THCB

Categories

Above the Fold

POLICY/POLITICS: The evolution of Hillary Clinton and the failure of reform in 1993 (TO BE CONTINUED)

• 5

I have been meaning for some time to write about what really happened in 1993-4.  But I’m finally going to get off my duff (or more accurately) sit on my diff and do it because of the close to ridiculous rubbish written in an article called The Evolution of Hillary Clinton in Wednesday’s New York Times. But as that’ll take me a little while, I’m reproducing the key part of the argument about health care here:

No other policy issue defined Mrs. Clinton in the 90’s as starkly as health care. Not only did her effort to establish universal health insurance end in embarrassing defeat for her husband’s administration, but it also emboldened Republicans and contributed to the notion that she was a big-government liberal. More then a decade later, it is clear that that experience has profoundly altered her approach now that she is a member of Congress.

She has deliberately avoided the major mistake she made as first lady, namely trying to sell an ambitious plan to a public with no appetite for radical change. Over the last four and a half years, she has stuck to a host of more modest initiatives, apparently mindful of the political perils of overreaching. She summed up her approach in the first floor speech she delivered in the Senate about four years ago, when she unveiled a series of relatively modest health care initiatives.

"I learned some valuable lessons about the legislative process, the importance of bipartisan cooperation and the wisdom of taking small steps to get a big job done," she said, referring to the 1994 defeat of her health care plan. She has not completely discarded her 90’s view that there is an urgent need to overhaul the way health care is delivered in the nation. In fact, she has not been shy about embracing proposals that might be seen as liberal in some quarters, like seeking to provide medical coverage to everyone living in poverty.

But on the whole, Mrs. Clinton, who has served in a Republican-controlled Congress for most of her tenure, has assembled an agenda with practical-minded initiatives that appear to be aimed at the political center.

Perhaps one of the most notable is one that drew support from unlikely quarters: Senator Bill Frist, the conservative majority leader from Tennessee, and Newt Gingrich, the former House speaker who had a major role in defeating her health care plan in 1994.

The bill these three embraced seeks to encourage greater online exchanges of medical information among patients, doctors, medical insurers and other health care experts. Mrs. Clinton has argued that such an approach would, among other things, reduce medical errors resulting from poorly kept paper records and reduce the number of costly malpractice suits.

She has denounced the "contagion" of sex and violence in children’s entertainment, apparently attempting to move the issue beyond the question of morality and values, where Republicans have long held a political advantage. Citing studies indicating that graphic images of violence lead to more aggressive behavior among children, she has cast the problem as a health issue that amounts to an epidemic and requires a vigorous response from public health officials.

Her longtime focus on children’s health has also continued through her Senate service, most notably in the passage of legislation she sponsored ensuring that prescription drugs approved for adults but prescribed for children be tested for children.

I’ll be back later to explain why Hillary Clinton doesn’t understand what went wrong in 1993-4 and why that may have some big time implications if she is the candidate in the game of "continue the dynasty" that we’ll be playing in 2008 or 2012.

Meanwhile, read the full article

To Be Continued

BLOGS/TECH:Sacred Cow Dung and physicians and technology

• 2

Chris Mayaud is one of the more amusing entrepreneurial doctors it’s been my pleasure to go drinking with and have on the odd panel (Also the only one ever to use an almost appropriate 4 letter word and get away with it!). He also was a founder at Physicians’ Online and these days appears to be the most connected person in the world on Linkedin as well as being some type of venture capitalist (although I’m still waiting for the check!).  And of course he’s got a blog, called Sacred Cow Dung — pretty interesting stuff mostly about the VC world, and you can usually get him to buy you a beer if you’re visiting New York.

Here’s a interesting post he put up a few weeks back on why it’s not doctors’ fault that they don’t use IT — Sacred Cow Dung: MYTH: Physicians are Resistant to New Technologies.

