburton school of “how to stick it to the taxpayer properly.”

The other wisecrack I’ve heard is that  the way to determine the list of functions an EMR needs to have to get CCHIT certified was to copy the feature set of Allscripts TouchWorks. (Of course you can insert the name of any of the other big EMR vendors here too).

OK, so we’re kidding around here, but underneath this discussion are some serious points. And those serious points have got little to do with what has indeed been a pretty close relationship between the powers that be at HIMSS,EH(V)RA, CCHIT & HITSP.

In any case I assure you that the back room dealings and conflicts of interest are nothing compared to how the rest of the Federal government has colluded with industries it regulates for the last 8 years. The money given from ONC to CCHIT wouldn’t even be a rounding error on what’s been completely lost in Iraq in cash in suitcases. let alone what Blackwater, Halliburton et al have stolen, And there’s no evidence that the Feds didn’t get what they/we paid for from CCHIT, which is a certification process.

So if this is a non-story, what are the actual issues?

1) Part of the justification for a certification process is that there is a great deal of fear and trepidation among physicians who have heard the horror stories about EMR implementations, and are now being bribed (and later to be threatened) by the Federal government into installing EMRs. Given the plethora of vendors out there, and the fact that these providers are more or less Federal contractors who tend not to understand IT, it’s not unreasonable to suggest that the Federal government (or someone) gives authoritative guidance as to what’s a robust system that has the right features and functions. Remember that the nation’s biggest and richest integrated provider organization trashed not one, but two national investments in EMRs before getting it right at try three. Having recalled that it becomes reasonable to agree that most providers need some help. And of course there is some slight protection for the taxpayer if the providers who are about to get their $40K have to do more than just claim that they bought an EMR from Sonny on the corner.

2) Of course once you say that the Federal government will pay out only to those purchasing certified products you then run into two other problems. First, the certification process is going to get somewhat politicized. Despite all the yakking about “volunteers” on all these committees, what we’re talking about is the people with a deep interest in EMRs et al being those “volunteers” and of course they are mostly from the vendor side or users who know the vendors well. I don’t see a way around that unless we really want to develop a civil service that has expertise in health care IT and also is prepared to stay in the job for 30 years like they do in Japan. Second, by its very nature the certification process is likely to run behind the development of technology, which means that vendors building for the certification process are like teachers prepping students for tests, not creating innovations. Again that may not be a terrible thing, but it’s not how innovation works in most other industries. (John Moors at Chilmark has a rather blunter, bleaker assessment of how this might work out)

3) And of course, the reason that you don’t see Federal certification of, say, MP3 players or automobiles is that there’s a somewhat effective market there that means that innovation and user experience gets rewarded. Make a confusing MP3 player, you don’t move the needle much. Figure out how to make it easy and elegant and you’re called Steve Jobs and you sell a gazillion iPods a year. Health care doesn’t have such a market, or even rationally managed incentives from its Federal paymaster.

So I don’t have the answer, but I do have the question. And it’s the same one being posed by the Dogs, in response to the Cats. Can we realistically expect CMS and the rest of the big payers to start rewarding providers for producing the correct outcomes. If we paid for outcomes, providers would change their organizational structure, and their processes, and the technology they use. The ones that worked would succeed and the others would go away. That’s how a market works. And that would create lots of interesting technological innovation of the type that is already happening in the consumer health arena in Health 2.0.

But (beware: run-on sentence coming up so take a deep breath) if we realistically can’t get to some massively enhanced version of pay for performance very soon, and instead are going to insist that providers use EMRs or something like them and the Feds will pay them for it, and we are happy to declare that that solution is as good as we’re going to get while we work on wider health system reform later, then I don’t think that we can complain about the CCHIT process too much. We have to accept that the Feds are going to put a stake in the ground somewhere as to what is an acceptable technology to reward. And those rewards are not going to be market or outcomes-based yet.

So the ultimate question, is what’s the time-scale for junking our stupid current health care incentives and finance system? And the answer is, not in the next 2–3 years.

Which means that if we’re paying directly for technology (which we are as the law is now passed), a certification process is a necessary evil to help providers and to make sure that the tax payer isn’t being defrauded (see we’re back to Iraq again!).

Of course, this doesn’t mean that the certifiers shouldn’t be made to appear to be (as we;; as actually be) completely above board and be watched like hawks to make sure that they’re not putting too many restrictions on smaller companies or discriminating against them. And maybe that kind of oversight demands that we see greater separation between the HIMSS/EHRA/CCHIT/HITSP/ AHIMA players, which would fit in with Obama’s “no lobbyists in the Administration” line.

