THCB

Categories

Above the Fold

POLICY: Shock, horror–I almost agree with John Goodman

• 8

John Goodman, the president of the right-wing pressure group NCPA from which he and his wife draw down nearly $600,000 a year, has a piece in the Wall St Journal called, Perverse Incentives in Health Care. The shocking thing is that I mostly agree with him about the perversity of incentives in health care. He is though wrong to blame third-party payments for everything and more importantly wrong to assume that private third-party payment imitates government third-party payment. In fact the reverse is true. Medicare is modeled after the typical Blue Cross major medical plan of the 1960s, which is why it is so damn hard to reform today. And it’s not third party payment, it’s the way we organize third party payment that’s the problem.

But after reading Goodman’s piece I have no idea what his overall solution is. He even spends some of the article slagging off HSAs, which is pretty rich given that he and his organization pushed them on an unsuspecting nation, mostly in the pay of Dan Rooney and the other scumbags at Golden Rule. His problem with HSAs is that they are connected to third party insurance policies, which then mandate their own rules on what is covered and what isn’t. I’ve been telling anybody who will listen that that’s the problem with high deductible plans for a long time. Well done Goodman on catching up.

Goodman does have one solution. People should only have conditions and diseases that can be cured by one-time procedures that are relatively cheap and can be paid off using a credit card in a finite amount of time. It’s probably a shocking revelation to Goodman and his cohorts in the free marketeer camp, but most health care is required by a small minority of people who are very sick, and they can’t afford to pay for their care with the loose change they find in their couch cushions. That’s why we have third party payment in the first place. So perhaps it makes some sense to figure out how to reform that. Of course Goodman has no answers, which is not something that can be said for either Alain Enthoven or the single-payer crowd.

Actually I guess Goodman does have an answer–just make sure your country’s only illness is relatively mild myopia, because he thinks Lasik is the cure for everything (even if the actual research shows that there’s lots of lies told about that too!).

And then there’s a guy I’ve never heard of at Yahoo Finance called Charles Wheelan writing a very sensible piece about how we fail to rationally ration health care in the US. Why isn’t he writing in the pustilent sore licking section of the NY Times, or perhaps more appropriately, shouldn’t he get his shot in the WSJ opinion page?

CODA: This post is a reminder of why you should never use a web form for anything. I had written the whole thing, got distracted by something else, thought I’d saved it, and when I left the form I discovered that I had set a time for it to publish but not actually told it to publish. So of course it had all vanised. I usually write my post in a third-party client editor called Blogjet.  I’m now trying to quickly redo what I did before using voice dictation, but of course Dragon NaturallySpeaking is giving me a really hard time– it’s really not quite ready for prime time either.

BLOGS: World healthcare blog

You may remember that around this time last year I was the official blogger at the World Health Care Congress in Washington DC. Well now the WHCC folks have got quite carried away and have their own new blog and lots of official bloggers. And yes I’m one of them. Hopefully I’ll get some podcasts with speakers in advance of the conference, and some pod/videos-casts from the conference itself.

The conference itself will be April 22–24 in Washington DC. If you’re planning to be there, and (just say) you want to use your expense account to buy me a drink—get in touch!

HEALTH PLANS/POLICY: Well we know who’s side CMS is on!

• 2

CMS has decided that Medicare private plans are going to get higher rates this year despite the fact that many Congressional Democrats want to cut the rates they’re paid. There’s been a healthy debate on THCB in the last few days on whether or not these plans add much value (and to whom that value is added!). However, it does seem a bit crass for CMS to go an announced next years rates, when it’s clearly being changed in Congress as we speak. Even if they say “well it was Congressionally mandated” they too need to notice who’s running Congress these days.

PHARMA/POLICY: John Tierney covers the Hurwitz Trial

• 2

John Tierney, who sadly gave up his libertarian op-ed column in the NY Times reports on the William Hurwitz trial. Regular THCB readers will remember how appalling the DEA is in its draconian persecution of pain doctors, and how they deliberately changed their own guidelines during this trial and removed them from their website because the defense was going to show that Hurwitz prescribed by them.

If I believed in hell, I’m sure that DEA head honcho Karen Tandy would be going there for her statement that Hurwitz deserved 25 years because he “was no different from a cocaine or heroin dealer peddling poison on the street corner.” But apparently Tandy’s travels are instead taking her to more interesting locales at the taxpayer’s expense.

TECH/PHYSICIANS: What’s wrong with eRx?