TECH: PHRs for health plan members…maybe, maybe

• 6

And in the bitter, twisted segment of THCB this week, apparently Empire Blues will be offering personal health records to their patients. And the records will be prepopulated for the members with information gleaned from claims data. including outpatient lab test results, physician visits, hospital stays, reported diagnoses and prescriptions. They can also (self-enter, I assume) values, such as cholesterol levels, that can be grouped together and graphically tracked over time. They’re using WebMD (who bought Wellmed, the last man standing in the PHR space phase 1 c.2002) to provide the service.

This is a screamingly logical thing for health plans to do. It gives them a compelling front end web application for their members, and thus gives their members a reason to stick with the plan (given the choice, although I know a lot of members are not). In addition they are the only ones who’ve got the majority of a member’s data all in one place. The only real exceptions are providers with a full service HMO like a Kaiser or a Group Health of Puget Sound who can then offer views into their electronic medical record system (e.g. MyEpic). For the traditional health plans, who’s CRM for their members has been completely crap for decades, this is an easy and relatively cheap way to improve their "customer service".

I’m just a little bitter that they’ve decided to do it now rather than FIVE years ago when I was selling exactly the same thing….

However, if any health plan or tech company wants to know more about this, I will work for food.

POLICY: Yup, it costs more here

• 6

Two studies out. Not exactly new news. I did a study looking at laproscopic cholecystectomy between Japan and the US for my master’s thesis in 1992. The result then was that it cost twice as much here, when in those days everything else in Japan (land, food, cars, golf club memberships, hookers) cost twice as much. Outcomes seemed to be similar even though patterns of care were very different overall.

Now a similar study (albeit done in a major journal and not for some punk’s masters thesis) is showing the same thing about the costs of CABGs between the US and Canada. They cost twice as much here too. Outcomes again seem to be similar.

The in-hospital cost of CABG in the United States is substantially higher than in Canada. This difference is due to higher direct and overhead costs in US hospitals, is not explained by demographic or clinical differences, and does not lead to superior clinical outcomes.

Finally, in a repeat/update of an article he wrote with Uwe Reinhardt a while back called "It’s the prices, stupid" Gerald Anderson shows that we spend more money here because in general we pay more for the same thing.

U.S. citizens spent $5,267 per capita for health care in 2002—53 percent more than any other country. Two possible reasons for the differential are supply constraints that create waiting lists in other countries and the level of malpractice litigation and defensive medicine in the United States. Services that typically have queues in other countries account for only 3 percent of U.S. health spending. The cost of defending U.S. malpractice claims is estimated at $6.5 billion in 2001, only 0.46 percent of total health spending. The two most important reasons for higher U.S. spending appear to be higher incomes and higher medical care prices.

So we’re shopping at Nordstroms and the rest of the world goes to K-Mart. Of course if you can’t "afford" Nordstroms, you’re SOL.

POLICY: Joe Paduda on consumer spending restraint

• 9

Joe Paduda has an article about Steve Case’s determination to piss away $500m changing health care. In it he correctly notes the problem with Colin Powell’s argument that buying health care services and buying TVs are about as simple as each other. (Actually I think buying a TV is very complicated but that’s another discussion). Joe has a very interesting case study about his own decision when concern for his daughter’s health over-rode concern for his pocketbook.

We are insured under a high-deductible MSA plan, so any charges would come out of our pocket. I thought about it for a few seconds, than agreed. I also agreed to have her brought over in an ambulance for the fifteen minute trip. I knew full well that the risk was minimal, the costs would be over $2000 for this “preventive” measure, and I would pay all that out of my own pocket. Was the very small risk worth the outrageously inflated cost? You bet your life it was.

Now the next question is, what if Joe were not a well educated and (I guess and I’m sure he’ll tell me if I’m wrong) a relatively wealthy consultant, but a single mother to whom that $2000 would mean not being able to pay the rent or put food on the table. That’s where the fallacy of an at the point-of-care economic decision by the consumer is demonstrated. And that’s where this isn’t like buying a TV.

