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The Health Internet vs. the NHIN

Nov 16, 2009• 23

There is growing tension within the Obama administration’s health team over who will control health data exchange: everyone (including consumers and their doctors), or just large provider organizations. The public debate will be framed in terms of privacy, security, and the adequacy of current exchange standards. But what really matters is who gets to make decisions about where health data resides, how it can be accessed, how much exchange will cost, and how long it will take for exchange to become routine.

Now is a good time to re-visit the plans for a National Health Information Network (NHIN), since we can finally observe and compare different health data sharing and exchange models in the marketplace. NHINs represent an older model that tries to use regional health information organizations (RHIOs) to establish secure networks, privately owned and operated by large provider organizations, mostly hospitals and health systems. The idea was that, over time, each private regional network would develop a gateway to other networks, creating a “network of networks” that would allow Stanford to talk to Partners Health, or Kaiser to Mayo. This communications model was enterprise/provider-centric. Patients/consumers were relegated to depending upon each RHIO’s policies for access to their health information. It was also a massively expensive and time consuming – think decades – way to build a health data network.Continue reading…

The Outlook for a Health Reform Bill in 2009

Nov 15, 2009• 2

Congress Readers know of my year long pessimism over our getting a trillion dollar health care bill in 2009.

With the historic passage of the House bill, are we now on our way to a big health care bill in 2009—or even by early 2010? Clearly, Democrats desperately want to pass a bill. Given their compromise over abortion and the neutering of the public option in the House legislation—things most liberals said they would never agree to—it is clear the Democratic leadership will take any deal they can get.

But there are still some giant obstacles on the way to a Rose Garden bill signing late this year or early next:

Getting and keeping 60 Senate votes across a wide spectrum of complex issues. Senate Majority Leader Reid has not achieved a 60-vote consensus on any of the dozen or more contentious issues. In the wake of Pelosi not being able to get more than a two-vote margin for the neutered public option, some Democratic Senators will have no interest in the “robust” version with the state opt-out Reid has been talking about. He has made even less progress on all of the other contentious issues–and you can put abortion on the top of that list. Figuring out the “sweet spot” on each issue that keeps the same 60 votes on side for the entire bill would take a super computer—if that were even possible. The growing angst over these health bills not bending any cost curves and actually getting the savings from Medicare that is projected. With the demise of the robust public option even a lot of “sympathetic voices” are having second thoughts. How many op-eds and editorials can you have announcing this is not health care reform and it is likely to continue adding to deficits before everyone wants out?The latest blow was the report from the CMS actuary that says Medicare beneficiaries will suffer from the program cuts in the bills and health care costs will more likely continue to add to the deficits. I expect opponents are cutting new ads using the CMS report against the Democratic bills at this moment.
The polls are still showing opposition well ahead of support for the Democratic bills. Pollster.com combines a number of polls finding 42.5% favor and 48.6% oppose. How do you pass so big a piece of legislation with approval ratings in the 40% range?

If Reid finds a way to keep 60 Senators onside it will be an example of a political master performance. If he fails it will be the more likely outcome.

More than anything else, I sense a rising tide of anxiety particularly among people who understand this issue and want a health care bill: Somewhere we lost our way on the road to health care reform and we now find ourselves headed to an entitlement bill that falls far short of achieving universal access and a bill we still can’t afford. This will eventually spill over to mainstream voters already anxious about a trillion dollars in new spending in the midst of an economic crisis.

That is not the place Democrats would have wanted to be just when they need to overcome what would have been stiff resistance under the best of all circumstances.

Robert Laszweski has been a fixture in Washington health policy circles for the better part of three decades. He currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia. Before forming HPSA in 1992, Robert served as the COO, Group Markets, for the Liberty Mutual Insurance Company. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog, where this post first appeared.

Measurables and Immeasurables

Nov 14, 2009• 33

“Our scientific age demands that we provide definitions, measurements, and statistics in order to be taken seriously. Yet most of the important things in life cannot be measured.” – Dennis Prager, 1948 – radio host, lecturer, columnist, ethicist

“My first goal for Intermountain is that anytime a physician or nurse says, ‘In my experience’ when they’re talking to a patient, they mean ‘In my measured experience.’ ”

– Brent James, MD, Chief Qualify Officer, Intermountain Healthcare, as quoted in “Dr. James Will Make It Better,” by David Leonhardt, New York Times Magazine, November 8, 2009

It all sounds simple enough. You measure everything you do. You gather claims data. You measure what works. You show measures of what works to doctors and nurses. You write protocols for doctors and nurses to follow what works. You pay more for what works. You pay less for what doesn’t work. You remove pay incentives that cause doctors to do more. You gather together doctors who lead organizations with track records for providing better care at lower costs at the White House.

Will Business Force Reform Back To The Drawing Board?

Nov 13, 2009• 62

By BRIAN KLEPPER and DAVID C. KIBBE

Brian Klepper Until now, non-health care business has been noticeably absent from the health care reform proceedings , and quiet about the bills’ impacts on their management of employee benefits, on cost, and on the larger issues of global competitiveness. Where have the voices been of the powerful business leaders who will pick up much of the tab?

