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TECH/HEALTH PLANS: Chris Rauber pokes more into KP

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For those of you who can’t get enough, Chris Rauber, health care reporter from the SF Business Times has discovered that the investigations into the KP Kidney transplant fiasco are getting wider. And if anyone from KP wants to go on the record about that, as did Andrew Wiesenthal about the HealthConnect issues, I’ll be happy to give a full and fair interview.

Meanwhile I’d missed this, but he also caught this one from July—Kaiser was trimming costs in its outsourcing for IT staff  by asking vendors to cut their rates. If you looked at HotJobs for tech jobs in San Francisco this year, you’d have noticed that KP was on a hiring binge for HealthConnect, so this all fits with the desire to cut costs.

Meanwhile even more gossip about Epic and whether running the future of health care on a 30 year old obscure programming language is a good idea or not here.

Oh, and at DiabetesMine, Amy Tenderich finally has her interview with KP’s PR guy in charge of promoting their HealthySolutions DM outsourcing group, who explains a little more about how their internal DM processes work. You get the impression Amy wishes that she’s done this interview a little later!

I’m sure there’ll be more, whether or not Epic employees think this is newsworthy!

 

POLICY: This is just brutal

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Ugly truth: no health insurance, no liver transplant.  Lose your health insurance in your 50s for a brief time period and your reward is death and bankruptcy. You cannot read this story without going “that’s not fair”. There may be a rational way to decide who gets a liver transplant, but this is not it.

And as more and more of these stories get out, the pressure for change will continue to bubble. (Hat-tip FierceHealthcare).

TECH/HEALTH PLANS: more on KP

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Well it’s coming thick and fast. First the podcast with Andrew Wiesenthal (previous post here). Then Gadlfy in her anti Kaiser site has some more about her take, including her commenters thinking that I’m just an apolgist being paid off by KP (and I’m still waiting for the check!).Finally MrHISTalk has much more on his site including this list of questions, which using what little I know and was told, I’ve tried to answer below (Questions have bullets; my answers are below)

