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TECHNOLOGY: ePrescribing is about renewals

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Edmund (Bill) Billings, another ex-Oceania MD & veteran now runs a consulting company called Phyxe helping docs get up and running with ePrescribing. 

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The first key point is that vendors are not focusing on renewals…when he was judging the contest for TEPR only 3 of the 12 vendors had "renewals" as a word search that came up. Yet renewals are the biggest pain in the system–actually worse than refills.  New scripts are not such a big deal

He had an example of one solo pediatric doc who had 400 kids with ADD who needed a renewal/refill each month. Using DrFirst it went from 10 mins per to less than a minute to do a renewal, and cut the staff time, phone/fax coming from the pharmacy, etc. Another example was a 2 internist practice who used Oncall. They cut phone calls down (Major problem had been legibility).  He cut each activity’s time down dramatically (such as renewal authorization, writing new Rx, Renewal request, calls from pharmacy) and made his practice much more productive. This practice is very satisfied with Rx at their end but less satisfied with the pharmacy processing end of it, suggesting that the pharmacy is up to scratch. And this practice wants to build out from this to get to better messaging, getting Rx authorization up and running, etc.

Overall renewals are a big burden and one that the physician underestimates the impact on on their staff. Sometimes, the doc now does more of the renewals after ePrescribing.

Both of these are ASP based.  Ed says the prices is around  $50 a month but that Docs might pay more when they figure out how much overtime for their staff this might cut down on.

This may be the first time that I’ve seen a real business case for a doc to pay for an ePrescribing app.

TECHNOLGY: TEPR and ePrescribing

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I’m in the ePrescribing track with a couple of smart people telling us the ePrescribing will happen. Danny Sands of Zixcorp (and of Harvard) thinks that in the last year it’s really picking up in Mass with 3,000 doctors on board. So he’s an optimist. He especially believes that ePrescribing will be a decent intermediate step for those practices who realistically are not getting to an EMR any time soon.

Tony Scheuth, who I knew when he was hanging out at an original CHIN company called IMS in Colorado, is now a consultant who spends 80% of his time in ePrescribing. He thinks that pay for performance is maybe enough to push it over the top. But at the moment the incentives aren’t big enough (although he’s going to say that the dollars may be big enough in California & Mass). And then he went through the list of the P4P groups and how their incentives are often linked to infrastructure (or more accurately system use).

Of course the whole issue is that there is no financial advantage to the docs unless they’re at risk for the drugs, which 98% of docs are not.

So two optimists.  Perhaps they should both know better!  Or just maybe they might be right?

TECHNOLOGY: Rick Peters on why he’s frustrated

Rick Peters, who founded Oceania and has been around the health care EMR scene for a while, keynotes at TEPR.  He points out a few facts obvious to TCHB readers, costs are up–employers can’t afford health benefits  and so are dropping coverage and putting people into Medical and uninsurance slices on that nice chart from the California Health Care Foundation. And in the new high deductible world, costs are way too much for sick people. He didn’t mention Walmart by name but he and Paul Krugman are on the same page here….

He had a few other fastballs…

  • Med malpractice is a red herring and premiums are are up because the insurance companies really screwed up that
  • EBM: we’re not doing it but DSM may not save much money.  Finally under pay for performance, won’t the sicker patients be kicked out of the practice by the doctor?  So EBM may not be a panacea.  Because 80% of what doctors do is unnecessary, and 80% of these workups were done before.
  • And I think he says (because his slides are horrible) that if we cut back to generic only drugs we’d save a fortune….physicians are not doing the cost effective thing.  And cant blame it all on pharma, 20% of patients who see the ad ask for it, but 70% of the time the doc will write the script/  Plus 60% of scripts are for off-label use (and therefore not EBM).

The result of all this is that we’re doing P4P and building the measurement systems for it. The  focus is getting measurements of what’s going on (and going wrong) not on getting the data that we need, and no ones forcing that on the system (no mandates).  Meanwhile admin overhead costs  physicians 40-60% of their revenue.  We know that EHR along can reduce office visits 9%, PCP visits 11%, and the % of members with 3 or more visits goes down 11% (all KP data).

