My final interview from my trip to Microsoft was with Nate McLemore, who is Director of Business Development for the Health Solutions Group and also involved in Microsoft’s policy & lobbying work. Nate talked about Microsoft’s role in the ongoing deliberations on meaningful use, ARRA and all that.
Can price competition cut health care costs? There are lessons to be learned from the airline industry.
Over thirty years, per capita health care costs, adjusted for inflation, have increased two and a half times. In the same period, despite a doubling of fuel prices, airline fares have fallen by more than half.
Why the five-fold disparity?
It’s obvious the two industries have followed very different paths. While airline travel has become an experience of packed planes, crowded airports, and peanuts (or less) meal service, health care has seen dramatic advances. Treatments that a few years ago seemed unimaginable are now commonplace: heart transplants, anti-depression drugs, artificial joints, laparoscopic surgery using miniature television cameras, and—of course—Viagra.
That’s only part of the story, though. While air travel is now safer and more convenient, with more frequent flights to more destinations, health care in some communities is so inadequate that morbidity and mortality rates are comparable to those of third world countries.
Why have airlines been apparently so much more successful in giving value for money?
Led by Southwest, the airlines that sprung up after deregulation recognized that individual flyers were price-sensitive, and cut their costs accordingly. They faced barriers, though, many of them analogous to those in today’s health care system. Business travelers flying on their employers’ nickel resisted efforts to move them to crowded peanut-only flights, frequent flyers resisted having to switch from their favorite mileage plan to that of another airline network, and travel agents much preferred to send their customers on airlines paying higher commissions.
Southwest and its peers succeeded by marketing directly to the public, through relentless emphasis on lower fares, and by maintaining standards that were, if not luxurious, acceptable to travelers. Few businesses are now sympathetic to employees’ preferences for more comfortable higher-cost flights, frequent travelers have adapted to low-cost airlines’ mileage programs, and travel agents and their commissions are almost a thing of the past.
And now, just as Southwest Airlines travelers found that they reached their destinations as reliably—if not quite as comfortably—as before, so recent studies have shown that there is little or no relationship, within the range of acceptable medical standards, between health care costs and quality.
So, what must health care reform do to emulate Southwest Airlines’ effect on fares?
First, just as deregulation ended most legacy airlines’ government subsidies, the tax exemption for employer-paid insurance should be reduced or eliminated. Not only is the $300 billion a year tax subsidy needed to help pay for reform, but cutting the exemption will discourage overly-generous coverage and remove the inequity between employer-paid and individual-paid insurance.
Second, just as travelers can compare airlines’ fares for the same itinerary using Orbitz or Expedia, insurers should be required to price the same basic benefits, perhaps through insurance exchanges. Supplemental benefits could be offered and separately priced, but being able to compare prices for the same basic coverage is essential.
Third, just as individuals purchase most airline tickets, so individuals should be responsible for choosing insurance to meet their own needs. In practice, this implies subsidies for the lower-income, and perhaps also some form of voucher model to facilitate the process. It may be appropriate, however, to allow self-insuring companies to continue to provide employee coverage since, with no insurer risk or profit involved, they typically provide better value.
Fourth, just as airlines’ pay is negotiated only with their own unions—not with every airline union in each airport—so there should be more effective constraints on provider monopolies in which specialists in an area group together to control prices.
Emulating Southwest Airlines won’t result in the cost of health care falling by half, but it offers a far more promising approach to cost control than the expensive band-aid solutions, superimposed on the worst features of our present system, apparently preferred by congressional committees.
Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE [reformupdate.blogspot.com].
The first draft of “meaningful use” came out early yesterday, and I was struck by two things. First, probably influenced by the NCVHS recommendations and the Consumer Partnership for e-Health (See Update), the work-group included a lot of consumer-facing aspects in the concept of meaningful use. Here’s the full draft. Comments are being accepted now (but hurry as they’re going to come back with version two in a month, you have 9 days!).
But in terms of getting consumer activities into the 2011 definition the “Objectives” suggest that meaningful use includes:
I spent a couple of days last week (June 10-11) at a conference co-sponsored by the HRSA Center for Quality and the NIH National Center on Minority Health and Health Disparities at which twenty of the highest-performing community health centers from the HRSA’s long-running Health Disparities Collaboratives (HDCs) described their accomplishments in improving primary care. They were stunning.
These health centers were not fresh-faced newcomers to the improvement collaborative du jour, but rather grizzled veterans who joined the HDCs ten years ago, have stuck with the method, and by now have embedded quality improvement deeply into their day-to-day operations and organizational culture.
