Five drugs are in risk of being the next Vioxx, the Senate panel looking at Vioxx was told this morning. The remark was made by the US FDA reviewer who is not allowed on the Bextra review panel as he’s already made his call about that one (thumbs down). Crestor, which has been multo discussed on TCHB over the last 18 months is on his list (as is Bextra), and Astra Zeneca’s stock fell nearly 10% as a consequence.
Above the Fold
TECHNOLOGY/QUALITY: A quickie on the DSM companies panel
This’ll be the last one today but it’s been an interesting conference. Some quick ones from the panel of DSM companies.
Carter Coberley from American Healthways likes neural nets to predict cost and therefore go for intervention early.
Frank Martin from I-Trax likes to tell people about the global cost of missing work through illness. Only 1/3 is health care cost, the rest is lost productivity and re-hiring costs. I-Trax has both the predictive bit and the onsite counselling and nursing services prosucing DSM.
Chris Selecky from Lifemasters wants to go for the intervention to the right person at the right time, using more and more sophisticated technologies–start with the high risk people, and then try to get to the people who are going to be sick, BUT they are held accountable for outcomes in only one year–so they have to be effective. Incidentally they are in-source and out-source, in that more case managers are using their system at customers than in their own centers. They are also trying to engage the patients.
I asked about the recent studies showing that it didnt save money. Chris Selecky’s response — people are buying it, and they wouldn’t if it wasn’t working (and she like Sam Nussbaum spent some time slagging off of the CBO report).
One of the biggest challenges is identifying a comparison. American Healthways did a controlled cohort with BCBS MN and showed a 14% PMPM improvement — the same as Anthem showed in the study that Sam Nussbaum showed at lunch. Plus Carter says DSM has an impact on standards of care for everyone else in an osmosis type of way.
QUALITY/TECHNOLOGY: Pay for performance in California
Next session is on P4P in California, where 6 health plans are busy running a P4P program via the Integrated Healthcare Association. (Presentations are linked)
At the moment (Lance Lang, HealthNet) it’s only 0.5% of the dollars for those participating groups, but there’s a lot going on in terms of work being done for that 0.5% and it’s heading to 1% next year and maybe up to 20% (?) by 2009. He thinks that they need to ensure that groups that are not deserving of a bonus get the message that they are not going to be around in the longer term unless they change.
Greater Newport Physicians IPA med director Doug Allen had three main points. Even though his IPA was at 90% in all the metrics, the amount they got from different health plans in bonuses varied 6-fold. So what are they supposed to do?
With the P4P dollars they have created and improved their data warehousing, but there’s nowhere near enough for an EMR. There’s no new money for investment here–the P4P is a variation of a whithhold. Plus some plans are starting to play politics by witholding some of the amount as a bargaining chip for other negotiations.
Finally, he’s (rightfully) concerned that the whole HMO-IPA model is under threat. Even if they can prove they’re better quality, employers are going to other types of health plan (e.g. high deductible PPOs). So this may all go down the tubes anyway? Or at least come under a lot of pressure if they can’t figure out a model to take P4P to the PPO or high deductible world.
In the Medicaid plan world in California, the San Francisco Health Plan did improve its health scores, even though there are no groups and no IT at the physician level. (Michael van Duren, SF health plan) They used direct member intervention (bribes) and direct physician intervention (more and bigger bribes. But it also required visiting the bigger providers (on the 80-20 rule to get at the most patients) face-to-face to get them to do immunizations, etc. To do the visits they are imitating drug reps’ sales tactics. They serve food, and they show the data very quietly, and then start working on improvement by showing them into the live data on the warehouse (online) — then they go down to individual patient data (claims of course). So the incentives get you in the door, but it’s showing the doctors the transparent data as a tool to make them change — and of course most of it is fixing the coding which was done wrong in the first place! Now the plan is doing direct bribes to the physicians’ staff. The provider relations people are entitled to authorize anything that works up to a few thousand dollars,to get them to get their data better (including hiring a low level analyst, but also getting their Internet connection up, etc, etc.)
Of course, as W might say, this is really hard work.
Jeff Flick from CMS thinks that we’re heading from 33% of Californian seniors in Medicare Advantage to 50-60%. (Havent we seen this movie before–the private plans didn’t like the endsing and ran out before the end last time.) He wants to drive it there because he thinks that provate Medicare plans are easier to get to provide better quality care. Also worried about the impact of PPOs. HSAs and other higher deductible plans on shredding the community rating aspecy (as Alain Enthoven said to me in a quick corridor conversation).