  • On George Halvorson’s first day, he cancelled KP’s existing $442 million KP-CIS project to implement electronic health records.
According to Wiesenthal, Halvorson asked a big team to take a look at what the right solution was–postponing the CIS project at that time. Separately a senior KP doc who’s a tech expert, who I know and respect and has not been in the news, told me that the IBM code was the worst he’s ever seen, but that Epic’s was good (He also said Soarian might be better if it ever got into production!). CIS was considered as a potential option going forward.
  • Mr. Halvorson had also pushed through the selection of Epic at the health plan he previously had led, in Minnesota.
  • George Halvorson’s previous employer, HealthPartners of Minnesota, has faced significant problems with its Epic project, and, so far, the Epic software has only been able to completely cover about half of HealthPartners members. 
HealthPartners definitley selected Epic while Halvorson was CEO and it seems to be working OK there—according only to a patient that I know! Not clear who lead that selection or how badly things have gone there compared to what they hoped to achieve.
  • KP’s CEO and CIO ignored internal engineering reports which said Epic software would be unreliable for KP’s size and difficult to adapt to KP’s scope.
Unclear as to whether this is more than rumor. Wiesenthal said a large team looked at Epic, CIS and Cener (on Halverson’s request) and decided that Epic was the best option for what they were trying to do. He says the current problems are to do with Citrix (some thing to do with too big a server installation in one place) and power and UPS problems in their S. Cal data center. His quote "Epic is rock solid"
  • Mr. Dodd brought in a company called Tanning Technology to give an opinion on the viability of Epic within an organization as large as Kaiser Permanente. Mr. Dodd, while serving as an officer of Health Plan, also simultaneously served as a director for Tanning. Ignoring this significant conflict of interest, Mr. Dodd paid nearly $1 million dollars for Tanning Technology to give a favorable report on his and Mr. Halvorson’s predetermined plan to shift KP’s business to Epic.
Tanning apparently was brought in for a different task not related to HealthConnect, who’s selection Dodd was NOT part of. Wiesenthal claims not to know why Dodd resigned but claims it had nothing to do with the Deal email
  • A decision was made to replace almost all of the KP home grown systems … with one "integrated" system and do it in three years. Those making the decision had no concept of the real scope this project or the expertise required to do it. Epic is a good product whose average client was no bigger that 2,500 users running on one instance. Kaiser retooled it to scale to 150,000 users and 20 instances using the same building and configuring techniques as the average client, which is manually building and configuring again and again.
This is basically true. But only because no one had done anything this big before in health care and certainly not in the US (outside of the VA), so it’s likely that they didn’t know what they were getting into. The proof though will be in the pudding when it’s all up and running system wide in a year or so, and seeing whether it works as advertised. They’re clearly not turning back
  • KP-CIS (the homegrown system that Epic replaced) was not a $400 million loss for KP, it was much more. Somewhere around $4-5 billion. In 2000-2001, KP-CIS was spending between $500,000 and $750,000 a day.
Highly unlikely. In this period KP went from losing money in 1998ish to making big profits in the early part of this decade. How they would have hid a $4bn loss/write-off in 2002 is unlikely. If CIS was spending $500,000 a day from 1998 to 2002 that still way less than $1 billion ($500K x 365 = $182m. $182m x 5 <$1bn. So the $400m write off sounds much closer to the truth given back of the envelope math.  And according to one interview I read (I think with Halvorson) some of the money they paid IBM in that $400m, they got to transfer over for use of hardware, etc.
  • One of the major problems with KP-IT stems from the continuous turmoil in the organization.
And this makes them different to other large American corporate entities, how? In addition apparently HealthConnect and the KP-IT stack are not the same people (which of course may be part of the problem!!)
  • J. Clifford Dodd was soon discovered to be on the board of directors of one of the companies he was outsourcing to. He first resigned from Kaiser (in an e-mail) and then said that he really meant to resign from his outsourcing company.
Second part is rumor (unless someone kept that email). First part appears to be confirmed by Tanning’s SEC statements referenced elsewhere on HISTalk–he seems to have selected Tanning for work while he was both a director there and was their hirer at KP. I assume that this is why he resigned–on the presumtion that either this was kept from the board/management or ignored by them between April 2002 and last week.
  • Epic outages called "Code White" have increased from just over 9,000 user hours per month in June to over 59,000 last month. When the system is down, no paper or locally stored data is available, so treatment decisions are made without any previously recorded information.
Wiesenthal suggests that this is to do with the power and Citrix issues mentioned earlier and that the major problems were earlier this year. (More details in my interview with him). He claims more than 98–9% uptime since. Someone smart than me can work out how many user hours there are, and how many a single half hour failure adds to that total (as happened this week) and how much that relates to the 99% claimed uptime.
  • The 26,500 concurrent KP users figure isn’t anywhere near accurate – it’s more like 9,000 to 13,000, on average. Saying 24 hospitals are live on "several apps" means they’re live on check in and registration, and maybe a few people are echarting. Those two hospitals that are "completely rolled out" regularly (at least every few days) drop to Code White (back to paper).
More details are in the interview, but Wiesenthal says that the outpatient side of HealthConnect is up everywhere outside Calif and up for 30-40% of both California regions. (That’s were most of the users are of course). Only 2 hospitals in Cal are fully up on Inpatient Epic plus other apps in the suite, but others are coming on board over time. The concept that both hospitals are using paper seems unlikely as Wiesenthal stressed that outpatient clinics on Epic use no paper. Rationally, paper copies of everything for an EMR doesnt make sense. As with the Parkland experience discussed in HISTalk, a strong unbreakable contemporary electronic back up is what’s needed and what Yahoo, Ebay et al do for their businesses.
  • Bruce Turkstra is interim: as soon as they can find someone outside who will take the job, Bruce is gone, too.
Who knows. Certainly doesn’t seem that Dodd’s departure was planned. Wiesenthal stressed that HealthConnect is his baby on the Permanente side and Louise Liang’s on the plan side and Dodd had nothing much to do with it.

TECH/HEALTH PLANS: A Permanente Group Executive speaks

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There continues to be much flack in about the “email heard around the health care IT world” about Kaiser Permanente’s HealthConnect program and its success or lack or it, and its contribution or lack of it to a potential massive shortfall or profit  in the organization’s finances. If you want to know what lots of insiders and outsiders think, go read these comments on KP in this HISTalk post. Suffice it to say that there’s a wide, wide divergence of views on whether Epic is scalable or not, or if anything else would or could work. Given that this is America’s largest health care EMR deployment, it’s not a trivial issue.