If ever there could be a vivid demonstration of what is possible and right in the future of American primary care, this was it. Consider:
As team after team presented their stories, it became clear that these results were being achieved by safety net organizations on shoestring budgets, with highest-risk populations, despite the extra burdens of improvement work, data management and reporting. At La Clinica de la Raza in Oakland California, since 2007 100% of persistent asthmatics have been on controller medications. At Holyoke Health Center in Massachusetts the percent of diabetic patients with HbA1c’s over 10 has declined from 29% to 10% since 2000. At Hunts Point-Mott Haven in New York City, asthma hospitalization rates have decreased by 58% since 1997.
Together, these CHC leaders described a radically transformed model of primary care based on a fundamental change in attitude: instead of caring for patients ‘one at a time,’ they have accepted responsibility for a population of patients, based their criteria for quality on measures of the whole population, and persistently sought ways to improve those measures.
All of these high-performing health centers relied on information technology to achieve and measure results. But they referred to their systems as ‘registries’ – not as ‘electronic health records’ or ‘EMRs’.
EHRs versus Registries? – Lets Talk About Functions Instead
Despite the ever-present risk of oversimplifying a complex issue, and without worrying too much about what is really an EHR or a registry, let’s try to sidestep the controversy and focus instead on the software functionality that is needed to support the new model of primary care, as illustrated by these high-performing community health centers.
Today’s discussions of EHRs typically center on a relatively narrow range of functions that support the ‘one-at-a-time’ model of care: storing and displaying patient-specific clinical information at the point of care, reminding providers of the care needed by a patient during a visit, increasing the reliability and safety of common processes such as ordering tests and prescribing medications. When patient data can be readily shared among providers, these benefits are amplified across the continuum of care. These functions are important, but are only part what is needed to improve quality.
The registry functions described by high performing CHCs focus on using data to directly monitor and improve care for a population. We can distinguish two broad levels of registry functionality.
‘Base level’ registry functions are the starting point for practices working on quality improvement and are widely familiar to those participating in improvement collaboratives. They include:
The high performing CHCs who presented at the HRSA/NIH conference, many with over 10 years of experience in sustained care improvement, described uses of their registries that extend far beyond either EHRs or base-level registry functions. Advanced registry functions mentioned by these teams include the ability to
HITEP or Mis-Step?
As I listened to the conference presentations, I scribbled notes. I was pushing a deadline to respond to a Request For Comments from the Office of the National Coordinator for Health Information Technology (ONC) [http://edocket.access.gpo.gov/2009/pdf/E9-12419.pdf ] regarding a proposed ‘Health Information Technology Extension Program’ (HITEP). This program, fueled by $2B of stimulus funds, envisions a national network of ‘Health Information Technology Regional Extension Centers’ which will employ ‘extension agents’ to coach providers on the selection, implementation and ‘meaningful use’ [whatever that means] of certified EHRs.
Parsing the RFC during coffee breaks, I was struck by the disconnect between the ‘silver bullet’ overtones of the ONC’s vision of EHRs everywhere, and the dogged improvement work being carried out by the CHCs presenting their results to the audience of HHS personnel and health services researchers.
I was also struck by the fact that no ONC staff attended the meeting, although many agencies across HHS were represented. So I fear that the message about the software functions that are so ‘meaningful’ for quality improvement will go unheard as HITEP is put into play.
As I was leaving the conference I talked to a physician leader of one of the CHCs who was in charge of his center’s EHR adoption project. His center has been a long-standing user of registry software and has accomplished dramatic improvements in care. Their group adopted an EHR product based primarily on it customizability, and he has personally spent half of his time for the past two years reshaping the EHR software to support the registry functions that his practice has come to rely on.
More than ever, I am fearful that the ONC is pushing technology for technology’s sake, without thinking through the software functions that are actually needed by the providers who are pioneering the transformation of primary care.
ehrRichard Scoville, PhD, is an independent consultant specializing in healthcare quality improvement and performance measurement. He is an Adjunct Professor in the Department of Health Policy and Administration at the University of North Carolina at Chapel Hill where he teaches courses in healthcare quality improvement and informatics. He serves as an improvement advisor to the Institute for Healthcare Improvement, NICHQ, the Cincinnati Children’s Hospital Medical Center, and the Federal Health Resources and Services Administration on a range of collaborative improvement and systems design projects.
Just a few years ago The New York Times was on its last legs, printing Judy Miller’s re-mouthing of Cheney’s lies, holding back the wiretapping story until after the 2004 election, and generally spouting a lot of rubbish about health care.
Somehow the leadership there looked to THCB for inspiration.
Democratic Senator Maria Cantwell of Washington is a prime reason President Obama will have a hard time getting health care reform passed this year. Let me explain this seeming oddity. At a news conference on May 27 in Yakima, Wa., the purportedly liberal Cantwell, who represents a state that voted 58 percent for Obama, announced her support for two new, bipartisan bills that would advance a key goal of Obama’s reforms — increasing access to primary care physicians and other doctors who are in short supply. As Massachusetts has discovered, making sure nearly everyone has health insurance doesn’t help if there aren’t enough doctors to take care of them.