• 2

Health Affairs has a study from HSC about ePrescribing. here’s the press release. The team interviewed a bunch of practices using eRx and some not. About 2/3 were using it as part of an EMR, the rest were using a standalone eRx system. It’s not an encouraging study. The main problems identified:

1) Challenges to maintaining complete patient medication lists. Most physicians were able to use e-prescribing systems to access prescriptions written by other physicians in their practice. But none were able to access comprehensive lists of patients’ medications prescribed outside their practices. As a result, physicians continued to rely on patients as the main source of information to complete medication lists.2) Difficulty obtaining accurate patient-specific formulary information. Physicians in slightly more than half of the practices did not have access to formulary data electronically, because either the systems did not have the feature or the practice had chosen not to enable it. In the practices where physicians had access to formulary information, respondents pointed out information was available for only a subset of patients, with estimates ranging from 25 percent to 90 percent. Even when information was available, practices often questioned the data’s reliability. Physicians’ views varied on the value of the formulary information, and in many practices, physicians routinely ignored it.

If the RxHUB vision is working the information about both current medications and formulary information should be available for a substantial share of patients in the eRx application. 90% sounds a little optimistic, but 25% doesn’t sound at all good, considering that the 3 big PBMs who own RxHub allegedly account for more than 90% of commercial lives. It appears tha accurate patient identification is a problem within RxHUB. Given that we’re not getting a patient identifier anytime soon, that’s also not good news..

3) Limited connectivity with pharmacies and mail-order PBMs. Only the practices with stand-alone e-prescribing systems were using electronic data interchange (EDI) that allows electronic transmission between computers in the physician practice and those in the pharmacy or PBM. Local pharmacies’ lack of readiness was cited as a barrier to full electronic transmission. Most practices using electronic fax or EDI reported spending substantial time educating local pharmacies about e-prescribing. It took a couple of months of daily communications about individual patients for pharmacies to be able to treat electronic transmissions as routine.

That tells me that neither of the Surescripts and RxHub visions are yet working in practice. By this stage most pharmacies should be getting the eRx direct into their pharmacy system. If it’s a Surescripts certified vendor (which mot standalones and many EMRs are), then there shouldn’t be a need to rekey in the information at the pharmacy. In fact this line from the actual report “For example, a physician in Syracuse reported that despite the presence of national chains reportedly capable of electronic transmissions, pharmacies in the area were not yet even "fax-friendly." is pretty frightening and suggests that Surescripts has much more work to do amongst its owners!

4) Challenges continue after initial implementation. Practices were not prepared for the amount of interaction needed with outside parties, such as vendors, state regulators, and local pharmacies, to implement and maintain the system. Practices continued to devote staff resources for maintenance well after e-prescribing products were in use.

Hmmm….also not good. The idea is that this is supposed to save staff time.

5) Limited use of clinical decision support. All but one of the practices’ e-prescribing systems offered some clinical decision support (CDS) in the form of drug-drug interaction alerts. However, access to more advanced CDS was limited; about half of practices reported being able to check for drug-allergy interactions, and only 20 percent for drug-condition contraindications. There was general agreement that pop-up alerts were triggered too easily. As a result, physicians typically overrode them.

Alert fatigue is commonly talked about by the vendors of these systems—it’s a problem that will take some intelligence to overcome. But I’m not so sure that this is a gamebreaker. The previous four may be.

There is though some hope:

Practice efficiency. Most physicians agreed that writing new prescriptions electronically took about the same amount of time as writing them on paper once they became familiar with the system and had created a "favorites" list. For those practices that sent new prescriptions electronically, e-prescribing systems eliminated much of the staff time spent printing, faxing, and calling in prescriptions.Legible prescriptions also meant many fewer callbacks for clarification. But respondents believed that the greatest time savings came from streamlining management of renewals, particularly for patients with multiple medications.

Only one practice could quantify savings from e-prescribing. Most of the others provided examples of how it had freed up support staff to do other tasks, although they could not point to staff cuts exclusively from e-prescribing. Several respondents felt that there were no substantial savings because any efficiency gains needed to be balanced against the up-front and ongoing costs of implementing the system and the additional effort invested in tasks that had not been done routinely–for example, collecting information on outside prescriptions. Their perspective was that e-prescribing produces better outcomes for a comparable effort.

Furthermore the data in the study is more than a year old now—so we have to hope that things are getting better. But clearly more work on the plumbing is needed.

assetto corsa mods