But I can’t see that this is an issue for anyone to go to the barricades about. And in the end if CCHIT helps providers get better tools than they have now, it’s probably a net positive—even if it may prevent greater innovation happening faster.

Divided we might get somewhere, but not yet

Matthew HoltThe NY Times describes the Republican-less lobbyist meetings with Democrats that are allegedly getting 
towards a consensus on an individual mandate as the way to universal health care. Funnily enough some of those same groups (e.g. The Business Roundtable & the NFIB) appear to be lessening their commitment to the worthily named “Divided we Fail” campaign.

And then on the second page of the NY Times article there’s this:

Many businesses, crushed by soaring health costs, say they now support changes in the health care system as a way to control their costs. But in its summary of the recent discussions, Mr. Kennedy’s office said, “There was little consensus on the employers’ role.”

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Connecting the dots–Uninsured people are poor!

A bunch of random articles all hit at once on Wednesday morning. And they win the John Madden award for stating the bleedingly obvious. This is kind of  a companion piece to my rant about Friday’s NY Times article on the health industry and its political allies and adversaries sitting down to come to consensus.

Inquiry featured a worthy study. It tried to suggest that high costs “crowd out” health insurance spending.

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Someone sit Michael Cannon down before telling him this!

Matthew HoltApparently there some kind of experimental clinical innovation going on in the UK. If this isn’t a typo from 
the Torygraph, how is the mental model of the free-marketeers going to survive? I suspect that Gratzer, Giuliani, Kling & the rest had better join Michael in taking a seat. Yup, communism can mean innovation, (after all who won World War II)?

Meanwhile there is a little more news on the topic of Cato (Michael’s employer). First, they created some economic stimulus of their own Monday, with a one page ad in the WSJ opposing the economic stimulus package.

But they haven’t been listening to Robert Reich and the others suggesting that we get money into the hands of the poor to create more immediate economic impact, or at least they weren’t paying attention when they gave their cash to Rupert Murdoch. Perhaps they should have put it in Street Sheet instead!

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Grand Rounds

Welcome to Grand Rounds. It's been quite some time
since THCB hosted the medical blogosphere's major compendium. So sit
back and enjoy a stroll through the gardens of medical and health care
obsession.

It's still a fresh political season, so we start with the wonks:

At TNR's The Treatment blog, Jonathan Cohn gets a top administration official to confirm
that health care will be a "central focus" of the budget proposal Obama
submits in a few weeks, signaling a major commitment to reform even
with Tom Daschle gone. He also runs down some possible successors to
Daschle and decides Howard Dean won't be the man, even though he'd do a great job.

Elsewhere on The Treatment, Harold Pollack says it's bad enough the U.S. opposes successful harm reduction strategies for drug addiction at home. Why do we have to use our clout to discourage other countries, too?

At Health Business Blog David Williams thinks that universal coverage
is a worthy goal, but says that if we get there by enrolling everyone in existing
public and private insurance schemes and maintaining existing levels of
utilization we’ll be doomed.

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Jon Cohn: Obsessed with baseball and a hopeless optimist

Jon thinks that Baseball Teaches Us (something) About Health Care Reform. Replace the star player with a bunch of utility infielders, and we’ll still win the pennant. Don’t worry Jon, Daschle isn’t the only one who came in with high hopes and didn’t make it through the week. So long Luiz Felipe!

But more importantly, unity (for the bailout) is a bust already, less than two full weeks into the Obama Administration with only 3 Republican Senators prepared to buck Rush Limbaugh, and then at a pretty big cost to the President and common sense. As Krugman pointed out today, bipartisanship is a crock, with the Republicans telling Obama to go whistle despite his bail-out package being less in total and way less in degree than a centrist Democrat would want. He left in all those tax cuts to please Republicans and they dissed it anyway.

So what would the Republicans do if serious health reform came up for discussion? I think I know! And if Obama starts with an already watered-down plan, it’ll just get more watered down.

The AMA Wins a Round Against Accountability and Patient Information

On January 30th, a 3-judge DC appeals court overturned a lower court decision that would have forced public release of Medicare physician data. Writing for the majority in a split 2-1 judgment, Circuit Judge Karen LeCraft Henderson declared that

“The requested data does not serve any (freedom-of-information-related) public interest in disclosure. Accordingly, we need not balance the nonexistent public interest against every physician's substantial privacy interest in the Medicare payments he receives.”

But in a strongly worded dissent, Judge Judith Rogers, the third member of the ruling panel, found that the request by the consumer group, Consumer Checkbook, represented “a commanding and important public interest in disclosure of the data.”

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