In addition the CMS Docket program (seems not to have a Googleable web presence which may be why it’s not so popular!) Doqit program (thanks for the correction, Catherine) helps poorer and smaller practices get into information age, although it has not had much of an uptake so far. He does think that there’ll be a tipping point when doctors get the tech. He also thinks that the chronic care demonstration projects are part of Pay for Performance as they do mandate improved quality, satisfaction and guarantee savings. He said it: "We think that we are going to be able to figure out what works for disease management in Medicare" and it can then go into the main program with no further legislation needed. But in addition to focusing on chronic care, they are focusing on end of life issues which are very expensive and these people are getting no help from intensive case managmenet, or consumer support programs for those people. CMS is going to do a national demonstration for intensive case management. These are all forms of P4P that he thinks have a bright future in Medicare.
Finally CMS is also trying to figure out how to make claims data be useful for measuring quality and performance. As you can’t pay for perfomance if you can’t measure it, but they are working on this. (Ed’s Note. Going down this road will, you might suspect, be tricky given the reputation claims have for accuracy). But they also have to work out the payment issue on the FFS side. From 2006 there’ll be reductions in fees for the next four years. He thinks this needs to be fixed, but how will this be fixed legislatively? His personal hunch (not CMS dogma) that the solution is to increase fees for those physicians with quality information (and the IT to support it) and not for the rest.
In response to me asking him if we hadn’t seen this movie before (Plans launch into Medicare Advantage; rates go down plans so plans quit Medicare) Jeff says that the Rx benefit, risk adjustment and quality indicators will drive people into Medicare Aadvantage — but of course politics may change this (i.e. the way the BBA reduced payment rates) and he can’t say that it won’t.
TECHNOLOGY/QUALITY: DSM and IT at the HIT meeting
Shorter Sam Nussbaum (CMO Anthem) "DSM does work, really. But the baseline changes (sick people are not homogenous or constant–they also get better (or die). It’s worth about 14% on a PMPM basis across populations, but has an ROI of 2.85 to 1".
TECHNOLOGY: More HIT notes — barriers to EHR acquisition session
Brad Holmes from Forrester breaks up docs by age (under 44 makes them much more accepting of technology). Breaks up demand for software based on what docs want. Want ePresribing and charting, get Medicalogic (GE). Want diagnosis, use Next Gen. So you buy based on what you do. No one size fits all. BUT PMS systems revenues going down, EMR applications are taking off and 2004 will cross the line of PMS revenue
Blackford Middleton (ex Medicalogic, these days at Partners Healthcare in Boston) has worked out the cost-benefit model for rolling out their "LMR". Now used by 3500 of their 7000 affiliated physicians. The biggest impact is for drug savings, by using the on-formulary drugs. For CPOE there are levels; most basic is structuring data capture, second is providing some patient data, third is decision support based on algorithms and the patient record. Partners has the most advanced, and the result is that per provider saves up to 9 ADEs per year and costs savings of up to 28K per year per provider. Most valuable ones have by far the most impact ($28K per year vs $3k). For systems capitated at 14% they think this will cost solo providers a whole lot, and only save money for big groups. BUT Of all the benefits, only 11% go to the physicians. The rest goes to everyone else in the system, primarily the payers.
Gloria Austin from Brown and Toland, a 100% capitated group in San Francisco is just getting their EMR modules up (and now have lab data online) by working with affiliated hospitals, etc , etc. It’s an interesting talk (although her charts suck for readability) but I think it’s mostly irrelevant to most physicians in the US. But they are focused on implementing the EMR by concentrating on providing the physicians with the benefits, and creating the infrastructure foundation to do that. This process started for B&T in 2000 and its taken them till now to get it up. What is it costing them? $8m in first 4 years and another $10-12m going forward. Using IDX Flowcast and Allscripts Touchcast (because they were already using them and the integration was easier) plus you can import this into the Business Intelligence tool they use (Cognos). And in a nutshell this is really, really hard work, and costly organizationally to do. But she believes that you can create a seamless group that looks like a Palo Alto clinic, or a Kaiser.
Blackford said it, in reply to a question from me….there are potential operational improvements for small and solo docs (not just savings to capitated systems) but we have a major public policy problem getting these physicians to the table. And (he didn’t say) no real answers.