But in addition there are wider rumblings that something is going awry at Kaiser Permanente. Given that it’s just coming out the other side (bar the lawsuits) of a scandal where something went very badly wrong in its new kidney transplant program in Northern California, this latest brou-ha-ha is more grist for the mill for the anti-KP folks. I am not one of those, and in fact have been criticized for being too supportive of pre-paid medicine in the past. But I call things the way I see them, and I don’t get any money from Kaiser. So I’m trying to remain “neutral” in what is a highly emotional issue.

Today Andy Wiesenthal, an Executive Director with the Permanente Federation, the umbrella group for the regional PMGs emailed me offering to go on the record. I told him that I would ask about HealthConnect, the kidney transplant fiasco and how TPMG works with the health plan. This podcast is what he had to say when we spoke late Friday evening. It was via cell phone so the sound quality isn’t the greatest.

He was unable to comment on the kidney transplant story, claiming to only know what he read in the papers. But about everything else he had strong and I think relatively balanced opinions–especially as he was the physician executive in Colorado who was in charge of the CIS project that was being implemented system-wide when it was scrapped in favor of the Epic/HealthConnect software system–which he strongly defends.

Whatever your views, it’s very interesting stuff. I hope I asked him the tough questions and in general I think he gave very thoughtful answers. And it’s to his credit that he decided to get his and Permanente’s side of the story out, as they’ve been far too reticent to talk openly in the past. Here’s the interview. There’ll be a transcript as soon as it’s available.

TECH: Medsphere; what’s going on?

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Fred Trotter, advocate of open source for health care , has tried to help out Medsphere which is having a nasty dispute with its founders Scott and Steven Shreeves. This is long and complex, but if you’re interested read this one first then this less happy one — Medsphere betrays community

Fred is particularly concerned because Medsphere is seen as the leading open source health care company. Fred believes (probably rightly) that if Medsphere is seen either not to be able to hold a rational open source model together or to be betraying the open source model, then open source in health care is probably dead.

UPDATE: Dmitriy writes in to say "I know, for a fact, that a "well known HIT infrastructure firm"
decided to not pursue MedSphere for a partnership because of this mess.
As a company MedSphere is done – who in their right mind will
contribute to their project? But I have no doubts that other flavors of
VistA, under better stewardship have bright future."

BLOGS: Business Blogging for Health Professionals

Dale Hunscher of FutureHIT is a glutton for blogging punishment who wants to afflict his addiction on the rest of health care’s unwashed masses. So he’s written a book and a has a blog called Business Blogging for Health Professionals. Go check it out but don’t say you weren’t warned when you find yourself in Dale’s predicament (and mine!), and notice that in his “five reasons you should be blogging”, getting paid wads of cash is curiously absent from the list!

JOBS: Hospital Accounts specialist for software co

And on the not really existing jobs board… (it’s the board that doesnt really exist, the job is real!)

a healthcare financial services, software company seeks Hospital Accounting Specialist. Ideal candidate will have an accounting background with work experience in a hospital business office or finance department. Must have experience in the preparation of Medicare cost reports as well as Medicare and state Medicaid disproportionate share calculations. Also must have experience in the review and analysis of hospital AR days and government receivables

Email me your resume if this is you!

INTERNATIONAL/POLICY: Compare and contrast the attitudes

Crowd Protests Health Care in China (in the New York Times)

Some 2,000 people mobbed and ransacked a hospital in southwestern China on Friday in a dispute over medical fees and shoddy health care practices……essential medical care was denied the boy until his grandfather, who was taking care of him, could pay for the treatment. The boy died after the grandfather left to raise money, the group said. An official report from the New China News Agency confirmed that a dispute over medical fees erupted at the hospital, but also said doctors there had treated the boy even though the grandfather did not have $82 to pay for the service.

But no one seems to care in the US, in fact it’s fine and legal in the Sacramento Bee

And then one day my husband was in excruciating pain and the morphine we had at home, nothing I could do would relieve his pain, so I called Cedars Sinai to say I’m bringing him in, he needs — he needs something. He needs to be relieved of this pain. And they said I’m sorry Mrs. Christensen you guys are not allowed through these doors anymore, your insurance has capped out, they’re not paying us anymore and your bills are high. And we can’t allow you to come through these doors anymore. So I had to take my husband to an emergency room where he sat for about eight hours, you know, which is the worst place for a cancer patient to be.

