Tag: Transparency

The AMA Wins a Round Against Accountability and Patient Information

Feb 6, 2009• 13

By Brian Klepper

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.”

Saving Health Care, Saving America

Feb 1, 2009• 47

So far, Congress’ response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors’ interests rather than to those of the American people. More than 3,330 health care lobbyists – six for every member of Congress – contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

Second, by carefully avoiding reforms of the practices that drive health care’s enormous cost growth, Congress pretends to make meaningful change where little is contemplated. For example, current proposals would not rebuild our failing primary care capabilities, which other developed nations depend upon to maintain healthy people at half the cost of our specialist-dominated approach. They fail to advance the easy availability and understandability of information about care quality and costs, so purchasers still cannot identify which professionals and organizations are high or low performers, essential to allowing health care to finally work as a market. They do little to simplify the onerous burden associated with the administration of billing and collections. The proposals continue to favor fee-for-service reimbursement, which rewards the delivery of more products and services, independent of their appropriateness, rather than rewarding results. Policy makers overlook the importance of bipartisan proposals like the Wyden-Bennett Healthy Americans Act that uses the tax system to incentivize consumers to make wiser insurance purchases. And they all but ignore our unpredictable medical malpractice system, which nearly all doctors and hospital executives tell us unjustly encourages them to practice defensively.

Most distressing, the processes affecting health care reflect all policy-making. By allowing special interests to shape critically important policies, Congress no longer is able to address any of our most important national problems in the common interest – e.g., energy, the environment, education, poverty, productivity.

Over the last four years, a growing percentage of individual and corporate purchasers has become unable to afford coverage, and enrollment in commercial health plans has eroded substantially. Fewer enrollees mean fewer premium dollars available to buy health care products and services. With diminished revenues, the industry is unilaterally advocating for universal coverage. This would provide robust new revenues. But they are opposing changes to the medical profiteering practices that result in excessive costs, and which often are the foundation of their current business models. And these two elements form the troublesome core of the current proposals.

Each proposal so far contemplates additional cost. But we shouldn’t have to spend more to fix health care. Within the industry’s professional community, most experts agree that as much as one-third of all health care spending is wasted, meaning that a portion of at least $800 billion a year could be recovered. There is no mystery about where the most blatant waste is throughout the system, or how to restructure health care business practices to significantly reduce that waste.

Make no mistake. A failure to immediately address the deep drivers of the crisis will force the nation to pay a high price and then revisit the same issues in the near future. It is critical to restructure health care now, without delay, but in ways that serve the interests of the nation, not a particular industry.

Congress ultimately must be accountable to the American people. The American people must prevail on Congress to revise the current proposals, build on the lessons gleaned throughout the industry over the last 25 years, and directly address the structural flaws in our current system. True, most health industry groups will resist these efforts over the short term, but the result would be a more stable and sustainable health system, health care economy and national economy, outcomes that would benefit America’s people, its businesses and even its health care sector.

Finally, the American people should demand that Congress revisit and revise the conflicted lobbying practices that have so corroded policymaking on virtually every important issue. Doing so would revitalize the American people’s confidence in Congress, and would re-empower it to create thoughtful, innovative solutions to our national problems.

Brian Klepper is a health care analyst and industry advisor. David C. Kibbe is a family physician and a technology consultant to the industry. Robert Laszewski is a former senior health insurance executive and a health policy analyst. Alain Enthoven is Professor of Management (Emeritus) at the Stanford University Graduate School of Business.

Dr. George Lundberg for Surgeon General

Jan 25, 2009• 18

By Brian Klepper

The report that Mr. Obama’s Surgeon General choice might be neurosurgeon and CNN medical correspondent Dr. Sanjay Gupta produced an upwelling of strong opinion, particularly in the medical community. Some argued that Dr. Gupta has clearly demonstrated his abilities as an able communicator.

But others said that Gupta lacks the experience, seriousness and focus on public health. (I can’t help thinking that anyone who has achieved working neurosurgeon and national TV commentator status is pretty capable and serious, demeanor notwithstanding.)

And so it is that on Facebook, that Dr. Richard Lippin, a longtime Preventive Medicine physician based in Pennsylvania, has posted a letter he sent to President Obama and Secretary Daschle, urging the consideration of Dr. George Lundberg for Surgeon General.