TECHNOLOGY: More on HIT
In the response and Q&A to Brailer, we’re told that adoption can happen in small offices and by PCPs. But CMS in California has been handing out some incentives for smaller groups (something called the Docket program) and only 256 out of 15,000 PCPs have so far expressed an interest. As the guy from CMS region said, this is disappointing.
Now the conversation has veered off as to whether we should all use the VA system (Vista). Come on people, the reason that doctors don’t use EMRs is not because the software costs too much or hasn’t been any good. In countries where they do use it a) the government paid for it all (including the hardware) and b) they were told they had to use it!
TECHNOLOGY: Live blogging from HIT conference
I’m at SBC Park in the bar (really!), the Wi-Fi is free and my lap top is propped on one of those big barrels of Coke cans and somewhere in the distance David Brailer is telling us that the US will exceed the achievements of those more centralized (code for socialized) systems. He thinks electronic records will happen but he’s a little less optimistic about inter-operability. No money, no mechanism and no demand for it. I’d agree that it sounds like there’s not much market for it, although there’s a hug amount of value from doing it. He calls this the "first-mover disadvantage". Like the first guy with a fax machine….
OK, Brailer’s just done. He mentioned the RFI released on Monday that is to get at the nitty gritty of the basics behind the NHIN (national health information network). Is this pure peer to peer? Is it regionally based.
He also talked about the Regional health exchange networks (RIOs). There are some 25 now, some 12 Federally supported. But he is counseling against a government solution — "this is the same government that brought you HIPPA!"
He also said that if we get the EMR at the bedside but we don’t get interoperability, then we might make the problem worse. But then he laid out all the reasons why inter-operability wont happen. I don’t think that he’s as optimistic as he thinks he is.
POLICY: Bush Plans Tax Code Overhaul, with UPDATE
Look at this trial balloon–Bush Plans Tax Code Overhaul. Getting rid of tax deductibility of health insureance as a business expense!! Are they serious? If so that really would put the cat amongst the pigeons!
UPDATE: Ross works out the logical process if this happens without some associated legislation creating the ability to buy collectively (and it must be pointed out, mandatedly with risk adjustment a la Enthoven (as the NY Times reports today). And yup, it’s not pretty
TECHNOLOGY: HIT meeting today
Thursday (Pacific time) I’ll be at the HIT meeting in San Francisco, held at PacBell SBC Park so that we don’t have to cross a picket line at the downtown hotels. I’m informed Barry Bonds won’t be there but current health care IT MYP David Brailer will, as will the rest of the good and the great of the health care IT world. There’ll be live blogging if you’re lucky and if the stadium wide Wi-Fi is all it’s cracked up to be.
POLICY: Jonathan Cohn on the politics of real reform
Jonathan Cohn, who besides being a deliriously happy Red Sox fan is a health care journalist and a senior editor at the moderately liberal New Republic, has been corresponding with me a while. (Does it bug anyone else having to keep The National Review, The New Republic and The Nation straight? Couldn’t the conservatives, the liberals and the real lefties have chosen titles with slightly different alliteration or words beginning with letters not N or R?). Jonathan’s on the book grind himself (and doubtless scared of my review!) and writes regarding my post yesterday as to why things might change in the longer term regarding reform:
Good post today about the politics of health care reform. I’ve been thinking a lot about this myself lately, as part of my book, and am starting to question the conventional wisdom that moderation plays better politically — at least in the context of a presidential campaign. Look at the election we just had. Policy wonks could (and did) make a very good case for incremental reforms like the ones Kerry proposed, and Kerry did fine on the health care issue because voters tend to trust Democrats more than Republicans on the issue if they don’t know any other information. But it’s not like Kerry’s health care plan was a major draw, and part of the reason is that it was so damn complicated it didn’t break through the policy fog.
Now consider single-payer. Put aside the debate over whether it’s really the best policy. I’m starting to wonder if — strictly in political terms — bolder isn’t better. You can explain single-payer three simple words "Medicare for all." And while that
instantly ignites a very hostile opposition, it also arms you with (a) the aura of a popular program, namely "Medicare" (b) the virtue of simplicity (c) the virtue of seeming bold.Admittedly, selling single-payer gets much harder if you actually get elected and have to start dealing with the legislative process. Maybe you compromise at that point. But I don’t think we’re going to see *any* substantial health reforms until
somebody puts a big, bold idea — and that probably can’t happen outside the context of a presidential campaign.
Meanwhile The Prospect blog had another wild idea–let everyone join the Democratic party and let it start its own health plan. Pity they’d never heard of adverse selection. (Thanks to Jones the Policy Wonk for the tip).