Rational consumer-choice advocates (i.e. Alain Enthoven) tried to push this level of selection back up to the "sponsor" level. That meant that the health plan made the decision about treatment based on some level of cost-effective assessment about what was the best thing to do in each case. The UK now has a central body (the NICE) that hands down these guidelines. But no one who’s well versed in health policy seriously believes that these judgment should be made at the point of care, because the situation is totally uncertain, and the consumer almost always knows less than the provider and half the time is not in a coherent enough shape to make the decision.

There are plenty of places where there is a need for much better consumer-ist focus in health care — notably health plan and provider customer service.  But making these types of decision at the point of care is not one.

POLICY: Individual insurance, sigh, with UPDATE

• 12

The NY Times had a pretty decent article on what a pain in the ass the individual insurance "market" is and it also reminded me of one reason why the eHealthinsurance study last week was so flawed.  That study compared apples to oranges when it looked at rates for 30 year olds in New York versus California. To wit:

In some ways, Mr. Forst was lucky because he lives in New York. It is one of the few states with guaranteed-issue laws, which basically ensure that all residents can buy coverage. In New York, the law means that if you have been turned down by the big national companies, any H.M.O. operating in the state would be obligated to sell you a policy. New York also has community pricing, meaning that everyone who applies from the same part of the state pays the same premium for the same plan, regardless of age or health. So it is easy to see why insurance tends to be more expensive in New York – at least for the young and healthy – than in other states. But the flip side is that some people living in other states cannot buy insurance.

Of course the other side of that is that individual insurance in New York is so expensive that many uninsured who could afford the cheap California policies can’t buy it. (And don’t forget employer group insurance is not covered by state laws because of the wacky world of ERISA). So the free marketers (like my commenter Greg Eric Novack) say, let them buy a California policy. (This is the basis of the AHP movement that our Dear Leader is so keen on). That would then immediately lead to the remaining healthy New Yorkers getting out of their state-regulated policies and buying cheap ones from out of state, with the result that those remaining in the New York plans — who couldn’t buy those out of state policies because they’re old or sick or both and the AHP’s wouldn’t be forced to sell to them — would be unable to afford their premiums and the plans would go belly-up.

So is community rating like New York’s a good idea?  Well only if you enforce it on everyone, including groups and the uninsured — otherwise known as universal insurance. But it is a risk pool of sorts and the efforts of the so-called "free-market" lobby are helping to destroy what’s left of it, when what we need is everyone into it.

Meanwhile over at Signal Health Tom Hilliard spent the time that I didn’t in my post on the subject to really deconstruct the McKinsey study on CDHPs.  And he comes to the same conclusion I did about whether it can be trusted.

UPDATE: Brian Klepper tells me that I’m being too tough on eHealthinsurance.com and should be thankful for baby steps.

I think you’re dwelling a little too much on the obvious by complaining that the eHealthInsurance study is flawed. Of course the costs are significantly different in states that have or do not have guarantee issue. And of course the market dynamics are completely fouled up by the games that every insurer plays in trying to limit exposure.Maybe I don’t get it, but I see the real value of the eHealthInsurance study in the fact that it shows clearly what the rates are for a particular type of individual. Typically, we don’t have this knowledge. You’re bellyaching because the underlying forces aren’t balanced, but that’s only a nuance to the analyst; the purchaser doesn’t have this luxury. And until we’re able to SEE the damned rates for what they are, controlled for who they target, we can’t do anything to course correct.That’s why its useful.

TECH: The Switch is the trouble with CPOE and EMR

• 6

Last week I had two separate, but close to identical, conversations with software companies that claim to have found the solution to the problem of getting physicians to use the EMR.  But in neither case did they perceive the problem to be exactly what I think it is. I don’t think the problem is the cost of the software, or the lack of ROI, or even the functionality of the current tools.  I think the problem is the "switch".  And trawling around the web today I found an interesting article on COPE in HealthImaging which basically makes my point.

