Today from 1:00 – 1:30 p.m EST (10-10.30 am PST) we’re hosting a TweetJam for our friends over at Xerox (FD-Yes they are paying us). We’ll be discussing the results from their recent survey on Electronic Health Records and invite you to join in on the conversation. Never heard of a TweetJam before? It’s simply a time to gather on Twitter around a particular topic and learn from each other. Anyone can ask, or answer, a question. All you have to do is login to Twitter, follow the Twitter handles @THCBStaff and @ServicesatXerox and use hashtag #EHRJam to participate in the discussion. We hope to see you there!
Above the Fold
Vermont’s Bold Experiment
I was delighted to see the lead article in Health Affairs describing Vermont’s new single payer health care financing system. Harvard Professor William Hsiao and his coauthors describe this as a “Bold Experiment” and I couldn’t agree more. It is also a very welcome experiment. For over thirty years I have heard the rhetoric that a single payer system would never work in the United States. For that matter, I have heard that a true market-based system (with vouchers) would never work either. Why not let the states experiment and find out what will and won’t work? Thankfully, the Vermont legislators and Governor Shumlin had the courage to take this leap of faith.
The biggest obstacle to implementation appears to be ERISA, which limits the extent to which states can regulate self-funded plans. Apparently, self-insured employers could object to having their tax payments used to support the plan. But Vermont can apply for an ERISA waiver under terms in the Affordable Care Act and the state hopes to begin its bold experiment in 2015.
As bold as the plan might be, Hsiao et al. might be even bolder in projecting the potential cost savings, which they peg at 25.3 percent. Academics rarely go out on a limb with projections like this that can easily be assessed in a few years time. And academics are rarely so optimistic. I wish I could share that optimism.Continue reading…
Don’t Forget Medicaid
As we wait for the white smoke to emerge from the “grand bargain” negotiations at the White House, most Americans are already aware of the Republicans’ plan to dismantle and privatize Medicare and Social Security. But what many people may not realize is just how dangerous it would be to slash funding for a program that 60 million Americans rely on for their basic health care needs: Medicaid.
While it seems that just about every major industry or interest group has teams of lobbyists in Washington looking out for them, some of our most vulnerable citizens simply don’t have a voice in a town where unfortunately, money still talks the loudest.
Why? Medicaid covers only the impoverished and disabled, so it lacks a traditional advocacy base. This may be news to Republicans — but most poor people I know are spending all their time trying to find a job and put food on the table. Lobbying Congress just isn’t on these folks’ to-do list right now. Unfortunately, this means that my colleagues aren’t going to spend a lot of time over the next 30 days sticking up for the 60 million Americans who rely on Medicaid to pay their medical bills. That’s unfortunate, because if the Republicans are successful in turning the program into a block grant program that greatly diminishes funding to states, three awful things are going to happen — people are going to die, more jobs are going to be lost, and health care costs and taxes will actually increase.
Why Everything We Are Doing in Health Policy May Be Completely Wrong …
A relatively obscure paper (gated) published in an academic journal the other day was completely ignored by the mainstream media. Yet if the study findings hold and if they apply to a broad array of health services, it appears that the orthodox approach to getting health services to poor people is as wrong as it can be.
At first glance, the study appears to focus on a rather narrow set of issues. Although most states try to limit Medicaid expenses by restricting patients to a one-month supply of drugs, North Carolina for a period of time allowed patients to have a three-month supply. Then the state reduced the allowable one-stop supply from 100 days of medication to 34 days and at the same raised the copayment on some drugs from $1 to $3. Think of the first change as raising the time price of care (the number of required pharmacy visits tripled) and the second as raising the money price of care (which also tripled).
The result: A tripling of the time price of care led to a much greater reduction in needed drugs obtained by chronically ill patients than a tripling of the money price, all other things remaining equal.
This study pertained to certain drugs and certain medical conditions. But suppose the findings are more general. Suppose that for most poor people and most health care, time is a bigger deterrent than money. What then?
If that idea doesn’t immediately knock your socks off, you probably haven’t been paying attention to the dominant thinking in health policy for the past 60 years.
Letting Go Of Employer-Based Health Insurance
Other than the egg-laying exercise surrounding the ACO regulations, 2011 was a quiet year among Washington health policy experts until June 6 when McKinsey released the results ofa survey of employer plans under the Affordable Care Act. The McKinsey study found that roughly 30 percent of employers were considering dropping their employee insurance coverage and encouraging their employees to receive federally subsidized health insurance through the Exchanges created in the Affordable Care Act. This compared to low- to mid-single digit estimated drop rates based upon economic modeling by the Urban Institute, Lewin and, importantly, the Congressional Budget Office (CBO).
To judge by the storm of angry political reaction, you would have thought that McKinsey had advocated mass psychedelic drug use. Senator Max Baucus (D-MT) sent McKinsey a letter demanding that the firm disclose its methods and questioning its motives. There followed a flurry of hostile press coverage of the study, echoed in the progressive blogosphere. Horrified, McKinsey released its study methodology, survey instrument, and tabulations of responses.
Why such a sharp reaction? If McKinsey turns out to be right about employer intentions, the cost estimates of the federal subsidies for individuals to purchase coverage through the Exchanges (roughly $777 billion from 2012 to 2021 according to CBO’s March, 2011 analysis) are far too low, making the program even more vulnerable to Republican efforts to cancel it. And if a third of employers drop coverage, President Obama’s pledge that “if you like your health insurance coverage, you can keep it” won’t look so great either.