The header reads: “We need a physician with the gravitas and the moral credentials and authority to use this bully pulpit position to speak for science and values based priority public health issues for all Americans. Dr. George Lundberg fits the bill.”

The letter provides a brief bio of Dr. Lundberg, the brilliantly eclectic, progressive, Alabama-born, down-to-earth physician who has been a visible mainstay of American medicine for decades. Dr. Lippin doesn’t mention Dr. Lundberg’s landmark 2002 book on American health care and reform, Severed Trust. (The title alone provides a lot of insight into Dr. Lundberg’s view of the world.)

But Dr. Lippin does believe the Surgeon General choice is about healing both America and American medicine, He writes, “we have a genuine crisis on many levels in US Medicine. Also we need desperately for the medical profession to regain its moral and ethical foundations and furthermore we also need medical leaders who must regain the trust of the American Public which has been dangerously eroded.

I agree with Dr. Lippin that those are the tasks, and I agree that Dr. Lundberg is a terrifically suitable candidate. Over many years, I have developed a warm friendship with him. It is impossible to not be bowled over by his range and grasp of issues, and by his unswerving willingness to stand clearly and openly for approaches that are tied to evidence and reason. The ultimate critical thinker, his judgments are founded most closely to merit, possibility and an unshakable belief in the correctness of the pursuit of excellence in health.

He is also bold and politically savvy. You don’t become the longest running Editor-in-Chief of the Journal of the American Medical Association (until he got politically at odds with them) and then build Medscape into the most widely read Web resource for clinicians worldwide unless you can continuously strike the delicate balances between science, sensibility and moral imperatives among your peers.

I can’t say whether Dr. Lundberg would be the best candidate for the job ahead. He has a huge following in the medical community, nationally and worldwide, the result of many, many years of consistently high performance infused with unassailable integrity. Whether he’s the right person for this moment is another issue, though, fraught with the complexities of political consideration, a vision consistent with the larger plan of the Obama team, fluency with the bewildering array of new technologies that are changing the face of medicine and the patient-physician relationship, and so on.

But Dr. Lippin makes an important point. American medicine is demoralized in the field. Overt, rampant financial conflict has caused many to believe that the profession has lost its compass. With that loss, the trust of patients and the authority that trust conveys have also diminished.

Restoring that trust and authority isn’t simply a matter of leadership or preaching, but will depend on fundamentally changing the business of medicine, a much larger task indeed that will require an orchestrated effort by all of us, not just physicians.

But the new Surgeon General, whoever he or she is, should be grounded first in science, evidence and best practice, in tirelessly advocating and maneuvering for a care delivery system that is as advanced and nuanced as the diagnostic and treatment approaches we’ve developed, and on advancing the health of ALL our people in ways that leverage rather than squander increasingly precious resources.

While there is no question that Dr. Lundberg is worthy, I’d be surprised if the call for his consideration is heard in the din of this transition. Even so, it is deeply gratifying to see an outpouring of support by his peers, the result of successfully dedicating his life to advancing medical knowledge and its best application.

Five “Shovel-Ready” Health Care Reforms

Jan 21, 2009• 23

By Brian Klepper & David C. Kibbe

Microsoft Health Vault’s leader Peter Neupert has a wonderful blog post that makes two important points really well. One message is that health care reform is about the outcomes, not the technology. We should think expansively about which technologies to invest in, based on the results we want to get.

The other message is the economic stimulus package is different than the reform effort. It is moving at hyper-speed through Congress, and it may be difficult for staffers and other advisors to sort through and incorporate what may seem like opposing Health IT views against a backdrop of traditional ideology and extremely forceful special interest lobbying.

Even so, there’s consistency among the health care professionals who worry about these issues all the time. Peter unexpectedly discovered that the messages of his fellow panelists from the Health Leadership Council, the National Quality Forum, the Permanente Federation and the General Accounting Office were remarkably in sync with his own testimony to the Senate Health, Education, Labor and Pensions Committee.

Congress is about to make some big moves in health care that will require immense resource expenditures but, depending on what we pay for, may or may not bear the fruits we hope for. They should move carefully. Not all health care reform has to be labyrinthine. Not all ideas must require huge cost or take years to come to fruition and gain market traction. There are relatively simple actions that are available now, and that the Obama Health Team could tackle to effect tremendously positive, immediate impacts on the system.

