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HEALTH PLANS/TECH: Looks like the Deal’s over–or is it?

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So it looks like from Justen Deal’s website that he’s essentially going to be fired in absentia by Kaiser. My assumption is that he knew this was going to happen all along, and was essentially preparing the way for some kind of entry into politics and/or law career. Kaiser too seems to yet again be getting unnecessarily gummed up about the whole thing—for example according to Deal having people from the insurer side handle the case, rather than from the medical group which he works for.

I don’t know much about employment law, but I do know that California is an “at-will” state, which means that you can fire anyone for basically any reason. It’s obvious from Halvorson’s reaction, let alone the exasperated comments from Permanente’s Andy Wiesenthal on THCB, that they had no further interest in communicating with Deal after he went public, and didn’t want him around. So I don’t see why that didn’t happen straight away. Making up a (fake?) policy about “not abusing the email system” is basically a waste of time.

Deal seems to be appealing to a base of supporters within KP in order to “right” the ship. But if there really is malfeasance and/or an Enron-type meltdown going on within KP over HealthConnect–as opposed to normal teething problems from a huge IT installation (which as you know I suspect to be very, very unlikely) –the best route would be to go to those people who do oversee non-profits. That is regulators and the politicians who supervise them.

Given the various issues that Kaiser is having with the State DMHC over other aspects of its behavior , I suspect that Deal must be involved in some protracted discussions with local politicians. After all if there really is financial mismanagement going within KP, then Chuck Grassley is interested in this type of thing, as is Pete Stark.

If on the other hand, Deal is not pursuing those options, then I’m a little curious as to what this whole thing has been about. As an appeal to the massed ranks of KP employees about HealthConnect might seem appropriate if it was a worker’s collective, but it’s hardly likely to sway the board. Unless of course there’s something going on in the works that we can’t see.

TECH/POLICY/PHYSICIANS:American medical care, or Larry Weed on Speed

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Denver
(This one is long on links and short on explanation….sorry, but it’s all old ground here on THCB).

Larry Weed was at IHI last week using the same line that he was using in 1998 and was probably using for years before that.

"What’s the point of outcomes data?" Weed wonders. So what if there are four times the rate of prostate surgeries in Salt Lake City as in Denver? "I wouldn’t know whether I should move to Salt Lake so they don’t miss my cancer of the prostate or move to Denver so I wouldn’t have unnecessary surgery."

That statement has been true for a while, but Eliott Fisher et al are basically now showing that care is better in Salt Lake City. As Fisher says in the roundtable in the Health Affairs blog

The increasing fragmentation — almost atomization — of medical care, and a payment system that rewards commercial behavior on the part of physicians that, from all of my work, looks as if it’s on average certainly wasteful and quite often harmful.

The situation is certainly worse in Miami (and the rest of Florida), and it costs a hell of a lot more there. I know that’s true because Brian Klepper says so too! (read down in the article for his quote). And even the pestilent sore-lickers at the NY Times have finally figured it out.

And much of the reason is the inconsistent incentives that, Jeff Goldmsith points out in a recent Health Affairs article, are making the physicians primarily in the Sunbelt leave their compact with the hospitals and open up their own shops/heart hospitals—all of which are turbocharging the natural incentives that FFS gives them to do more anyway. Not that this is exactly hurting all hospitals; some of the biggest of which are having banner years. But while everyone in the business makes hay, there are those who suffer as a consequence.

And we’ve known about this for thirty years and nothing has been done to stop it.

PS. “Larry Weed on Speed” is an Ian Morrison line about the future of the EMR. 25 years later no one is using the Problem Knowledge Coupler. Which is a pity and a problem.

TECH: Interview with David Blauer, CEO of Click4Care

Click4carelogo_1
David Blauer is trying to raise the profile of Click4Care. He gave an interview to HISTalk a while back, and we tried to connect then. It didn’t happen for a few technical and timing reasons, but thanks to the diligence of his PR slave handler Kim Miller, it happened this week. Click4Care is a relatively new software company (although a lot older than most of those Health2.0 companies I’ve been featuring) that’s spent a lot of time building a very, very complex system for what can broadly be described as care management, sold primarily to plans and payers—with United HealthGroup being the marquee customer so far.