So why ain’t happening? Generally computer technology is going to Internet based architecture and XML.  Why does health care think its different. Still opposing the adoption of these advanced techniques.  OK, so IT spending is higher elsewhere. But Wall Street spends limited amounts of its money on infrastructure–which it rents–and most of its money is spent on other advanced techniques like data mining.

We are preoccupied with duplicating the patient chart.  Peters thinks that a PDF alone would be good enough to move that data around.  We just need to get the data in useful form. We need that data in whatever form from whatever.  (By the way, for those of you with long memories this sounds like Chris Mayaud’s "physicians as short order cook" line that he was using in in 1997!)

Other artificial opposition — HIS v Amb record vendors; big institutions are not good innovators, but all the money goes to the big elephants. (He was pretty brutal about the IBM UPMC deal). Peters believes that innovation is coming in the smaller vendors integrating PMS/EHR.  But existing vendors cant switch to ASP as they’ll take a revenue hit.  So technology is blocked by business issues.

He thinks that ePrescribing is taking off. Although 99% of mail order/retail pharmacy is already automated. He thinks that SureScripts is driving this very quickly.  SureScripts is an utility infrastructure that is rented not owned.

Rolling this altogether (employer costs, Medicare costs, infrastructure we can plug into is there, tech development tools are better, OPM [Opium or other people’s money] is available if we want it) Peters thinks that we should go straight to revolution and chuck out the evolutionary phase that we’re in.

TECHNOLOGY: On the (Wasatch) front lines at TEPR

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Today THCB comes to you from the Salt Palace, just across town from the Mormon Temple.  Yup, TEPR is in Salt Like City, Utah, and I chose this as a nice occasion to get to one of my favorite places (Park City) and do a little cave exploring, mountain walking and paragliding (and hanging out with my friend Regina). Oh, and TEPR is going on here too.

As I sit here the first major technical snafu of the conference is ongoing as David Sundwall, the head of Utah’s department of health is telling us that not only Utah’s CHIN/RHIO, called the Utah Health Information Network (UHIN), whatever is better than anyone elses, but also quite impressively has 100% of hospitals and 90% of doctors on the system.  (The other slides of what he wanted to show about the interloper Johny come latelies in Indy and Massachusetts are not working, hence the PowerPoint data loss in the picture below).

Imgp3085UHIN has all HIPAA transactions on that platform and he wants to add the clinical part and public health reporting to that….and then add that to other RHIOS. But what he wants eventually is a single standard connection for all users everywhere.

And then he makes the logical leap, which is that the important information is in the physicians office and that needs to be made electronic. Otherwise the important data has to be re-keyed

56% of physicians here allegedly have EMRs. I’m not sure I believe that, but CPOE is up at 34% of hospitals, lab is 65%, radiology in that range (Yup, Intermountain has a huge market share here– can’t you tell? Here’s more from Brent James about Intermountain’s system).

So we’ve got the RHIO here in Utah, we’ve got a more advanced medical system in terms of IT use, and it’s all happening here (if not in the rest of America)….. and of course the skiing is the best in the world….but make sure that you the miss the trees in the back of Jupiter Bowl at Park City.

POLICY: The (Very) Odd Couple

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This week Hillary Clinton met with Newt Gingrich and together they declared
unity and agreement on America’s health care future —  at least as far as the
role of information technology goes in it. 

The author of "The Great Right Wing Conspiracy" cosying up with the woman who dreamed up "HillaryCare?" 

That surprising sight led to an immediate media
freakout. What could it all mean?  Could some sort of earth-shattering political announcement be about to follow? 

The New York Times sheds some light on things:

"As it turns out, Mr. Gingrich and Mrs. Clinton have a lot more in
common now that they have left behind the politics of the 1990’s, when
she was a symbol of the liberal excesses of the Clinton White House and
he was a fiery spokesman for a resurgent conservative movement in
Washington."

Both Clinton and Gingrich seem to agree that government should help fund the technological transformation of the healthcare industry.  Historically, the implications of this kind of bipartisanship are big indeed.  Well, sort of.  Providers and payers can expect more legislation impacting information
technology, but realistically probably not much more
money from the feds.   