Of course, right now the Health IT industry is focused on the promise of a huge stimulus windfall that would be dedicated to their products. But the opportunities we describe below follow principles that have broad support among students of the health care crisis. Two would change the way we pay for health care services, tying payments to documented results. Three are based on how we pull together and make use of the data that can drive clinical and financial decisions, and they overlap, though not perfectly, in their potential. Still, if any system adjustments can be passed through policy initiatives that focus on what’s best for the common rather than the special interests, these should be among the most straightforward.

Payment
Re-Empower Primary Care
There is general agreement that primary care is in crisis, the result of years of abuse and neglect by the medical establishment and by CMS. In simple terms, the primary care/specialist ratio in the US is 30/70. In all other developed nations, its about 70/30. And our costs are roughly double theirs.

We should allow primary care physicians to do the jobs they were trained for, changing their roles from “gatekeepers” to “patient advocates and guides.” We should immediately start financially rewarding them for collaborating with specialists to manage patients throughout the full continuum of care. Keep in mind that, as the Dartmouth Atlas and other studies have made clear, most health care waste is concentrated in the sub-specialties and in inpatient settings, incentivized by a fee-for-service reimbursement system that rewards more procedures, independent of their utility. One very thoughtful approach to invigorating primary care has been advanced by Norbert Goldfield MD and colleagues.

Of course, truly re-empowering primary care will require more than just paying primary care physicians more. Higher reimbursements will help them afford to spend more time with each patient, yes, but PCPs also need help acquiring tools that can help them better manage those patients. And they need the authority to work collaboratively with specialists. Challenging, but certainly doable and important!

Changing America’s current imbalance between primary and specialty care should drive significant downstream waste from the system, dramatically improving quality and reducing cost.

Increase the Incentives For Programs That Tie Payment To Outcomes
Projects like the CMS/Premier Hospital Quality Incentive Demonstration (HQID), in which 250 participating hospitals got 1-2 percent bonuses for achieving quality improvements, have clearly demonstrated that incentives work. The hospitals that pursued the incentives made greater strides in quality improvements than their peers who did not work toward the incentives.

But we need to make the financial incentives large enough to drive real paradigmatic change. Too many programs offer incentives that are trivial in the minds of providers. Does it make sense for physicians in small, busy practices to rework their office flows to try to meet the challenges associated with hitting targets in exchange for a 1 or 2 percent financial bump, tied to a fraction of their patient population?

Now that there’s no question that incentives work, we could easily give these programs teeth by raising the incentive antes to 15 or 20 percent, while also demanding commensurate levels of savings. And we should go in, understanding that the goal is to drive out unnecessary care, and create expectations that, by managing better upfront, the total spend will be lower.

Data
Establish a National All-Payers Database
Data sets, including those comprised of health care claims, must be large to generate credibly useful information.

But health care is financed through many different payer streams and by many players within each stream. Nearly all treat their data as proprietary, and information remains fragmented. So, for example, physicians rarely receive useful information on their complete pool of diabetic patients: instead, they get small slices of data from each payer, each analyzed using a different proprietary methodology. Or, we fail to accumulate adequate sample sizes to identify which treatments, interventions, drugs, devices, health plans, physicians or facility services provide the best value.

But merging those data across payers and making the aggregated set freely available would create the basis to identify true evidence-based best clinical and administrative results. Based on hundreds of millions or billions of records, we might be able to credibly identify which professionals, services or approaches most consistently produce the best results within value parameters. The data set would always be building, providing an always slightly-new base for answering our most difficult questions. Together with the analytical tools that are also becoming stronger and more refined, the potential is vast.

Of course, health plans, always politically formidable, might fight tooth and nail to maintain the competitive advantage they believe is inherent in their data. But health care is a special enterprise, with objectives that are ultimately rooted in the common interest, so they have no real excuse to refuse this. And health plans, like the rest of us, would gain access to much larger data sets that can be mined to advantage.

There also are precedents here. Several states have already begun to establish all-payer databases. At a June 2008 meeting, a presentation on Maine’s experience highlighted 3 fundamental, telling principles that are challenges to any effort.

1. Nobody wants to pay to develop and manage the database.
2. Nobody wants to contribute their data to the database.
3. Everyone wants the aggregated data that develops in the database.

The solution: make it a national effort, paid for by CMS, and with mandatory participation, user fees, and open access to the data.

