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TECH: JSK on PDAs, me on Epocrates, and eRx

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The ever wonderful Jane Sarasohn Kahn has written a pretty definitive piece on physician PDA use at iHealthbeat. (Yes, Jane is a co-author and long time friend, so I’m biased, but she is wonderful). It’s called PDAs Reach the Tipping Point . The point is that somewhere between 50% and 60% of doctors and plenty of other clinicians are using PDAs for reference use.

Epocrates is a big reason why. I met with Epocrates’ Michele Snyder briefly at HIMSS. Epocrates has now some 135 people and hasn’t taken any more cash since the dotcom days when it took in $35m. It still gives away its drug databases for free to any PDA user, including a scad of formularies—some 400. It’s got around 500K active subscribers (updated in 6 months) — including 200K physicians in the US alone. The struggle is of course to make money off that database.

They do that by charging for a symptom and diagnosis checker ($60 a year each or $149 for the lot) and by charging health plans and PBMs to show their formularies. In addition they have 130K physicians in a market research panel which you can ask questions of, for a fee of course! Doctors can even do CME short credit courses on the device. And one of five of their alert messages are sponsored, so there is a little advertising, but less than on a prescription pad. And apparently using the database is worth it for doctors

Let’s use one of Epocrates’ findings from the Brigham and Women’s study to calculate potential revenue savings generated by using a PDA for drug reference information alone. The study found that 35% of Epocrates physicians saved at least 30 minutes per day. Assuming the average physician generated $1.26 a minute (according to the MGMA’s 2004 physician compensation survey), using a PDA for drug reference could produce about $10,000 a year saved for a single physician. Now, consider additional applications for the PDA and what they could generate in productivity savings (and thus income enhancement). Epocrates’ recent survey on Medicare Part D offers another factoid to consider: 70% of physicians surveyed believe accessing Medicare Part D formularies via Epocrates software will help them save at least an hour per week. These time savings would be in addition to the drug reference savings already calculated.

Of course the key question is whether the PDA as a platform becomes a transaction tool rather than just a reference tool. Palm, whom I met with last week, of course hopes so, and has recently brought out a Windows mobile version of its Treo to increase its range in health care—as well as other industries. (Epocrates already ran on both systems, but some ePrescribing tools like Zix were Windows only). It’s also worth noticing that cell phone penetration amongst docs is in the 90% range, and that the integration of PDA capability into the smart phone makes it easier to get transactions into the work-flow. When everyone’s used to getting email on their smartphone, eRx will fit right in.

In fact JSK has a list in her article of PDA applications in health care. Several (like PatientKeeper) are looks into larger health care IT systems, and Allscripts’ Touchscript is probably the leading eRx application—a transactional system. So this is coming together. And as we told you in our recent piece, the infrastructure is being laid so that the eRx applications can get to the pharmacy work-flow and improve efficiency in the pharmacy and the physician’s office.

Now we just have to beat the clinicians to the point of pain to make them use it!

 

THCB: Crass commericalism

So THCB is making a little progress. Over to the right, that squirrel with a tough nut to crack is an ad from the Healthy Oregon Plan –  a group supporting ballot measure 111 promoting universal health care in Oregon. Although I’m generally in sympathy with the cause, this in not an endorsement, it’s an ad. So THCB is moving very slowly into the world where political campaigns use us to advertise themselves, and raise funds. So go take a look, give money if you like, and one day I’ll be as rich as Instapundit or Atrios.

There’ll be more ads coming soon…hopefully!

Meanwhile, the main point of THCB is to sell my consulting and speaking services. My speaking page has been updated with a couple of video and audio clips, for those of you wavering on whether or not you should hire me for your group. I can fit most subjects and budgets. I’m also giving a talk at PARC in Palo Alto next month that will be open access and free. So look out for more news on that.

Finally in Google Adsense news, this site says that “mesothelioma lawyers” is the highest paying adsense word on “Google. Epocrates” is also remarkably high, for no good reason that I can think of, unless competitors are holding it hostage. My guess is that it’ll be about 35 minutes before Google figures out how to route around the list on the site, but to be fair I don’t really understand how the whole thing works!

POLICY/QUALITY: Sliding Down the Back Side of the Health Care Quality Curve: Who’s at Greatest Risk?, by Brian Smedley

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The recent RAND study that suggested that there were few or no differences in the quality of treament of minorities when they got into the US health system has not been taken lying down by those who believe that there are great differences, and that ignoring them to look at the bigger picture, as the RAND researchers suggested, is not the way to go. Brian Smedley, the research director at The Opportunity Agenda wrote this opinion piece criticizing the RAND study for THCB:

Ask anyone who’s worked in, received treatment in, or studied American hospitals and health care systems, and you’ll find broad agreement:  U.S. health care systems are beset by quality problems.  Information systems don’t "talk" well with one another, medical errors remain all too common, and many patients don’t receive the types of treatments and services that they should.