HEALTH PLANS: Legal cons abound in health insurance

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(Hat tip to Don McCanne). Apparently being a scummy insurance company and selling not-quite-fraudulent policies to dumb consumers is all fine and dandy—or at least legal. This is not the first or last we’ve head of this type of thing—a company called Mega Life and Health selling a cut rate policy via commission salesmen to unsuspecting punters. When something really bad happens the punter discovers that the policy is worth basically squat, and they owe $200K plus. The judge says this is America and you should have read the fine print. We all know that the best cons are the legal ones.

There’s a related category of insurers who pay out on small claims but dissapear completely when enough big ones come in. Jon Cohn’s soon to be published book will blow the lid of that bunch (I hope) so I won’t say much about them. But essentially these are all on a sliding scale from California Blue Cross cancelling coverage after the fact, to Golden Rule selling their underwritten products, to the con artists and outright fraudsters. And given the collapsing state of the employer insurance market, and the growth in desperation from people like the couple in this article, I guess it’s only a matter of time before these insurers become a bigger and bigger piece of the market and someone like United HealthGroup buys them.

And if Active Health Management is over on the Yin side of the health insurance world, these shysters are out there on the Yang end. There is a possible solution to the whole thing, but if the responsible heads in the insurer world won’t push for serious reform of their own industry, these kinds of stories will make a government run system much more likely. I suspect I’ll be saying “I told you so” in 2016 or thereabouts

CODA: I missed this at the time, but the (now fortunately dead) Shadegg bill would have aloowed the shysters at Mega and their ilk to do this everywhere, as PBS NOW reported. See the excellent transcript.

HEALTH PLANS/POLICY: Policy wonks explaining the bleeding obvious

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KFF has some new reports out. The first is a Comparison of Expenditures in Nongroup and Employer-Sponsored Insurance. Here’s what the press release says:

The first Snapshot examines the differences in costs associated with individual, nongroup insurance and employer-sponsored insurance. Premiums for nongroup health insurance available from online brokers or reported by insurance industry surveys are much lower than premiums observed for employer-sponsored coverage. This is surprising to some because nongroup health insurance has higher administrative costs. The paper uses data from the Medical Expenditure Panel Survey and finds that people covered by individual insurance have much lower health care spending on average than people who have employer-sponsored insurance, but pay a greater share of that spending out-of-pocket. It also shows that those with individual insurance are significantly more likely than those with employer-sponsored insurance to report that they are in excellent physical and mental health. These findings may help explain why premiums for individual coverage are actually lower than group coverage. The analysis suggests that proposals to extend coverage to lower income people through lower cost nongroup health insurance need to account for the higher out-of-pocket costs associated with these policies.

In other words when someone tells you that eHealthInsurance.com is selling a product cheaper  than employers buy it for (as the Galen folks and David Gratzer’s book have recently done), you need to understand that they’re not only selling something different (lower benefits) but that they’re refusing to sell it to people who might actually use it.

The second is a little more subtle. It’s about the ratio of sick people to healthy people in an insurance pool, and the impact on the pools overall cost (premiums). Again from the press release:

The second Snapshot examines the sensitivity of health insurance premiums to enrollment shifts by high cost enrollees – a process often referred to as adverse selection. The introduction of high-deductible, consumer directed health plans has raised concern about their potential to attract younger and healthier people away from more traditional insurance plans, which could increase the costs of those plans. The public discussions of this possibility are often phrased in rather extreme terms – for example, that consumer directed health plans attract primarily the young and healthy. The new report shows that extreme selection behavior is not needed to produce real premium differences between insurance pools, and that the shift of even a small percentage of high spenders from one risk pool to another can have a dramatic impact on average costs – and, therefore, premiums – in the pools

In other words, you only need to avoid a very few sick people to make your pool cost much less. This is something that Medicare Advantage plans (and the GAO) as well as those in the individually underwritten market have known for years. And it’s why the only rational policy outcome (note I said rational, not likely) is a single national pool.

CODA: This is too funny. The very next email into my inbox after the KFF one was the charlatans at Consumers for Health Care Choices (Greg Scandlen) promoting a dinner for Pat (loony) Rooney–the guy who founded Golden Rule and pushed HSAs, and basically is more responsible than anyone else for fracturing what was left of the nation’s insurance pool, and causing all the problems that KFF is explaining!

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