John Fitzpatrick, MD, director of medical informatics at Forrest General Hospital (FGH) says the biggest barrier the hospital first encountered with CPOE was that it took too long to use and was not intuitive for physicians.<snip>…Fitzpatrick recommends that healthcare providers in private hospitals find a CPOE system that physicians can enter the orders in as fast as doctors can hand write them or else the chances of success will be slim. "If the system can be made faster than on paper, all you have to do is incentivise the doctors through the learning curve," says Fitzpatrick.

"We are paying the pilot physicians for a limited time frame for their efforts acknowledging that at least initially it takes more time than on paper," he continues. "However, as they become more comfortable with the system, they get faster and faster at entering orders. Our original incentive plan was structured based on an incremental target for percentage of orders entered spread out over six months. However, most of the physicians are entering more than 95 percent of their orders from day one, and are probably reaching paper neutrality within six weeks."

So "time breakeven" on the switch to CPOE is 6 weeks or about one eighth of a year. Unfortunately translated into private practice that means that moving to an EMR will cost a physician some considerable chunk of one-eighth of their income in lost productivity. Let’s say that number is 30% of their productivity for that time period and lets say that the average doc’s annual revenue is about $500K, and for the sake of easy math let’s say it’s a 5.2 week period of lost productivity.  That translates into a $15,000 loss in practice income, ignoring the cost of the software and hardware.  And there are no corresponding costs to be cut, so the upshot is that the average small practice doc is looking at taking $15K that as income loss.

And there alone is a good reason not to do this…which is why some kind of bribery incentive is required.

TECH/POLICY: Why health care costs so much, part 37

• 1

Bend OR, pop 100,000, now has 8 MRI machines. That compares to the fact that all 97 million Canadians have to share one MRI in downtown Saskatoon that’s only available on Tuesday mornings when they take the cow that shares the barn they keep it in out for a walk. But don’t worry about that having any impact of practice patterns or health care costs — Oh no.

The idea that physicians will inappropriately order MRIs as a way to make money, said Jim Kronenberg of the Oregon Medical Association, is a bit of a leap in judgment.

Meanwhile the New York Times reports on the ongoing case of proper fraudulent medical embezzlement, rather than the legal kind going on in Oregon and the rest of the nation.

BLOGS: Hospital impact

• 3

Hospital Impact is an interesting new blog that has several issue areas mostly, but not exclusively, of interest to hospital admin folks. Worth checking out.  I can’t quite figure out who’s behind it, but it seems to have some connection to the HFMA…. or I might be imagining that.

HEALTH PLANS: Mckinsey on CDHPs

• 9

McKinsey, a very smart firm that should be trusted about as far as it can be thrown in terms of putting its clients’ interests above its own, is out with what looks a pretty well researched report on CDHPs.  My less well researched opinion is that the CDHP is an intermediate step on the employer’s retreat from offering health insurance, and that the HSA is a foolish tax-deductible sop to the people who would have put that money aside anyway. But then again I’ve got one, as there’s no better alternative.

Essentially the report says that the employees who had CDHPs (connected to HRAs not HSAs but it’s the same sort of thing) were more cost conscious in their health choices than they had been in the good old days of more generous plans, but that they were less satisfied with their health plans. However, the lower spending on care for patients is similar to the introduction of managed care back in the 1990s, other than initially managed care recipients were happier with their plans — as they had lower out of pocket costs than in FFS. One thing I do know is that high out of pocket costs correlates with higher patient dissatisfaction, so as the employees are left more and more on their own, dissatisfaction will likely increase. Still I suspect at least one of my commentators (can anyone guess who?) will tell me that I’m wrong.

And despite some long and complex correspondence with a couple of advocates I still can’t understand why an employer would give their healthy employees money for an HSA and then let them keep it if they didn’t spend it. (In an HRA, it reverts back at year end).

assetto corsa mods