Create Uniform Nationally Accessible Disease Registries
Many physicians have come to appreciate the value of disease registries. Registries allow clinicians to count all active patients with distinct conditions, e.g. hypertension or diabetes. They can track characteristics within a patient subset, e.g. diabetic patients on a particular medicine. They can monitor and stratify patient status and progress within each group, and generate reminders and alerts to assure guideline level care. And they can identify trends in performance and, with relative ease, get a sense of what works and what doesn’t.

Even so, many registries are still in silos, meaning that the sample sizes remain small and that the parameters that define the registries’ characteristics often vary between implementations.

What we need are freely available, Web-based registries with easy data entry and easy querying capabilities. The impact on our management of patients with chronic illness, who consume 70 percent of our health resources, would almost certainly be powerfully positive.

Release Medicare’s Physician Data
Nearly a year and a half ago, the consumer advocacy organization Consumer Checkbook sued the US. Department of Health and Human Services (HHS) for the Medicare physician data in four states and DC. HHS argued that physicians have a right to privacy, even though, in the case of Medicare and Medicaid, they are vendors taking public dollars, and even though hospitals do not enjoy the same protection from scrutiny. In August 2007, the court held with Checkbook, and on the AMA’s “advice,” HHS promptly appealed, locking up the data for the duration of the Bush Administration.

The large commercial health plans have traditionally considered their claims data proprietary and so have not made their data sets publicly available. Self-funded health plans, administered by Third Party Administrators (TPAs), develop sizable data sets but have resisted collaborating, and have also not expressed an interest in making their data available.

So for those outside the health plan community, there are few, if any, data sources with sample sizes large enough to accurately evaluate and profile physician performance. This is significant, since studies have shown that there can be profound differences, 6x-8x, in resource consumption (i.e., cost) between the least and most expensive physician (within a specialty and market) to obtain the identical outcome.

In other words, not all doctors perform equally. While more patients are paying out-of-pocket for a larger portion of care, there is still virtually no credible information to guide their physician choices.

The American people could quickly learn which physicians within a specialty and a market consistently get the best outcomes at the lowest costs if Medicare physician data were made publicly available. Releasing these data would also put pressure on physicians everywhere to understand their own numbers, and to improve if their performance values are lacking. We see this as beneficial to the great majority of physicians who seek excellence in their work.

Smoothing the Way
American health care is a vast enterprise in which millions of professionals and hundreds of thousands of organizations vie for an ever larger portion of what has historically been an always growing resource pool. The chaos and dysfunction that has developed in health care is largely due to two system characteristics. One is the fee-for-service reimbursement system that has rewarded more rather than the right care. The other is a lack of transparency that prevents us from knowing and understanding performance, even when that performance is dangerous: what works and what does not, which approaches are high and low value, who does a good job and who does not.

The five action steps outlined above would allow us to better identify the problems and opportunities in our health system, as well as the strongest solutions to drive decision-making. Then they would leverage that information to create strong incentives for the right care, organically changing the dynamics of care and reimbursement and, to the degree possible, smoothing the transition required to heal the way we supply, deliver and finance care in America.

Let’s Reboot America’s Health IT Conversation Part 2: Beyond EHRs

Jan 6, 2009• 9

By DAVID KIBBE and BRIAN KLEPPER

Yesterday we tried to put EHRs into perspective. They’re important, and
we can’t effectively move health care forward without them. But they’re
only one of many important health IT functions. EHRs and health IT
alone won’t fix health care. So developing a comprehensive but
effective national health IT plan is a huge undertaking that requires
broad, non-ideological thinking.

As we’ve learned so painfully elsewhere in the economy, the danger we
face now in developing health care solutions is throwing good money
after bad. We don’t merely need a readjustment of how health IT dollars
are spent. We need to reboot the entire conversation about how health
IT relates to health, health care, and health care reform. To get
there, we need to take a deep breath and start from well-established
and agreed-upon principles.

Most of us want a health system that, whenever possible, bases care on
knowledge of what does and doesn’t work – i.e., evidence. We want care
that is coordinated, not fragmented, across the continuum of settings,
visits and events. And we want care that is personal, affordable and
increasingly convenient.

Most of us also agree that, so far, we have not achieved these ideals.
In fact, health care continues to become costlier, quality is spotty,
and the gap between the health care we believe possible and the current
system is widening.