Health
care veterans may recall the last time significant legislation affecting health
care IT was passed: in 1996, when the Senate voted 100-0 in favor of the
Kennedy-Kassenbaum legislation. That law is better known today as HIPAA. Ten
years later payers and providers are still struggling with the implications.  So cast
a jaundiced eye when you hear that Washington is preparing to intervene. 

INDUSTRY: A little on the Advisory Borg

I have a lot to say about the Advisory Board, not all of it bad by the way.  But before I do, go read HISTalk Blog on the subject here and then here (scroll down). Back tomorrow (am way crunched today).

HEALTH PLANS: Promoting HSAs, by Ron Grenier

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My commenter Ron deserves to have this post promoted from yesterday’s open thread. I oppose HSAs (and for that matter employment-based health insurance) as a policy because they are diametrically opposite to being the overall solution to universal health insurance, although I’m pretty much indifferent to whether we go with a tax-based single payer system or a strictly-regulated, compulsory, community-rated (non-underwritten) individual or group insurance system as the preferred outcome.  However, in real life we’re not getting to any of those politically any time soon, and as a solo operative with some of my own health problems it appears to me that a high deductible plan with an associated HSA is my best option.  So I’ve got one.

Ron explains in this example why that might be a good option for others….of course he doesn’t get to the community-rating/risk pool division issue, but that’s for another post.  Here’s Ron’s example:

A 30 Year Old Nurse Who Is A Single Mother
Pick Any Des Moines Hospital
Annual Income:  $50,000

A single parent mother making $50,000 a year is not rich. Many
employers will pay $400 a month for single coverage but the employee
must pay the additional $400 a month to add on their child, out of
their paycheck. Now the Mother has deductibles and co-pays on both her
and the child. Probably, knowing health insurance like I do, the
employee insurance has switched from co-pays on RX to co-insurance
($10 co-pay for Generics and $25 co-pay on Brand Name PLUS Co-Insurance
of 50% on Brand Name). Remember, some people when they get sick have RX
bills of $1,500 a month, ask Montel Williams. So if the mother or the
child got sick we have no idea what will be the out of pocket annual
expense for just RX. PLUS, If the mother got ovarian cancer and could
not work, a requirement for keeping her insurance, she would be put to
COBRA for insurance termination. Everybody, including people who sell
group insurance, say they can’t comprehend why that makes even the
slightest difference in the world. To me it’s simple, I would prefer a
contract that can’t be singled out for termination because of my
relationship to some employer.

The HSA Individual Option

The Mother pays the total family premium of $78.68 per month. Now
she saves $400 a month coming out of her paycheck that she can save or
spend on her baby. The $400 a month, that the employer is currently
spending on the Mother’s single insurance, is redirected to the bank,
in the Mother’s Tax Free Health Savings Account or HSA. The bank must
be FDIC insured, it’s the law.

Annual Deposit From Employer: $4,800
Maximum Annual Out-Of-Pocket (OOP) for the family:  $5,200

So the maximum annual OOP expense for this Mother and child is
capped at $400 a year and she is currently paying $400 a month, out of
her check, with no idea how much she could owe with co-pays and
co-insurances.

No FICA Tax on HSA deposits. The FICA tax is 15.3% and is split
between employer and employee. Now the hospital won’t pay 7.65% on
every dollar the mother earns. Employers love the HSA when they figure
it out.

The Hospital is depositing $4,800 a year in the mother’s HSA. She or
her employer may maximize her HSA annual deposit and save on taxes,
another $400 or a maximum of $5,200 may be deposited each year.

When the mother goes to the doctor everything is the same. The
doctor’s bill is $80 for example. The first thing is the charge is run
it through the PPO, exactly like they are doing it now, and the charge
is sent to the insurance company. The insurance company then sends an
Explanation Of Benefits (EOB) that says, your $80 charge has been
diminished to (example) $50. Do you want to pay the $50 with personal
funds or would you prefer to have it deducted from your HSA? Once
covered charges hit the deductible they are paid at 100%.