Why Cost Cutting Doesn’t Work – And What Will Work
Cutting costs does not cut costs. If we hope to steer health care toward a better cheaper future, we have to wrap our minds around this conundrum: Slashing spending does not necessarily improve the bottom line.
Governments in Ireland and the United Kingdom have come up hard against this conundrum. They have both faced soaring deficits due to the economic downturn, because their tax revenues have fallen at the same time that their costs for unemployment and other kinds of social support have risen.
So they both did what might seem like the sensible thing: They attacked the problem by cutting spending, in the professed belief that such a move would also increase the financial markets’ confidence in the future, and thus pump up the economy, reduce unemployment, reduce the interest the government has to pay on its debt, and increase tax revenues.
Result? Their deficits have grown even larger. Why? Because what economist Paul Krugman likes to call “the confidence fairy” never showed up. The austerity measures tanked their economies even further. Firing a lot of people, it turns out, drives unemployment up and tax revenues down. The worsening debt picture increased the cost of borrowing. Many U.S. states are headed down the same path right now, slashing spending in order to slash deficits, and the U.S. Congress is famously and forever wrangling over the same formula.
Why Medicare Is the Solution — Not the Problem
Not only is Social Security on the chopping block in order to respond to Republican extortion. So is Medicare.
But Medicare isn’t the nation’s budgetary problems. It’s the solution. The real problem is the soaring costs of health care that lie beneath Medicare. They’re costs all of us are bearing in the form of soaring premiums, co-payments, and deductibles.
Medicare offers a means of reducing these costs — if Washington would let it.
Let me explain.
Americans spend more on health care per person than any other advanced nation and get less for our money. Yearly public and private healthcare spending is $7,538 per person. That’s almost two and a half times the average of other advanced nations.
Why Let IPAB Control Health Care?
Former House Speaker Nancy Pelosi once said that Congress needed to pass the new health care law so the American people can find out what’s in it. Many have since taken her up on that — and they do not like what they see in Obamacare. Seniors on Medicare are particularly alarmed by the new Independent Payment Advisory Board, which could severely restrict their access to treatments and medications.
The advisory board would change Medicare forever. This group of unelected, unaccountable bureaucrats has now been given the power to restrict access to health care for our seniors. They can do so through price controls on medical services that would become law without a vote in Congress.
This board, included in Obamacare, was bad enough to begin with, but now President Barack Obama wants to strengthen it further. After two years of wasteful spending, he sees the new board as the key to reducing Washington’s budget deficit. Instead of reforming our entitlement programs responsibly, he wants to appoint 15 “experts” to balance the budget on the backs of our seniors.
Errors of Omission
I am a rural Family Physician who has been in solo practice for more than 22 years. I am neither a technophobe nor an information technology Luddite. I have been using electronic prescribing for over 6 years and am in the market for an EHR that is net-based, scalable, interoperable and linked to a nationwide patient database.
While I wait, over the years I am seeing more and more patient care that is less co-ordinated and even thwarted by the very health information technology (HIT) that is supposed to increase efficiency. In my opinion, this is leading to decreased information transfer that is wasting precious time and putting patients at risk with errors of omission.
I will give anecdotal and real examples of HIT run amok that I suspect are more common than generally appreciated. Alarmed by the lack of awareness of the potential frequency of these errors, I am writing this hoping that the blogosphere can somehow counter the momentum of an all-powerful HIT cerebrosphere.
1. e-Prescribing (ERX): While mandated alerts about potential drug interactions in this software is often life-saving, it can also be life impairing. There are two reasons for this: 1) at point of care, the warnings are just too darn sensitive and I’m being conditioned to ignore 90 percent of them. I am afraid that this will cause me to click the “ignore” pop-up at the wrong time. For instance, doxycycline and Dilantin have an interaction and a prescription of one in the presence in the other always prompts a warning. When I researched this, I found the plasma concentration of doxycycline is decreased by a clinically negligible amount. 2) at the pharmacy window, the warnings can override physician judgment. A colleague of mine described to me how he prescribed a fluoroquinolone antibiotic to a patient on Coumadin and, aware that there was an interaction, ordered the appropriate follow up testing and dosage modifications. The pharmacist not only refused to fill the prescription, they also did not notify him. Instead, he asked the patient to call the doctor. Two days later the patient was admitted to an ICU with life-threatening sepsis. In both cases, needed prescriptions were omitted.
Most Americans Don’t Yet Perceive the Benefits of EHRs
Consider all the stakeholders with something to gain by moving from paper health records to digital electronic records. Who do you think would gain the most from EHRs, and who the least? A survey from Xerox finds that the among all the groups American adults say have the least to gain through EHRs is, the most common response is…patients.
29% of people aren’t really sure who’s to gain from moving to EHRs.
To better understand Americans’ views on electronic health records (EHRs), Xerox polled 2720 adults 18 and over in May 2011.
The topline finding is that 83% of people have concerns about digital medical records. The most concerning issue is that “my” personal health information could be hacked, cited by two-thirds of people. The second most common concern is that digital medical record files could be lost, damaged or corrupted (noted by 54%) and that personal health information could be misused (52%). Another worry is that a power outage or computer problem could prevent providers from accessing health information, cited by 52% of people surveyed.