But their goals go way beyond that..to the edges of consumers and patients managing their entire life & health via their software.

Take a listen to the podcast—transcript will be up in a few days

TECH: More wingeing Brits complaining about IT

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Those damn Brits are whining about their shiny new technology again

As revealed in a joint investigation last week by Computer Weekly and Channel 4 News, after Newham Primary Care Trust in East London and Nuffield Orthopaedic Centre at Oxford implemented a system from US supplier Cerner, some patients did not receive a timely appointment with a specialist because of IT-related problems. An enhanced version of this same Cerner system is due to be implemented across England as part of the NPfIT. John Bourn, head of the National Audit Office which investigated a report of a serious untoward incident after the go-live at Nuffield, said in a letter to MP Richard Bacon, "The [Cerner] system reported that it was printing letters inviting patients to clinics, and yet it soon became clear that far fewer people were turning up to clinics than expected as they had not received any notification to do so. "Conversely, other patients were turning up for clinics that they were not recorded as having been invited to. The impact of this was inconvenience to patients, wasting of doctor and staff time and a need to reschedule appointments. The missed appointments then resulted in a backlog of outpatient appointments building up." After a go-live at Newham hospital, details on patient appointments were lost – more than 110 of them for children. The problem was spotted in October 2004, but it was six months before health staff tried to contact parents of the children, and 30 were never tracked down. The incidents at Newham and Nuffield were not specifically the fault of the supplier or the trust, but happened for a variety of reasons.

Why they can’t just order in more pizza and fix it themselves, I (and Neal ) just don’t know. And while I’ve scooped MrHISTlk on this piece of tech news, (and that doesn’t happen often!) he’s clearly in the top 3 health care bloggers, whatever Fared says, and the link to the Patterson (Cerner) Pizza Memo comes via him.

On a more serious note, the UK problem sounds relatively trivial, but it appears that no one followed up to fix it. Given that Nuffield was one of the first to go live with Cerner and both London and the South are following (now that they’ve changed in IDX for Cerner) and with who knows what happening in iSoft land in the North West this problem needs to be jumped on pretty quick. The Brits are very attached to their health care system, but not so to major government IT initiatives. I still remember people telling stories about the ill-fated initial computerization of the DVLC (national car and driver registry) in the 1970s, particularly the mistaken registering by the new computer of a scooter as a “2 wheel fire engine” being featured on That’s Life (a consumer tales of woe show which was a British national institution). The UK is not like the US where a big governmental agency IT screw up won’t matter politically, and the NHS NPfIT is a) way behind where it should be, and b) losing the support of the doctors and the public.

It doesn’t do any of us any good (other than the total luddites) to see the major IT project in world health care go down in flames, especially as the vendors are the same ones as are working over here…

PHARMA/POLICY/QUALITY: Cost-effectiveness in drug approval

I’ve been hanging with the libertarian Canada-bashers from PRI! They and the California Health Institute (the Cal biotech and drug company industry group) invited me to a very, very nice dinner last night. I assume that they used the drug companies’ money rather than the Scaife’s so I can keep my lefty credentials! Then they had a meeting Friday morning, intended to scare the world about the prospect of an Australian-type cost-benefit analysis requirement for drugs coming here.

IMS put out a report saying that access to drugs in the US would be massively restricted if an Aussie style system was imported here; Randy Frankel from IMS gave the talk (although I sat next to him at dinner and he has a varied and interesting background including setting up disease management at Medco and he basically agreed that we were out of easy targets for drugs and had to decide what to do about biotech drugs that cost $100K for an extra year of life).