 

Recently, a new study expands on these problems, finding that treatment is mediocre at best for all patients, regardless of race, ethnicity, gender, or income.  This study, published March 16 by physician Steven Asch and colleagues in the New England Journal of Medicine, finds that, on average, patients receive a little more than half of the care recommended by a set of "gold standard" guidelines.  And even though few patients are well-served, women and minorities were found to fare better than whites and men in receiving recommended care.

 

This finding wouldn’t be so shocking to most Americans, who tend to believe that health care is fair for all groups, even if less-than-stellar.  Many Americans tolerate (and therefore tacitly accept) that fact that minorities are more likely to be uninsured or underinsured, or to live in communities that lack high-quality primary and specialty care, access-related problems which have profound implications for quality of health care. But once patients are in the health care system, we believe, race or ethnicity doesn’t matter.

 

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don’t speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary.   Even the U.S. Department of Health and Human Services’ National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago.   

 

Importantly, the Asch study confirms that quality problems abound.  But the authors’ conclusion – that "quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care" – unfortunately presents a false choice.  Policymakers are not confronted with the question of whether to prioritize efforts to reduce inequality, or efforts to improve overall quality. Rather, these problems are inextricably linked.  The persistence of healthcare disparities is a clear warning that systemic problems plague our health systems. Moreover, many of the same interventions that will reduce disparities – such as promoting the broader use of evidence-based guidelines and public reporting of hospital quality scores by patient race, ethnicity, and primary language – will help to improve quality for all patients.

Progressive health care advocates should seize upon health care disparities as a key political issue and an argument for stepped-up quality improvement efforts. Unequal health care is not only wrong, it’s one of many signals that American health care is reeling from systemic problems that hamper the best efforts of hard-working physicians, nurses, administrators, and others to provide the best quality care.  Our concern and focus should be on raising the quality of care for everyone, with particular attention to those who are least well served.

POLICY/PHARMA: Yup some do benefit from Part D. This is not news! And politically it won’t matter. with UPDATE

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After all the yarling and snapping of the introduction of Part D, there was a curious article in the New York Times on Sunday suggesting that "For Some Who Solve Puzzle, Medicare Drug Plan Pays Off." Of course this is not exactly news. Several of us said at the time that the plan would improve the financial well being of lower-income people not poor enough to Medicare who were heavy Rx users and would now have catastrophic coverage. A real study funded by Kaiser FF said exactly that in 2004. In fact it’s headline was

LOW-INCOME MEDICARE BENEFICIARIES CAN EXPECT SUBSTANTIAL HELP FROM
PRESCRIPTION DRUG LAW, BUT OTHERS WILL GET LESS ASSISTANCE

And that report’s summary said:

Low-income people with Medicare
who sign up for new Part D drug plans and receive the additional subsidies – an
estimated 8.7 million people – are projected to pay 83 percent less for
prescription drugs in 2006 than they would have spent if the Medicare drug law
had not been enacted, according to a new report released today by the Kaiser
Family Foundation. Those who enroll in the new drug benefit but do not receive
the low-income subsidies – an estimated 20.3 million people — are projected to
pay on average 28 percent less out of pocket for their prescription drugs as a
result of the new law, the analysis finds.

Of course that all was based on a higher forecast of enrollment than it looks like we’re currently seeing.  But that means that if you enrolled and you fit into that category, then you will be paying less. In fact an independent pharmacist quoted in the NY Times article gets it basically right.

Todd E. Pendergraft, owner of a Medicine Shoppe pharmacy in Broken
Arrow, Okla., outside Tulsa, said the new drug coverage was
"significantly beneficial" to one-third of his 750 Medicare patients,
"marginally beneficial" to half the patients and "no benefit at all" to
the remainder.

Because it’s of no benefit to most, and will eventually mean a reduction in employer retiree benefits, on a purely political basis I advocated Kerry running heavily against the bill in 2004. While he never really mentioned it (and my meager attempts at the time to get Democrats to pick up on it were ignored), it’s still a hot issue in 2006, and one that now will be picked up on politically. Of course because of the incompetence shown during the transition to the new program, it’ll be run on in the Katrina/Iraq incompetence meme, rather than the "destruction of Medicare" meme.

But the flat answer is that, yet again, because not everyone is put in the same pool (i.e. seniors are not forced to buy into Part D) there will be adverse selection amongst those who do. That adverse selection is coming from the people who are now better off (because they wouldn’t have bought it if they didn’t think they would be). Eventually in a couple of years the PDPs will start losing money, jacking up their rates and upsetting their senior customers — and the  subsidies hidden in the bill for those PDPs start reducing at around the same time. Just as happened with Medicare HMOs in the late-1990s.