Let’s Reboot America’s HIT Conversation Part 1: Putting EHRs in Context

Jan 5, 2009• 7

By DAVID C. KIBBE & BRIAN KLEPPER

Kibbe & Klepper are back with an update to their pre-Christmas piece on EHRs and the forthcoming Obama Administration’s investment policy towards them. Lest you think that this is just a small group here on THCB and fellow traveler blogs shouting to each other, I’d point you towards the Boston Globe article about their previous "Open Letter," which shows that this discussion (and a similar piece on THCB from Rick Peters) appears to be being taken very seriously. As it should–Matthew Holt

On Dec. 19, we published an Open Letter to the Obama Health Team,
cautioning the incoming Administration against limiting its Health
Information Technology (IT) investments to Electronic Health Records
(EHRs). Instead, we recommended that their health IT plan be rethought
to favor a large array of innovative applications that can be easily
adopted to result in more effective, less expensive care.

The
response to that post was vigorous. We received many comments and
inquiries from the health care vendor, professional and policy
communities – urging us to provide more clarity. One prominent
commentator called to ask whether we, in fact, supported the use of
EHRs. We both have been active EMR and health IT supporters for many
years. Dr. Kibbe was a developer of the Continuity of Care Record
(CCR), a de facto standard format for Electronic Medical Records
(EMRs), and has assisted hundreds of medical practices to adopt EHRs.
Dr. Klepper has been involved in EMR projects for the last 15 years,
and the onsite clinic firm he works with provides every clinician with
a range of health IT tools, including EMRs.

A new year’s resolution for greater hospital transparency

Jan 3, 2009• 6

By Paul Levy

Just thinking, along the lines of a New Year’s resolution. What if all
of the hospitals in the Boston metropolitan area — academic medical
centers and community hospitals — decided as a group to eliminate
certain kinds of hospital-acquired infections and other kinds of
preventable harm? And what if they all committed to share their best
practices with one another and to engage in joint training and case
reviews in these arena? And what if they all agreed to publicly post
their progress on a single website for the world to see?

Are We Finally Entering the Golden Age of Healthcare Transparency?

Dec 30, 2008

By BOB WACHTER, MD Robert_wachter

When will patients start reviewing quality data before choosing their doctors and hospitals? The answer has been “soon” for several years, but “soon” may finally be the right answer. If you doubt it, check out the Commonwealth Fund’s new site, “Why Not The Best?” The central premise of the healthcare transparency movement has been that
putting data on the Web (quality, safety, satisfaction, even cost) will change consumer behavior, the way such data does for autos and restaurants. The movement, which began in earnest with the launch of the HospitalCompare website by Medicare in 2003, lives by the following catechism:

Let’s post some, even rudimentary, quality data on the Web
Patients will look at the data, and demand improvement of their existing providers or choose better ones
This consumerism will create “skin in the game” around performance data
Hospitals and providers, now motivated to improve, will do what it takes to get better.

America’s CEOs set priorities for Obama Administration

Nov 21, 2008• 11

By Brian Klepper

This past Monday and Tuesday, The Wall Street Journal convened an extraordinary conference of about 100 CEOs to develop and recommend issue priorities for the new Administration. (See the participant list here.)

This meeting brought together the nation’s industry power players. Several Senators and Congressional representatives participated, as well as Rahm Emanuel, the President-elect’s new Chief of Staff, and others who advise Mr. Obama.

Based on their business’ core focus, the attendees were assigned into four major areas: 1) Finance and the US Economy, 2) Energy and the Environment, 3) American and the Global Economy, and 4) Health Care.

Then in the General Session that followed, the focus groups’ recommendations were incorporated into a final list and reranked by all the participants. Here’s the graph showing the relative ranking of all issues.

An Impending Hanging: Will Health 2.0 Be Compromised By The Economic Downturn?

Oct 21, 2008• 3

By Brian Klepper

Nothing focuses the mind like an impending hanging. — Samuel Johnson

I’ve been preparing for tomorrow’s 3rd Health 2.0 conference in San Francisco, where I’ll join my pals Matthew, Indu Subaiya, Jane Sarasohn-Kahn and Michael Millenson amid a Who’s-Who cast of health industry luminaries. I spent part of Monday reviewing the attendee and sponsor lists, impressive indeed, testament to how seriously this topic is being taken throughout health care.

The meeting is sold out at 950 participants. It’s worth remembering that, before the first Health 2.0 conference 13 months ago, Matthew, who with Indu took enormous professional and personal financial risk to pull this off, told me he’d be surprised if 75 people showed up. There were almost 500, many of them with genuine influence.