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POLICY: Tax health care benefits, go on I dare ya!

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Hat tip to Ezra, who clearly wasn’t partying enough this weekend and read the NY Times on Sunday. In it there’s a rational argument that me, Fuchs, Enthoven and Eric Novack all agree with: get rid of the tax deductibility of health benefits.

Next year, the federal government expects to provide about $130 billion for Americans to buy health insurance. The amount is substantial: it is equivalent to about 11 percent of all federal income tax revenue and more than a fifth of federal spending on Medicare and Medicaid. And it is growing fast: the bill is expected to surpass $180 billion in 2010.

Of course, this was recently proposed  by the same panel that suggested getting rid of tax deductibility of mortgages, and immediately disowned by the politicians who set up said panel.  But linking this to the issue of the uninsured and showing that it’s unbelievably regressive on those people who buy their own insurance and don’t get the tax break can’t be a bad meme for us wonks to pursue.

PHYSICIANS/PHARMA: Is academic medicine beyond salvage? by The Industry Veteran

Several people are concerned about the integrity of our medical leaders, and the latest Cleveland Clinic spat has upset a few people, notably local MD Medpundit. I have a more jaded view. I liken it to when I heard that lawyers have to take an ethics test but are only not allowed to practice if they fail it, I assumed that any lawyer passing an ethics test lacked the aptitude required for the job! However, making a welcome return to THCB, even the usually cynical-beyond-belief contributor The Industry Veteran appears a little concerned. He writes:

I had previously viewed the tussle between renowned cardiologist Eric Topol and his boss at the Cleveland Clinic, Delos Cosgrove, as principally an academic spat whose significance did not extend beyond the personal fortunes and the organizational power positions of the two principals. The Times’s article, by contrast, suggests the Cleveland bash reveals that the integrity of academic/high research medicine is fundamentally compromised. Instead of remaining disinterested researchers who help to develop and evaluate new medicines and technologies, big time researchers and their institutions own equity positions in the companies whose products they evaluate. The very notion that medical researchers are gatekeepers for the public, motivated by professional ethics and the search for scientific truth, remains a fool’s myth. Who guards the guardians?I recently asked a friend who teaches marketing ethics at his university to tell me his views about the recent editorial in the New England Journal of Medicine. That was the one where the Journal’s editors belatedly said they were shocked, shocked by the fact that Merck’s shills neglected to include three instances of myocardial infarction among a sample of Vioxx users. The specific issue for which I sought clarity concerned the relative responsibility of the academic physicians who authored the study (or, more accurately, whose names appeared above the study, since Merck’s medical writers doubtlessly wrote the paper) versus that of Merck, who sponsored the research. My friend’s pontifications assigned the lion’s share of blame to the physicians. They must reasonably be expected to know that the first and final interests of any corporation’s operators lie in obtaining profit to satisfy shareholders. In this particular case, the academic physicians would have been psychotically detached from reality not to have known that Merck’s pursuit of Vioxx profits included a thoroughly unethical inclination to twist and hide data. “If they were willing to accept research money and sponsorship from known crooks such as Merck,” he wrote, “then they had a responsibility to act with the very highest possible standards of ethics, and my guess is that they fell far short of that.” The Times article flicks off the lid to reveal that these kinds of self-aggrandizing conflicts are the routine condition of high powered, medical research.

POLICY/INTERNATIONAL/PHYSICIANS: It’s not just here that doctors fees are an issue

And from the THCB Japan bureau (well actually the Yomiuri Shimbun)….

It’s worth noting that the Japanese, who have one medical fee schedule for all of their multi-payers (and also a complex system of cross-subsidization between those payers), are about to cut fees and reallocate them. In Japan private doctors make lots and lots more money than hospital-based ones, and the government is slowly trying to move the incentives away from what’s traditionally been a system with a high-volume of office visits and prescriptions of dubious benefit.

We’re about to do the same here, calling it pay for performance. Like there it’s going to turn into a fight. Joe Paduda notes today that the AMA is having some success in its attempt to stop the 4% cut that’s scheduled to come into effect for Medicare at the end of the year. And is directly linking it with a demand to stop pay for performance.

The advantage that the Japanese have got is that there’s only one fee schedule to argue about. Here we have gazillions and no one really knows what they are…

TECH: More on CPOE

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Typepad (the hosting service I use) was down on Friday, giving THCB an involuntary day off. Here was my FierceHealthcare editorial on Friday. You can use this as a continuation of the discussion from last week:

There is little doubt that the big story in health IT circles continues to be
the CPOE study in Pediatrics which found an alarming increase in
mortality rates at Children’s Hospital of Pittsburgh. Those conclusions
generated a fierce debate as to whether we need CPOE systems, and whether EMRs
can be adapted for critical patient care situations. Yesterday, leading patient
safety expert Bob Wachter likened the phase medicine is undergoing to one
similar to that in aviation in the middle of last century–from independent test
pilots to team players–as described in Tom Wolfe’s The Right Stuff.
Even though no pilot would go back to doing things the old way, it was not a
painless transition. What is clear is that the introduction of new technology
requires a detailed examination of virtually every care process, and in some
cases the benefits can only be realized if the process is changed to fit the
technology. That is a very complicated sell.

TECH: Cerner’s very rough days

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So despite the denials, Cerner’s stock had another dreadful day. Following a fall on Wednesday, Thursday it was down another $10 on concerns that they’re cooking the books. Now Neal Patterson may be a rough around the edges guy, but he’s no dummy and he knows about Sarbanes-Oxley.