If you really wanted to run a proper drug benefit using private plans, you ought to force everyone to join so that you have a universal risk pool. But of course Congress would never dare have done that politically after the experience of Medicare Catastrophic in 1988 nor would they have forced the employers to pay into the pool for their retirees. So we get the hodge-pot we’ve got, with all the confusion and angst it’s caused amongst seniors.

And of course we’ve got two calendar issues coming up. The first formulary switch and the first donut hole "approachees".

Beneficiaries could face new problems in coming months. Insurers can
impose stricter limits on access to certain drugs after March 31, when
a 90-day transition period ends. In addition, some beneficiaries will
have to pay more at the pharmacy counter, because most drug plans have
a gap in coverage after a person’s total drug costs reach $2,250. The
gap lasts until the beneficiary incurs total drug costs of $5,100.
Beyond that point, Medicare pays about 95 percent of the cost of each
prescription.

The argument in favor of the formularies is that this is how private sector drug plans work. But CMS isn’t going to make much headway with the line that "formulary restrictions are how the private sector PBMs work" because seniors are rather more interested in their health care than working-age Americans. Somewhere at the end of this calendar is an election, I recall. And I can see the Ad now "Part D is worse than Medicare and those Republican bastards forced me into it."

And did you know that the very law creating Part D bans Medicare from negotiating with those evil bloodsucking pharma companies, even though the VA is allowed to? I suspect you did, and if you don’t you will by November!

CODA: You might want to see my other post this morning for a link to much more discussion about Part D.

UPDATE: And then there’s the power of the headline. Of course the entirely disinterested AHIP Solutions SmartBrief newsletter puts a slightly different spin on the story:

More praise from Medicare drug program
beneficiariesDespite reports of some problems with the Medicare prescription drug
program, some customers say the benefit was worth the sometimes confusing and
complex process of enrolling. People in places such as Tulsa, Okla., who were
more removed from the political debate about the program, say friends and family
helped them with the choices and the outcome is satisfying.

PHARMA/POLICY: Medicare Part D, yet more to and fro, and some on the uninsured too

A long transcript from a conference full of health care journalists (hat-tip Kasier FF) in which Leslie Norwalk from CMS proves that she’s very brave, or maybe even foolhardy.  And apparently Medicare Part D was all Al Gore’s idea….. Bob Hayes from the Medicare Rights center, Susan Jaffe, from the Cleveland Palin Dealer and Stuart Gutterman from Commonwealth, don’t exactly agree.

Well worth a quick flip through.

There’s also one on the uninsured which is horribly transcribed, but suggests that some of the reporting about Dirigo care in Maine has been wrong, including one that I picked up on in my Spot-on piece on why we need ONE insurance pool.

Here’s what Joe Ditre, executive director, Consumers for Affordable Health Care, says about the WSJ opinion piece and it does indeed sounds as though the insurer-backed Council for Affordable Healthcare which wrote the articel with a local right wing think-tank has been caught with its hand in the statistical cookie jar:

the Main Heritage Policy Center and they put out this piece that basically said that in the state of Maine that the Dario Program had …only twenty two-percent of all enrollees were previously uninsured. The fallacy is that they based that statistic on one quarter of enrollment which did not include the individuals who enrolled. Again, Dario covers small businesses and individuals, so they focused on the very first quarter of the program’s operation in which no individuals were allowed to enroll because they had to enroll in the second quarter. So they took that percentage, twenty two-percent and what did they do they applied it across the entire enrollment for the first year only sixteen hundred people were uninsured. Now, that’s problematic from any point of view but it is the story that has stuck in the state but one the government didn’t respond quickly enough to basically take away or say that’s false but too, these mouthpieces have been able to get this story, it was in the wall street journal, if you saw that story, and it was printed up on the Kaiser website, I mean on their you know their coverage of the when they do that sweep of the national stories it gets repeated everywhere and it’s false.The real number of uninsured is forty four-percent of them are uninsured overall, within the individuals it’s fifty-percent,– of the ten thousand forty four-percent overall are uninsured, were previously uninsured

POLICY/HEALTH PLANS: Shalala and the janitors update

Looks like the power of Health Care Renewal (and THCB) is proved again. (Ok, OK kissing…) But after featuring the story about Donna Shalala and the Univ of Miami janitors who didn’t have health insurance, apparently the university has caved. Correspondent JC reports:

Well, Shalala finally came to her senses (actually, her political senses). In addition to providing a 25% pay raise to the janitors (they are technically still not formally organized), they have agreed to offer health insurance coverage for $13 a month to employees. The janitors are to become effective 4/1.  If interested, I’ll let you know how it goes.

The interesting thing, is the publicity has put pressure on other entities.  A couple of other local universities (public and private) are beginning to feel the pressure to provide coverage to hundreds of uninsured low-wage workers. It is a positive ripple effect.

