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BLOGS: Health Wonk Review

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HwrWelcome to Health Wonk Review. The bi-weekly round up of the great and the good in health policy wonkery around the web. Putting HWR together this week confirms that health wonks know alot about health care, but can’t follow simple instructions to save their lives. There’s a lesson in there for health care as a whole, and the lesson is that user interface design of software, insurance products, compliance regimens, or blog carnivals has to be mind-numbingly simple and foolproof.

So on with the show…

From Managed Care Matters, Joseph Paduda notes that some US employers are sending their employees to India for expensive procedures and that word is bubbling up into the mass media—more evidence that drastic times call for drastic measures. His take? The more pressure from alternative solutions like Indian surgeons, the better as it will force us to confront our mess of a health care system.  Ain’t competition great?

At Ambulatory Computing Robert J Lamberts writes that Medicare has backed off due to pressure from device manufacturers. There were cuts due for reimbursement for high priced, high end devices, but caving to pressure from the lobbyists for the device manufacturers, the current administration has backed off from this plan. This entry is a rant by a primary care doctor who faces the threat of cutbacks on reimbursements for physician visits.  "Politics as usual" threatens to undermine any attempt at real reform. His version is called Medicare Cuts Scaled Back

On the same topic at Health Care Renewal, Roy Poses says that some naively thought that CMS proposed cuts of its high reimbursement rates for high-tech procedures might make more money available for primary care, etc.  Alas, the cuts were speedily rescinded.  CMS bureaucrats could not withstand the onslaught of commentary from executives of big device manufacturers and hospitals, and surprisingly two famous left-wing senators.

At TMBN Dimitriy shares reports from two Silicon Valley conferences which hint how blogs and social media will transform health care, much like news, politics and entertainment. The AlwaysOn Stanford Summit offers an analogy with Hollywood (do not miss the War of the Worlds spoof video!). BlogHer offers a model of online community fused with a conference and an inspiration for TMBN. Finally, note how the health care blogger survey may help us find the right way to apply BlogHer ideas to health care.

What do the Grand Canyon, a Lotto ticket and the Union Jack have in common? Henry Stern from InsureBlog reports on how one nationalized health system gambles with folks’ lives.

Meanwhile Glowing appraisals of Cuba’s state-run health care system are plentiful in the health policy literature. But even if a few isolated metrics indicate something good (like a high doctor per capita figure), does it justify the whitewashing of medical apartheid? And how reliable are health data from a dictatorship, anyway? The Lucidicus Project touched on these questions.

Of course if you want to get beyond the rhetoric, perhaps you should look at some real data on the topic, as I did on this posting on Canadians grumpily waiting on waiting lists at THCB. Sadly for the anti-single payer crowd it’s just not as simple as they’d like it to be, even if most Americans can’t tell Cuba and Canada apart.

Talking about grumpy, also writing at THCB, surgeon Eric Novack is most pissed off with CMS for deciding just not to pay up for a few days….he should meet some of my clients!

Meanwhile a real full-time wonk, Michael Cannon at Cato@Liberty has not one but two interesting posts on P4P’s role in Medicare FFS (Hint: he doesn’t think it should have one). Michael also busts certain bloggers (err..me actually) for just reading the press release and not the whole report!

David Williams of The Health Business Blog writes about anesthesia-related adverse events which are four times as likely to occur when surgery starts at 4 pm compared to 9 am. Authors of the study call the results "expected." He’s not surprised either, but thinks it’s a scandal that quality varies so much based on time of day.

From MSSPNexus Blog, Rita Schwab writes that participating in the medical blogosphere has educated her about how strongly many clinicians feel about the Joint Commission on Accreditation of Healthcare Organizations. However, this post supports the premise that for all the angst and expense a survey generates, US hospital care is better than it would be without a "big brother" looking over our shoulders.

Vreni Gurd who writes the Wellness Blog says that drinking good quality water in adequate amounts is one of the foundational principles of good health.  Therefore deciding where to source your water is important.  Here are some ideas to help you make informed decisions.

Carol Krishner who’s still Driving in Traffic, tells us about a new senate bill (S 3719) introduced by Tom Harkin (D-IA) that would amend the Public Health Act and Rehabilitation Act of 1973 to establish a competitive grant program to support activities that would improve the health and wellness of individuals with disabilities.