Cern

On the other hand, it’s not a bad time to be taking profits and people have sat around not believing it before, and then Enron and Worldcom happened.  So a little bit of panic selling/locking in profits is a logical explanation.

Still, I at least am looking forward to seeing whether the clear gain in market penetration that Cerner is seeing is really not being translated into more cash flow, revenue and profits.

TECH: Christiana hospital knows where you are

All the staff, patients, physicians and everyone else in the ED in Christiana hospital  (in Delaware) is now tracked everywhere they go…and it works — but no staff tracking in the break room or bathroom. But quite a few tracker badges get stolen by paranoid patients! (They lost 600 badges @ $90 each(!) in the first year from staff and patients, but now it’s going down) This is the future and it really helps with workflow through the system.

Very interesting talk from Linda Lakowski Jones, who runs trauma, ED and the helicopter service for the 800+ bed hospital — (please please never give me that job!!)

QUALITY/TECH: Bob Wachter on patient safety

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Bob Wachter is probably the leading expert in the nation on medical errors and a great speaker.

He’s worried about the lack of budget for training, and that IT = Patient safety. But he does think that the IT/EMR movement is now tipping, especially as the disconnect between patient’s perception of being high-tech and what’s happening in the health care system is not tenable, and docs saying that they can’t do it is not credible even for the older docs

He talks a little bit about computer induced errors and problems. There’s a new literature replacing the Bates stuff about how great the Brigham’s system was, and now it’s all about how it’s going wrong.  It’s not a mistake to computerize but you need to go in with your eyes open. You need to think about the process improvements…including the easy ability to cut and paste H&T and continuing on mistakes. What happened when the computer goes down? As at Beth Israel Deaconess. And then in the example for Childrens’ Pittsburgh, does CPOE kill people? Well the chaos still goes on and CPOE clearly gets in the way in ICUs. The critiques of this study are that they "didn’t do it right" but that’s what an implementation looks like. Plus what looks good in the demo doesn’t work per se in your local community hospital. Or the experience of the Brigham is not transferable …unless your hospital also has a 1,300 strong IT department.

The Cedars Sinai story: They built their own and they built in some decision support. But the medical staff revolted. Too many alarms, reminders, too many screens, etc, etc. But not just that, also a story about control over medical care.  Cedars was exerting central control.

So the question is, who exerts control. He quotes Spiderman. "With great power comes great responsibility"  Now there are institutions that are going to have to wrestle with this problem, and if you push too hard the backlash is very tough.  get it implemented first, and do the control later…one little thing at a time.  It’s like the Right Stuff which changed the test pilot from being a cowboy pilot like Chuck Yeager to being a goody two shoes Astronaut like John Glenn….it got more boring, but mortality rates fell dramatically. So this shift is coming too, and will be a huge shift.

Add to this the emergency dislocation of medicine, such as late-night radiology reading in Bangalore. This means that the world gets wired and we start to figure out how to provide care very differently. eICU from VISICU is another reason, seeing a real time data stream and facilitating the care remotely. One of the most profound affect is going to de-tether the assay from its interpretation.

TECH/QUALITY: Leapfrog

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I’m at a conference on patient safety…

Suzanne Delbanco is the CEO of the Leapfrog Group. This is the group which is where big employers get together to grouch about health care and ask the providers nicely to try to provide better care, cheaper, and suggest that they adopt some innovations like using computers–which of course get rebuffed. She thinks that "in this country we have a funny employer-based health insurance system".  So employers are moving to cost shifting, etc, etc, but they know that wont work.

So Leapfrog was started to try to improve the process, to make "leaps" in patient safety and quality. CPOE was the first not only because it was the gold standard for reducing errors but because it also required hospitals to put in the information systems that will enable process measurements. They’ve focused on inpatient setting, but are looking at outpatient eRx, lab tests, and care management prompts. Now as the base for Bridges to Excellence office link program.

They run their own online survey (voluntary and online) and license the data.

So how have they done? Well progress on CPOE has been slow. They think they’ve gone from 2% to 7%, and another 17% say they’re working on it.They are also creating a CPOE evaluation tool (something that HISTalk might want to get involved in)

She also asks is transparency enough? Well the AHRQ quality report showed improvement in nursing home care (15%) compared to only 3% in hospitals, because Medicare mandated reporting by nursing homes. Now CMS is quasi-mandating reporting by hospitals, so she expects that improvements will start showing up in hospital quality measures.

In addition P4P is getting closer to being standardized and less confusing, although not widespread…they are seeing more and more P4P, such as Bridges to Excellence. She’s also on the CCHIT committee that will be evaluating and later certifying products for the physician setting.

On the other hand I didn’t ask the nasty question which is given that
the employers have let their suppliers stick them with 15% annual
increases add infinitum why do they think that anyone is going to be
convinced by these efforts?

THCB: New feeds live!

After much tinkering and grumbling, THCB’s crack tech staff has set up new RSS feeds filtered by content category. This means you can now get Health Care Blog posts on specific topics delivered to your trusty RSS reader without having to look at everything. There are now individual feeds for pharma and technology. More categories will be added soon. 

BLOGS: Grand Rounds coming here for an end of year special

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I have finally been suckered into offered to host Grand Rounds, and will be doing so in the week between Christmas and New Year on Tuesday 27th December. And it’s likely that’s all I’ll be doing that week over here.

So to make it special I’m putting out a request for your best post of 2005–-the whole year. Please think about it and get it to me by the end of next week, that’s Friday 23rd.