They’ve finally surfaced, and now we’ll see whether they have the will to bring reform back on track. They certainly have the strength. The question is whether this salvo by the business mainstream could force Democrats to reconsider and revise the content and structure of their proposals.

On October 29th, a powerful collaborative of major employer organizations sent a letter to Speaker Pelosi and Republican Leader Boehner asserting that the House legislation “falls short of the bipartisan goal of controlling costs and jeopardizes employer-sponsored coverage which now serves more than 160 million Americans.” The same group sent a similar letter to Senate President Reid earlier that week.

Abortion Coverage Is About Math As Well As Politics

Nov 12, 2009• 16

By Al LEWIS

Let us start by acknowledging that those who think abortion is a sin must be respected, and not forced into a risk pool that covers abortion. Let us also acknowledge that those who are pro-choice need to acknowledge that abortion (except in the case of rape or incest or potential significant harm to the mother) is a personal choice (albeit usually as a result of an accident) rather than a health issue in the narrow sense of the word.

Therefore, leaving all the politics aside and just focusing on the question of what should be covered in a basic benefit, it is not unreasonable to require an actuarially appropriate rider to cover abortion.

What would that “actuarially appropriate rider” be? Probably only a dollar or two a month to begin with. Figure that there are 800,000 abortions per year. They cost maybe $1000 apiece. That’s $800,000,000. Divided by the 21-65 year-old health-insurance-buying population, we are talking about roughly $4/year. Next, figure some self-selection into the rider, so that people with the rider might, on average, think they have (for instance) three times the probability of an unwanted pregnancy than people without the rider, which is why they get the rider. Therefore their likelihood of abortion is three times higher than the average on which the above calculation was based. So that $4 becomes $12/year or $1/month, to begin with.

Regina Holliday’s mural for Fred

Nov 12, 2009• 2

By Matthew Holt

Regina’s story has been on THCB before—Fred’s Life & Death at 73 cents a page. But you may not have seen the mural. (From NPR)

The Best Health Care Idea All Year

Nov 11, 2009• 23

By ROBERT LASZEWSKI

Out of almost nowhere has come momentum for a proposal to create a bipartisan entitlement and tax commission to draft proposals to control the long-term costs of Social Security, Medicare, and Medicaid. The idea would require the Congress to quickly vote the recommendations up or down via a super majority vote.

The idea isn’t new–proposals for a such a commission have been around for a longtime.

What is new is the bipartisan enthusiasm that is growing–particularly in the Senate. Coming out of the Budget Committee, and Chairman Kent Conrad and Ranking Republican Judd Gregg, the idea is picking up bipartisan steam with, among others, Republican Senate Minority Leader Mitch McConnell expressing general support for the idea.

A number of Senators have threatened to tie their votes to raise the deficit ceiling to establishing such a commission.

If the recent Democratic health care bills have made one thing crystal clear it is that the Congress is wholly incapable of dealing with cost containment under present circumstances.

Robert Laszweski has been a fixture in Washington health policy circles for the better part of three decades. He currently serves as the president of Health Policy and Strategy Associates of Alexandria,
Virginia. Before forming HPSA in 1992, Robert served as the COO, Group Markets, for the Liberty Mutual Insurance Company. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog, where this post first appeared.

Medicare’s Biggest Change in 40 Years on the Horizon?

Nov 11, 2009• 2

By Vince Kuraitis

Earlier this week CMS issued a typically cryptic Announcement indicating that they were shelving the Medicare Medical Home Demonstration (MMHD) and instead would focus on the recently announced Multi-Payer Advanced Primary Care Initiative (MAPCI). My blog post from Tuesday provides details and asks the question “What does all this mean?”

Medicare’s Biggest Change in 40 Years?

CMS’ Announcement about the rise of MAPCI and the fall of MMHD struck me as highly significant…but all the pieces didn’t fit. I’ve spent a fair amount of time emailing and talking with colleagues this week…and the big picture is emerging…and it’s really BIG. My working hypothesis is that Medicare is on the verge of its biggest
change in 40 years:

Medicare was created as a centralized, monolithic payment model.
It’s been one size fits all, and that size is created in Washington DC.
There has been little tolerance of regional administrative variability,
and the ironic result has been high variability in regional costs and
quality.
Medicare seems poised to do a 180. It’s signaling movement toward
supporting state-based, multipayer initiatives — where Medicare is at
the table and influential, but not in control. It’s a recognition that
health care is local and that unique solutions will be needed in
different regional markets. The Obama administration is demonstrating
strong support for the Patient Centered Medical Home (PCMH) and
Accountable Care Organizations (ACOs) as important building blocks in
this transition.Continue reading…

Dave Durenberger on Lieberman

Nov 11, 2009• 2

By Matthew Holt

Former Minnesota Senator Dave Durenberger, a thinking centrist Republican (remember them?) puts out an occasional newsletter full of gems. This is today’s zinger:

The Senate has a better bill than the House, but it also has a 60-vote requirement which empowers the odd-ball “if not my way, the highway” members – like Joe Lieberman claiming that something like a public insurance plan violates his “conscience.” I guess I don’t understand Conservative Judaism.