At Drug Channels, Adam Fein has been busy..and he has a PhD too! He says that the Democrats are making Part D “reform” into a major theme of the 2006 elections, and wonders what effects direct negotiations between HHS and manufacturers would have on the pharmaceutical supply chain? Meanwhile the British fake Lipitor scandal continues to expand after an additional recall was announced. Adam wonders what can we learn from the European situation that can shed light on the misguided attempts to allow importation into the US? I think that we can all figure out his answers from his use of adjectives.

Finally people today are larger in stature and live longer than their ancestors. William Marcus Newberry, from Fixin Healthcare, tells us that most of this is the result of public health with sanitation, clean water, better nutrition and immunization, and antibiotics for life-threatening infections. Analysis reveals that conditions during pregnancy and the initial two years of life have a profound impact upon health status in middle and old age. The public would be well served if health policy was based upon these observations.

Meanwhile Fard Johnmar of Envision Solutions and Dmitriy Kruglyak of The Medical Blog Network have launched the first global survey of health care bloggers. It is open to all bloggers that spend at least 30% of their time blogging about health care-related subjects. The survey will run until September 29, 2006. Please go take it.

Next HWR is on August 24 at a to be disclosed location–check the HWR site for details or to volunteer. The one after that is at InsureBlog and the one beyond that at The Century Foundation.

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PHYSICIANS: The sky is falling

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Capitol2Mark McClellan says that Medicare payments to physicians are going down 5%. This of course is leading to political pressure, with the President of the AMA writing op-eds showing that the sky is indeed falling on the heads of seniors. And don’t let any of those pesky researchers at HSC tell you that cuts in Medicare reimbursement actually don’t lead to doctors dropping out of Medicare.

Oh well, perhaps the doctors will make their money back by investing in more specialty hospitals–after all, that moratorium is over. Let the self-referrals begin.

CODA: The AMA Pres uses this sentence "In 2006, Medicare is reimbursing physicians about the same as it was in 2001 — that’s in real terms, not adjusted for inflation." Someone needs to take him to a very basic economics class. "Real" means that it is adjusted for inflation. He means "nominal". And of course someone else needs to explain the P x V = I phenomenon.

 

TECH: Apparently there’s something called the Internet

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The Web Returns to Health according to the Washington Post. Who knew? SCasedadly not too much in the story. WebMD is still around, Steve Case, Time Warner put money in to something called EveryDayHealth—not launched yet. Healthcentral is back; rescued by defense-contracting money-bags the Carlyle Group. All these guys are aping the mainstream health success of WebMD.

Not in the report but more interesting is the attempt by Healthline, and a host of others—and of course Google—to create health information search verticals, and then the coming attempt to get at consumer long-tail sites which several people have been writing to me about.

Finally, the most interesting development is the integration of this information with the actual health information of individuals—that’s the role of the emerging PHR movement, and that’s where the really interesting health web activity is going on. And one version of that is the combination of those records with physician communication systems. yeah, yeah, I know you’re expecting some crack about RelayHealth and it’s long slow evolution, but the fact that at least the service exists is finally making some news. Today it’s in the Wall Street Journal in the column by single-payer touting Dr. Benjamin Brewer.

We’ve had our Web site going for about a year now and while only about 50 of my patients have taken advantage of our online services, they seem to like them. Currently, my patients pay $30 upfront for virtual office visits with a credit card. The software on the Web site takes a systematic and thorough history for any of more than 3,000 different complaints. I review the information and decide who can be treated online and who needs a face-to-face visit. Patients who are referred for office care are only charged for the standard office visit.

The histories these patients generate via the Web site might sound like a waste of time, but they aren’t: They go right into their electronic medical records, so I have their information ready when they come to see me. Patients like not having to repeat the same story to the receptionist, the nurse and then the doctor. I like it because it saves me time and eliminates transcription costs related to summarizing and recording what the patient told me — instead, I can just add some nuances I picked up while talking to the patient, as well as a key note or two. Online patient registration and insurance updates are our most-popular Web-site features, followed by secure bill payment and prescription-refill requests. (We don’t charge for simple email questions or for processing refill requests.) Patients will soon be able to access their own lab results and review their records online.

And of course there is the minor issue of consumer convenience, and competition for it!