TECH: Brailer takes weekend off in SF

The S.F. Chron has an article about local boy made good David Brailer and his attempt to persuade American health care to inter-operate, or whatever it’s supposed to be doing in the absence of a mandate or any money! Brailer lives in San Francisco and truies hard to be in California on the weekends. It’s a good article complete with actual photos of actual doctors in a real life-hospital trying to use an EMR. And there were people who scoffed that it would never happen!

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Meanwhile, the profile tells us something I never knew, not that it’s relevant to his gig or his career or in the least unusual in our fair city; Brailer is gay. He frequently mentions his kid in his speeches, and I just assumed and assumed wrongly. So given that my immediately previous article in THCB was about another Bush appointee who thinks that Brailer and his ilk will rot in hell, it’s good to see that the Adminstration for once ignored its maniac Christian right in a relatively non-political appointment. Or given that a quick google search shows up nothing on the topic, perhaps Rove at al were as political as usual but their background searches were as competent as their war-planning and hurricane relief efforts.

OFF-TOPIC: The ultimate theocratic fascist cashes in

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And in my end of week rant….. Arianna Huffington nails John Ashcroft, now lobbyist.

There’s no question that bible-thumping fascist John Ashcroft was my least favorite Republican of recent years. His Justice department converted the war on drugs into the war on patients and doctors. The former AG was determined that everyone using marijuana or opiates for their treatment be banned from doing so, and face incredible draconian penalties. Everyone that is apart from his nephew, who got probation despite running a sizable marijuana grow-op for profit (not for medical use) while he was Missouri governor. Funny that, eh.

He also was responsible for the FBI. You know the same FBI that was so good at tracking down the terrorists and managed to avert a catastrophic hijacking plot with some well-timed arrests in late August 2001. Then he signed off on the illegal wiretaps from his hospital bed.

In a just world where would he end up? In prison for constitutional crimes? On skid row due to a Bill Bennett like gambling problem? As a Rush Limbaugh-like pill popper unable to legally find the OxyContin he needs to control his pain from that surgery? Arrested at a raided cannabis club unable to deal with the nausea from his chemo?

No, of course he’s ended up on K street. He’s back in DC working for Israeli defense contractors and nebulous corporations like ChoicePoint (the goons behind the Florida “felons voter” list in 2000 that got Bush the election) to which his department awarded a huge contract while he was AG. And he’s becoming a very very rich man as a consequence.

Ashcroft is being handsomely rewarded for his helpful ways. “I’ve been stunned at how good people have been to me,” says Ashcroft, revealing a remarkably low stun threshold. “It’s been gratifying, and I’m earning significant multiples of what I’ve ever earned before.”

So what’s he doing for all that cash? Well apart from the after the fact bribes ChoicePoint is paying him direct now? Surprise, surprise greasing the wheels in the Dept of Homeland security as the booty capitalists swoop in to get the spoils of war on the home front. Well at least he understands well the corruption necessary to get around whatever we have left in the way of laws about that stuff. After all he didn’t care about the FISA law in the wiretapping cases, and he didn’t care about following a Missouri State law that mandated drug forfeiture seizures went to education when he preferred it to go to corrupt cops instead. It’s just now that the kick-backs are getting bigger and bigger. And of course Ashcroft is the AG who wanted all government departments to automatically not comply with freedom of information act requests, so we’ll never really find out what he gets up to in his new job any way.

Its a triumphant American success story. And his God is no doubt very pleased.

 

HOSPITALS: The transparency debate

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Here’s my editorial from today’s issue of Fiercehealthcare:

We’ve been hearing a great deal about price transparency in health care. California has a new law mandating that hospitals release their chargemaster billing data. The Administration’s advisors are demanding that hospitals and doctors reveal pricing, and one health plan (Aetna) has revealed its negotiated rates with physicians in one market (Cincinnati, OH). The theory is that pricing transparency will increase competition and make it easier for consumers to shop around. Proponents point to the reduction in the advertised price of LASIK surgery as an example of what might happen.

Speaking before Congress, Paul Ginsburg sounded several warnings about this trend. First, health care is in no way prepared to deliver pricing information. Several studies have shown that hospitals and physician groups do not know their costs or prices per service, and hence there is wide variation in what, if anything, they can tell consumers. Secondly, most health care is purchased not by consumers directly but by insurers. Ginsburg gave evidence that where contracted rates of insurers are exposed by regulation, prices tend to rise. Thirdly, there’s still little agreement on what we should be pricing. Each service? Each episode? Care per month? All care per year? Finally, apparently in the LASIK market, there’s less transparency than meets the eye, so to speak, and advertised low prices are in some respects come-ons like those cheap air-fares that aren’t really available. Transparency in health care is needed, but we need to think carefully what that really means in practice.

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