If the mother put the max in her HSA and didn’t use any HSA funds,
which some people do, at 65 years of age she would have over $400,000
at 4% interest. If she uses average $1,300 a year she will have over
$300,000. If she uses $2,600 a year she will have over $200,000 at 65
years of age. Also she has the freedom to place her HSA balance in
mutual funds for the possibility of a higher return.

I tell clients to max out their HSAs because 30 years of retirement
health care expenses will be expensive. HSA funds dedicated to
retirement health care expenses are never taxed and money that is never
taxed will last longer in retirement.

Next month retirement will be high lighted when the House throws it’s retirement bill on the table.

Who thinks this Mother should keep her present employer’s insurance at $400 a month out of her check?

BLOGS: Open thread

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Now I feel like a real blogger.  Between HSA maverick Ron, the Gadfly, Sue, TheoraJones, Abby, Graham et al, the comments in the last week have got bigger than the blog….and I’ve been real busy and unable to monitor.

That’s great but today’s were mostly way off topic from my pithy attack on Karen Ignagni’s letter.  So how about an open thread (like they do on the real big blogs) so that you can all chat about whatever you like.  My suggestion is that Ron tries to explain the maths behind everyone in America paying $130 a month in insurance premiums, while health care costs as a whole are closer to an average of $500 a month, and those costs are not distributed equally. But you can all talk about whatever you like!

Now I’ve lit the blue touch paper, I’m retiring

POLICY: Ignagni, AHIP, and the pesky fact checker that I am…

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The NY Times never called so I guess they’re never going to publish my letter about Karen Ignagni, the head of AHIP, in response to her letter the other day to the Times about Krugman’s column. I referred to it in my post on Friday. So what did she say and why was I so miffed?

Well let’s just say that if I had made so many factual mistakes in an essay in the third grade I’d still be standing in the corner wearing the pointy white hat with the big D on it. Here’s her letter with my comments cut into it:

In making a case for a one-size-fits-all health care system, Paul Krugman ("A Private Obsession," column, April 29) ignores the private sector’s progress in adding value to our health care system and stretching consumers’ health care dollars.

It is of course a joke to suggest that Krugman’s calling for a one size fits all system–which is code for government-provided (socialized) medicine. He explicitly criticized the UK system for being that, even while acknowledging that it was better for the poorer Brit than ours was for the poorer American  The vast majority of single payer systems (including the UK!) have a safety valve private care delivery sector, and in some of them (e.g. France, Germany, Japan) it’s much bigger than the government-run system. And by the way, some data on our government-run system, you know the one that’s good enough to our brave service men and women, suggests that it’s pretty damn good compared to private HMOs. But let’s ignore that and focus on the other end of the sentence, the part about how the "private sector is stretching consumers health care dollars".  OK, so in 1997-8 or thereabouts AAHP (Ignagni’s then employer, and forerunner of AHIP) put out a press release extolling a brilliant in-house study claiming that managed care plans had saved the economy billions of dollars in comparison to what people would have spent on health care had the rate of premium increases in the mid-1990s been the same as it was in the late 1980s–when they were going up three times the rate of inflation. That was such a crappy piece of "research" that I wrote a special article for my corporate clients explaining why, and suggesting that they never allow this kind of stuff to get out with their name attached to it. Of course we never saw the corresponding article published in 2004 or 2005 when those same health plans which had supposedly been so great at taming health care inflation completely capitulated, and the "consumer" saw their prices going through the roof. I suspect their researchers are still working on it. But it’s good to know that, for Ignagni, apparently the last 5-6 years of double digit health inflation has seen the private sector "adding value"! I guess if you’re a senior exec at  health plan, it does seem that value has indeed been added — mostly to your bank account of course. But there’s more:

During the 1990’s, Americans decisively rejected a single-payer system. They were concerned about the rationing of care, endless delays and lack of access to state-of-the-art procedures experienced in countries with government-run systems. That’s why residents of these nations go to great lengths to gain access to American health care, and why their leaders are reaching out for disease management, care coordination and other private-sector initiatives.