Meanwhile, retail health clinics are springing up in a lot of places. These clinics are dedicated to treating simple problems quickly, and they’re threatening to skim the easy patients and the easy money out of the office. For doctors, online visits are a way to keep this from happening. Two weeks ago I was in a CVS pharmacy in Seattle and noticed most Minute Clinic visits cost $59. My patients get online consultations for the same sort of problems for about half the price — and they get them from their own doctor.

Tech: Desktopgate? By John Irvine

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Allthepresidents3_2It seems like only yesterday that officials at the Veteran’s
Administration were issuing public  apologies and pledges to get serious about
security after the theft of a laptop containing the personal data for 26
million U.S. servicemen and women. Laptopgate turned out to be a little less serious
than the early reports predicted. The missing laptop was eventually recovered. The perps dragged away in chains. And
government officials left feeling highly embarrassed. Desktopgate looks to be a little more serious. This time
a large government contractor (Unisys) appears to be responsible.

Leaving aside the question of how exactly you lose a desktop in the first place, this looks like it actually might be a bigger deal than the original security breach at the VA. While less
data is involved, the missing information includes the names, addresses and
social security numbers for tens of thousands of veterans treated at VA
hospitals in Philadelphia and Pittsburgh. It  also includes insurance information and details about medical conditions. Making things even worse, data for an additional 20,000 patients
recently treated at the Pittsburgh hospital may also have been, er … lost. 

Before anybody resigns or holds a press conference blaming a
culture of official incompetence at the VA, let’s think about this. If the incidents over the past few years are
anything to go by, computer theft is a problem that has now reached epidemic
proportions. It seems logical to assume
that the number of unreported incidents is far greater than the number we’re
hearing about.  Unlike government
agencies, corporations are under no legal requirement to inform anybody if data
goes missing. Not many are willing to
take the PR hit that goes along to owning up to a mistake. Why would they?

As many observers have noted, it is apparently human nature to lose/take computers. So what can be done? Developing realistic
policies for data control would be a good start. One sensible approach might be
to equip all government laptops with RFID tracking technology (See: If he
beeps, He’s clean Bob) so that if a computer escapes it can be easily tracked
down. Alternatively,  we could use the Tommy Lee Jones method and handcuff people to their computers. But that doesn’t sound like a very good solution in the long run, given that handcuffs are generally considered fairly uncomfortable things.  I have a feeling that a fortune – not to mention a government contract – awaits whoever comes up with a clever solution to this problem …

TECH: Metcalfe’s law in reverse

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USA Today tells us that 3,000 Patients with defibrillators are now broadcasting their signals wirelessly

Patient demand is growing as the U.S. population ages. Use of implantable defibrillators has risen from about 21,000 in 1995 to more than 250,000 last year. With such high numbers involved, some doctors worry whether they’ve got enough staff and time to process the influx of data home monitoring systems can provide. For example, what responsibility do medical staff face to respond immediately to a potential sign of trouble that turns up in a batch of downloaded data? How do they sort out real problems from the false alarms?"There are concerns about information overload," said Dr. David Martin of the Lahey Clinic in Burlington. "Physicians have less and less time, and they don’t want to have fewer patients coming to their clinics at the expense of having too much paperwork." But Martin expects remote monitoring will enable his team of five electrophysiologists to track their more than 4,600 patients more closely. "There are not enough doctors and nurses to follow these people, so it makes sense to use technology to automate some of the functions that don’t require physicians’ input," Martin said.

So as the technology races ahead, the service organizations which will do the monitoring need to be put into place. But of course this being health care they are only going to be put into place if someone pays for them. And that someone is Medicare. So the key question remains, is this a medical service that has already been granted Medicare’s blessing, or is this some type of disease management service that is still in trial? We know which end of that scale the manufacturers want this to be on, but if this technology cuts physician visits and doesn’t replace them with other funding streams, it won’t be too popular amongst doctors. Which means that it’s all very well but for now these patients are a bit like the guy with the first fax machine!

PBMs/HEALTH PLANS: Medco makes out; Kaiser not so pretty

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So Medco is making even more money by switching to generics.

Medco Health Solutions Inc. reported a 24 percent jump in second-quarter earnings and raised its profit forecast, citing speculation that a generic version of the top-selling blood thinner Plavix may soon be available. Net income rose to $170.9 million, or 56 cents a share, driven by an increased number of customers and higher sales of generic drugs.

You wonder how long their customers will take to figure out that what they’re giving back in rebates they’re taking in spreads that they charge on generics. Apparently the answer is, a long time!