The two bills Cantwell endorsed feature provisions that would cost the federal government billions of dollars a year — scholarships and loan forgiveness for medical students who serve in shortage areas, increased funding for the National Health Service Corps, higher Medicare payments to primary care doctors, more Medicare funding for resident physician training, interest-free loans for hospitals starting new residency training programs, etc.Continue reading…
Below is a slightly expanded version of a letter I recently sent to Dr. Blumenthal, the new National Coordinator for Health Information Technology, and the members of the new national HIT Policy Committee.
Dear Dr. Blumenthal:
I am writing to you on the need for user-friendly electronic health record (EHR) software programs. As a practicing physician with first-hand experience with hard-to-use CCHIT-certified EHR software, I would like to share with you a solution to this vital issue.
The CCHIT model for EHR software certification is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design. This flawed CCHIT model takes valuable physician time and effort away from patient care and leads to increased potential for errors, omissions, and mistakes.
As a clinician, I have had first-hand experience with a top-tier CCHIT-certified EHR. Despite being computer literate and being highly motivated, after a year and a half of concerted effort, I still cannot effectively use this CCHIT-certified program. The poorly designed software constantly intrudes on my clinical thought process and interferes with my ability to focus on the needs of my patients.
Just this year the National Research Council report on health care IT came to a similar conclusion. The report found that currently implemented health care IT programs often
provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system. Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks.
Our health care system needs user-friendly EHR software, firmly grounded on what we have learned about how the human brain takes in, organizes, and processes information.
As an example of software based on usability principles, I would like to share with you a new design, the EHR TimeBar, which is one example of user-friendly EHR software design that can dramatically improve patient care. Please see attached figure and description at the end of this letter.
I have no financial interest in this software design. My goal is to promote the emergence of user-friendly EHR technology that will improve the day-to-day lives of my colleagues and help us take better care of our patients.
We absolutely need standards for data, data transmission, interoperability, and privacy. There is no need, however, to specify the internal workings of EHR software. To do so will stifle innovative software designs that could improve our health care system. If CCHIT is allowed to mandate the meaning of the term “certified-EHR,” the $17 billion allocated for EHR adoption and use will largely be wasted.
The solution is to keep EHR certification rules simple to encourage an open market model. An open market will foster a competitive environment, leading to the emergence of user-friendly EHR software that is simple, helpful, efficient, and inexpensive – software that will improve both patient care and the day-to-day lives of our clinicians.
I appreciate your work and the work of the HIT Policy Committee members in crafting our new national health care IT plan.
Sincerely yours,
Richard Weinhaus, M.D.
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ePatientDave and Giles Frydman have been working on the Society of Participatory Medicine for a while and Alan Greene MD will be the first President. Now there’s a editorial board for the Journal of Participatory Medicine. The editors will be Charles W. Smith (who announced it at the end of last month at his blog eDocAmerica), and Jessie Gruman, patient extraordinaire from the Center for Advancing Health. There’s also an advisory board including Kevin Kelly, Adam Bosworth, Esther Dyson, David Kibbe, Howard Rheingold, Eric von Hippel, & Peter Yellowlees—which is a good mix of Ubbergeeks and geeky doctors.
To me there’s a slight difference between Health 2.0 which in my definition is more about using tools and technology to change the health care system, and participatory medicine which is centered around the e-Patients blog. But that hasn’t stopped other definitionistas (yes, I mean you Ted!) from crunching them together—and of course any tension between them is significantly less than the common purpose of changing health care using the best tools available.Continue reading…
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What are people saying about health reform beyond the beltway and outside the health wonk debates? I’ve been meeting with Rotary Clubs and local Chambers of Commerce during the last several months, and they’re talking about different issues than the ones being debated in Washington, DC. When I talk with these groups about the prospects for national health reform, what are the top three questions they ask?
These are not the top issues being debated on Capitol Hill. If you just read Politico.com, the Washington Post, and the pundits’ blogs, you would think that the big issues are the public plan option, the employer mandate, and the cap on the tax exclusion of employer-paid benefits. There are important, but they aren’t the issues that most small employers and consumers are worried about.Continue reading…
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The Pew Internet/California HealthCare Foundation report, The Social Life of Health Information, is packed with new findings from a survey of 2,253 adults, including 502 cell-phone interviews, conducted in either English or Spanish.
We spent a bundle of money on making this a random sample of the U.S. population, but guess who got a call on his cell phone? None other than e-patient Dave! He had never talked with me about the survey questions or reviewed a draft, so I decided to keep his interview in the mix, but he surprised the heck out of the interviewer when he finished the sponsor identification for her at the end.Continue reading…
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