Next we come to the most blatant lie in the whole brief letter. Apparently Americans rejected single-payer in the 1990s. This is complete rubbish and Ignagni knows it. Ignagni claims that Americans were offered a single payer proposal in the 1990s. They were not — the Clinton plan explicitly kept a role for large private health plans. The political gambit of the Clinton’s was to ensure that they didn’t have total enmity from the private health plan sector. They were sufficiently successful that several members of the AAHP — the "large insurer" association which Ignagni then headed — initially supported the Clinton plan. Did she forget?  Well maybe selective amnesia has reared its head, as the HIAA (the small insurer association that merged with AAHP to form AHIP a few years back) was of course violently opposed to the Clinton plan. HIAA was opposed because the plan would have put most Americans into large purchasing groups and would have effectively banned risk-shifting and medical underwriting — the only way small (and many large) plans make any money.  It was HIAA that came up with the "Harry and Louise" ads which sowed FUD amongst wavering Democratic politicians with an astro-turf campaign run by PR agency Porter Novelli. But the rejection of the Clinton plan was caused by a bunch of factors, mostly connected to the fast improving economy and the  scandal mess the Clintons were getting themselves into over Whitewater, Travel-gate, Vince Foster, and Bob Dole refusing to let the moderate Republicans meet with Hillary about health care. Single payer had precious little to do with it, even if many Americans had a clue what it meant, which most didn’t (and still don’t).

And of course the issue about foreigners (i.e. Canadians) rushing down here for health are has been conclusively proved to be complete rubbish by the UBC/Michigan team that used actual data and actual research to look into it, and then published it in the leading academic journal in health policy — an approach that AHIP hasn’t exactly been known to much concern itself with. Meanwhile Ignagni continues:

Mr. Krugman’s government-versus-private juxtaposition minimizes the complexities of reforming health care and overlooks the vibrant public-private partnerships that millions of Americans count on. For example, Medicare and Medicaid patients who opt for private-sector plans are getting better care at lower costs than their counterparts in the government-only side of the program.

Perhaps Ms Ignagni doesn’t hold much truck with those Canadians and their biased use of data.  However, there’s a minor research organization called the General Accounting Office attached to a place called the US Congress that AHIP may have passing familiarity with, so perhaps we should introduce some of their research at this point. The GAO has twice in the past decade looked into the subject of the "Medicare and Medicaid patients who opt for private-sector plans (and) are getting better care at lower costs" and found that while those seniors in Medicare HMOs may indeed have been having lower costs than their colleagues in the standard Medicare program (because they were covered for their drugs) the actual costs to the overall Medicare system — that is to you and me the taxpayer — went up because Medicare was overpaying the HMOs. The HMOs were of course recruiting healthier than average seniors, pocketing an amount close to average cost for a Medicare recipient, and the taxpayer was making up the difference. Funnily enough as soon as those payments were cut to closer to what the seniors were actually costing the plans, the private sector bailed out of Medicare as fast as it could. Only now after huge bribes payments for private plans to recruit seniors were put into the MMA to buy AHIP’s member plans’ support is the number of Medicare recipients in private plans starting to tick up again. GAO by the way isn’t exactly brimming with optimism that the new PPOs, introduced as part of the MMA, are going to save any money either. But undettered Ignagni continues: 

Americans deserve a real health care debate and real solutions, starting with evidence-based medicine, medical liability reform and the information they need to make better decisions. That’s a more complex but ultimately more productive path to reform. (Karen Ignagni,  President and Chief Executive, America’s Health Insurance Plans, Washington, April 29, 2005)

It is indeed nice to know that we deserve a real debate, not some phony scare tactics cooked up by, say, members of the HIAA which never got close to discussing an actual "solution" in 1994 when they had their chance to be constructive. And frankly given the huge amount of cash that her members and their executives have been pulling down the last few years, why would any of them be interested in "reform"? I guess that given it’s a debate about health care in the US, we can’t  expect many actually correct facts to be brought up, but surely there should be some kind of special award to Karen Ignagni for getting so many wrong in so few words!

Coda: One thing I didn’t know about Ms. Ignagni before googling her is that she used to work for the AFL-CIO. Well at least she knows how to pick a winner!

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