Meanwhile, Kaiser had not such a good quarter, in that their revenues and membership went up but their profits went down to $272m for the quarter.

Kaiser Permanente’s hospital and health plan units saw membership and revenue climb in the second quarter, but quarterly profits plummeted by $91 million or 25 percent from a year earlier, the giant health-care system reported Friday. Officials at Oakland-based Kaiser attributed the steep net income decline to increased operating expenses, "including those associated with the continued investment in facilities expansion, seismic retrofitting and care delivery programs." George Halvorson, chairman and CEO of Kaiser’s health plan and hospital operations, said in an Aug. 4 statement that the giant system is using its earnings "to make important investments" in programs, services, facilities and technology. No further details were immediately available. Systemwide revenue for the quarter jumped from $7.7 billion last year to $8.5 billion this year, a nearly 10.4 percent increase. Enrollment jumped by nearly 44,000 members to about 8.59 million nationwide, more than 75 percent of them in California.

Of course that’s not necessarily a bad thing — it may mean relatively more money was spent on patient care — and at least they avoided the real bloodbath that seemed to be developing at the end of last year when it lost $211 million in Q4. But there remains a whopping big fine to come for the kidney transplant fiasco, so they’re not out of the woods yet.

TECH: It’s not how big your cross is, it’s where you put it

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English comedian Jasper Carrot once did a great election night skit which had a parent explaining politics to a kid in the same way they explain the birds and bees. Hence the line “It’s not how big your cross is, it’s where you put it” (Yes in the UK people just put a cross next to the name on the ballot paper, and the polls stay open way longer, but their electoral results aren’t ridden with fraud….unlike here)

A new article in iHealthbeat by Colleen Egan basically says that same thing about CPOE. Essentially Seattle Childrens and Pittsburgh Childrens both put in Cerner’s Powerchart in their Pediatric ICU. The title is Not Quite the Same: CPOE Studies Using Identical Technology Report Different Results.

Pittsburgh you may recall saw a big rise in infant mortality. Seattle saw a slight drop.

What was the difference? As I said in THCB when the Pittsburgh brou-ha-ha broke, it’s process. Particularly getting the clinicians involved in the implementation and workflow design.

For example, unlike Pittsburgh, Seattle “had active involvement of [the] intensive care unit staff during the design, build and implementation stages,” according to the study. Also, “Both institutions placed a great deal of effort in designing and implementing order sets, but CHP did not have the order sets for the critical care setting available at implementation,” the CHRMC study notes. According to the Seattle study, “implementation issues … rather than inherent issues with the CPOE itself … are the primary risk factors affecting mortality during implementation of CPOE.” Del Beccaro notes that CHP did not have the benefit of extensive previous data or studies to use as a model, so “some of the things they learned were by trial and error.”

That’s no surprise and it goes for virtually every kind of major software implementation—including of course CPOE, as we’ve known from the days of the Cedars-Sinai debacle.

 

BLOGS: Yet more abuse of Federal power?

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Go to the TIME Magazine site and click on the story in the right column below the picture of Madonna called “Blogging all the way to jail”. (Apologies for the odd routing, but there’s a reason for it—honest).

This is a pretty important one for the blogger/citizen journalist movement. A) Can the Feds can force an independent video-blogger to turn over unpublished material, and B) What jurisdiction do the Feds have in a purely local case? (I guess from the rulings on Medical Marijuana we know the answer to that one….) but Silicon Valley Watcher has more on that aspect.

 

POLICY/TECH: Just a wee bit more on CMS caving to the device guys

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I was going to write some more about the CMS capitulation but over at Health Care Renewal Roy Poses has already said it all. Go and read.

This is why the Enthoven plan for putting private entities (or at least non-lobbyable) entities in the middle is perhaps the solution for the US to avoid the whole system getting even more like defense contracting. If the “plan sponsors” got a flat rate (or PMPM) from the government or price sensitive consumers but still had to deliver a mandated uniform benefits package, then they’d have the incentive to beat up on the suppliers.

It is amazing that Kennedy and Kerry can be bought off by their loyalty to Boston Scientific less than a week after Kerry stumps for universal health care. Perhaps he just can’t make the intellectual connection between the high cost of devices and the un-affordability of health insurance. On the other hand, perhaps this country is just ungovernable. We have seen the future and it is Halliburton.

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