Ruth Lopert, adviser to the Australian system gave it a somewhat vigorous, but also defensive defence. She said a few things

  • Government doesn’t set prices…price is proposed by the drug co, but then accepted if it makes it under the cost-benefit analysis (i.e. better come into line!) so prices for me-too drugs are lower than for first movers
  • She says prices for innovative drugs are higher in Australia than they are here! (Gleevac, Embrel)
  • She says it’s not a mechanism for cost containment, Australia’s drug costs are going up 12% a year. (to which I should almost asked, but didn’t, why bother at all then!)
  • And if it’s not reimbursed by the state, you can pay out of pocket! And for most patients in Australia paying out of pocket costs less than the average payment me for drugs by a typical patient on Medicare Part D!

Marjorie Ginsburg, from Sacramento Healthcare Decisions, talked very entertainingly about their report in which they found that people where in general happy to say no to funding certain technologies (including Aricept for Alzheimer’s).  There is a subset of people who believe that if it saves one life (such as an implantable defibbilator) it’s worth it, but once you get past direct life saving technology, they don’t care. Only 12% said cost effectiveness should never be considered. 50% said it should always be. Other things they want — 67% wanted price controls, 56% wanted cost benefit analysis, 49% want more oversight. Her message is that this is acceptable—but don’t do it just by itself. It will have to be part of a whole package of how to deal with health- are. The way to get this done, she says, is to present as getting it best value, not cost savings.

Meryl Comer who’s been caring for her husband with Alzheimer’s for 12 years gave a harrowing talk about the impact that’s coming from that disease. She said that there’ll be 13.9m Americans with Alheimers by 2010. 650K are diagnosed while still under 65. Make it to 65 and there’s a 1 in 10 chance that you’ll get it; by 85 it’s 1 in 2. Still no cure, even though the disease was discovered in 1906. She wants to make sure that the access to successful cures is not prevented, because it’ll save so much.

Kwabena Adubofour, a diabetes care clinic director from Stockton gave a long talk about how EBM analysis for drugs is largely irrelevant while care is generally problematic, and that there’s massively unequal treatment based on ethnic origin, poverty, et al. His concern is that limiting pharmaceuticals via cost containment in this environment is a double hit on minority health care. He points out that there’s a huge gap in care for blacks compared to whites (much fewer rates of referral) women only got 60% of the referrals that men did, blacks only got 60% that whites did. He thinks formulary redesign is irrelevant—there’s lots more to do first. His long list of stuff included DM, pay for Improvement, reducing unnecessary care, etc, etc). He thinks that no one (as far as he can tell) is against rational thinking about how to tackle pharmaceutical costs (Can’t say that I agree with him about that!) But we should only be doing that in the context of this other stuff.

Peter Pitts, ex-PRI, ex-FDA, claims that the problem is that one size doesn’t fit all in health care (or anything else) because EBM is a regression to the mean. And the studies ignore the massive patient based variation. (and he’s right….) So his answer is no formualries. He says that restrictive formularies cause higher costs later. Genomics/personal medicine will fix all this. At least I think that’s what he’s saying. He’s saying we need innovation? (Are we opposed to that over on the EBM supporting side….I’d guess he’d say we are!)

BTW if you’re a former governor, you still have to show up at things like this. At least Pete Wilson is here. Another disincentive to run for public office!

The Q&A pretty much was a fight between Pitts and Lopert.

The audience was very amusing. 2 doctors asked random questions. One said “why is the government establishing these guidelines, shouldn’t a 100 flowers bloom”. Another decried cookbook medicine and said that “Evidence-based medicine is creating Alzheimers in doctors brains…” (i.e. it’s stopping doctors from thinking). Randy Frankel smacked them both down by explaining the variability in medical practice, and showed that it takes 17 years for a guideline to come into being.

Peter Pitts answered my long long rambling question/comment trying to figure out what the panel was about by (essentially) saying that he’s opposed to formularies, and that third party payers should pay for whatever the doctor wants to prescribe. Kwabena Adubofour says that in cost containment with pharmaceuticals, it’s always the cheapest drug that gets pushed—not the best “value” overall.

From the audience The medical director of Safeway (didn’t catch his name) and Anthony Barrueta VP of government relations at Kaiser Permanente both essentially said that EBM is about changing physician behavior and we need to do that. Because, for example, per capita we do 19 times the rate of back fusions than they do in Denmark. That’s some practice variation for you! That’s what happens when there are no guidelines…the Safeway med director says that when Australia is spending 9% of GDP and we’re spending 17% it’s crazy to think that we don’t have a problem.

An interesting session, but I don’t really know what it was about! We’re going to get some level of practice guidelines and EBM incentives via P4P, they’ll be fought tooth and nail, and cost-effectiveness analysis will be part of that process. But it ought to be done in the context of wider health care reform, because this is not the biggest problem in our health care system. And you know what is, with more evidence just last week…

POLICY: Wyden’s health care plan

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Wyden_smile
Oregon Senator Ron Wyden’s health plan is announced with a flourish and a call with a gaggle of bloggers. Best quick explanation is by Ezra

The bill is a replacement of employer-based health care with the purchase of individual insurance via regional pools, which look very like Clinton-style regional health alliances–except they’re now called “health help agencies”. No underwriting, guaranteed issue, community rating and an individual mandate with subsidies up to 400% of poverty and a minimum benefits package equivalent to the BCBS plan in the FEBHP. All very similar to Enthoven circa 1984

From the call. Some notes…

Wyden said that the Hillary bill was too big in 1994 and you can’t expect the Senate to consider a bill that has to be moved around in a wheelbarrow. His is “only” 160 odd pages.

Maggie Mahar asked if the plans just wouldn’t pay the providers for the cheapo plan way way less to the things they provide for the more expensive plans. Wyden says that there’ll be a “floor of decency,” and that all those commercial plans will pay a better rate than Medicare—so he sees the end of Medicaid and second class health care citizens. No global budgets, because the plan would reduce costs  also be a slightly barer plans than some employers provide now. Cost reductions would come from increased competition as people trade down to less rich plans, and through reduced administrative costs—he has a Lewin report to prove it (something else that smacks of 1993!)

Max Sawicky asked whether relying on consumer choice and market competition to hold costs down will work. Here’s what Wyden said. From the first paycheck, employees will see the added health benefits in their paycheck right now, and they’d be required to go out and purchase the basic package. (It would be a wash from tax standpoint for now, as they’d get a new deduction). After the first two years, there’s no longer a requirement that employers would have to pay the salary “increase” but employers would keep the wages up because otherwise the good workers would leave. But after that every employer would be required to make a payment based on their size—and that tax would total more than $100bn) a year. He was asked if that looks like an extra tax which penalizes the employers who were already good citizens and were providing rich insurance already. His response was that overall employers will pay less because in the first two years, the employers will not pay for the growth in health care costs over those two years, they’d just pay the cash amount they were paying in Year Zero. (That does presumably mean that any cost increases will be paid by consumers). Employer wins on day 1 because they don’t pay the increase. Then in 2 years they pay the tax. …..but they haven’t quite figured out that transition for the employers that had very rich benefits. How do you have real consumer choice? How do you make a market? Right now we don’t have one—he thinks his transition will help it.

I asked, so if that works, how are you going to get the provider and supplier industry to not object with extreme prejudice? After all, if we’re going to spend less money they’ll be less industry income! His argument is that primary care docs are going to get a boost in reimbursement; there also be a boost in chronic care preventative spending (although to be honest I missed the details). The doctors will also be bought off with malpractice reforms and all doctors will get paid commercial rates for all patients. He didn’t mention anything about the rest of the industry beyond primary care docs. So I think that he knows he’s in for a big fight! And of course if the plans actually do compete on not increasing costs to consumers in years 1 & 2 with a fixed benefit package, by definition less money will be flowing providers’ way.

Wyden ends by saying that elected officials have been way too timid, and nothing much has happened about health care for far too long. He wants a specific bill to force the debate so that Presidential candidates will have to engage in the debate. And that I suspect is the point, although I fear that he’s 4 years too soon. (And of course given the condition of S. Dakota Dem Senator Tim Johnson, there may not even be a Democratically elected Senate to introduce the bill into!)

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