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Above the Fold

On Clinical Groupware, Interoperability and the HITECH Bill

Apr 1, 2009• 6

By CHARLIE BIRMINGHAM

Was it not Aristotle who once remarked “Nature abhors a front end that is not connected to its backend?”

In his recent, insightful blog here on Clinical Groupware as an alternative “meaningful use” of IT under the Health Information Technology and Economic and Clinical Health Act (HITECH), contained in the American Recovery and Reinvestment Act of 2009, David Kibbe commented that the primary purpose for using these IT systems is to “improve clinical care through communications and coordination involving a team of people, the patient included…in a manner that fosters accountability in terms of quality and cost.”

Yet it takes a “connected” health care ecosystem to make this kind of communication possible, and thus HITECH is replete with references to “interoperability” and “data exchange.” Indeed, the concepts of “meaningful use” and “interoperability” are inextricably linked in HITECH. For example, Section 4102 states that hospital incentive payments are dependent on demonstrating, “that during such period such EHR technology is connected in a manner that provides, in accordance with standards applicable to the exchange of information, for the electronic exchange of information to improve the quality of health care, such as promoting coordination of care.”

Holt accepts Beltway role, pledges new era of ‘personable responsibility’

Apr 1, 2009• 14

By JOHN IRVINE

In a dramatic reversal, THCB publisher Matthew Holt announced today that he has accepted a position with the Washington based CATO Institute, a think tank devoted to sober analysis and rigorous defense of the ideals of the modern conservative movement.

At CATO, Holt will hold the title of Distinguished Visiting British Policy Wonk. He is expected to deliver a series of entertaining lectures designed to warn conservative audiences of the dangers of encroaching big government and the evils of internationalism.

Tentative topics in the series, scheduled to be held at the Rottweiler Student Center at the American University are “What the Hell is Government, Anyway, Really, When You Think About it?” and “Regulation 2.0: Here We Go Again, This Guy Reminds Me of Jimmy Carter ..”

The appointment represents only the latest chapter in a personal voyage spanning three decades and six continents for Holt. In recent years the blogger and entrepreneur had become synonymous with cheeky criticism of the healthcare industry.

“It all started when I read that Ayn Rand book on a bumpy flight from San Francisco to Nashville,” Holt said. “At first, I thought I was going to be sick, then, in a moment of clarity, I became aware of my numerous internal contradictions. By the time I got off the plane I was composing a personable e-mail to Michael Cannon in my head .. ”

Officials at CATO said they were initially skeptical when Holt approached them with the idea that he join the institute, but gradually warmed to the idea, after thinking about it for a little while. “Frankly. we thought it was a bit odd,” said Institute spokesman Chet McClellan “Shit. I mean. Matthew Holt? But people change. Especially in Washington around stimulus package time. ”

In recent months, Holt had been among a number of candidates rumored to have been headed to a high profile role in the White House Office of New Economic Policy. (WHONEP). According to highly placed sources in the administration with an intimate knowledge of events, that lifelong dream came to an premature end last month after Holt offended first lady Michelle Obama with public comments denigrating the Obama Health care reform plan.

According to several witnesses who asked not to be identified, Mrs. Obama flew into an extended rage after learning that Holt had called Mr. Obama’s bold plan to radically reshape the broken US Healthcare System in three months using a handpicked team of people from Massachusetts quote “really silly.”

“Really silly? WTF? The man has a stupid english accent and he can’t spell.” Mrs Obama is reported to have said. “And he doesn’t fact check his blog posts.”

A White House spokesperson denied the incident ever took place.

Commentology > More On Natasha Richardson

Apr 1, 2009• 3

Dr. Cory Franklin dropped us a note in response to THCB contributor Sarah Arnquist’s piece on the controversy surrounding the death of British actress Natasha Richardson, “Leave Natasha Richardson Out of the Healthcare Debate.”

“I wrote the article and have been reluctant to respond to criticisms
but since I read your blog I will here. So many people, both sides, are
tied into their political beliefs about health care that virtually no
one is actually looking at the record as we know it and asking a quite
logical question.

1. Here’s what’s important- the facts of this case- check the 911
transcripts in the Globe and Mail. The paramedics document the patient
has a Glascow Coma Score of 12 upon arrival to the first hospital at
St. Agathe. That is the key. The medical literature is quite clear –
patients who present with scores in that range on presentation almost
always survive. Where are the Canadian neurosurgeons and trauma people
commenting on that? The questions that should be asked in light of that
are who made the diagnosis and when, who treated and when, and what was
the condition upon treatment. But it is clear that at 4 PM she was
neurologically intact enough to survive with the appropriate treatment.
By the way, this major ski resort is no further from Montreal than Vail
or Breck is from Denver. And the Canadian defenders talk about how
close it is by ambulance to minimize the medevac issue. You can’t have
it both ways.

Whose Data is it Anyway ?

Apr 1, 2009• 18

By DOUG KLINGER

As we know, the Federal Government is planning to spend $19 billion to help the healthcare system upgrade its 20th century, non-standard, paper-based and proprietary system-based health records systems to a more standardized, electronic solution which will empower the healthcare system and consumers alike. This may be a side benefit of electing our first Blackberry-toting commander-in-chief. But, it’s not clear that everyone is ready to get behind the President on this one.

The New York Times just published an article entitled “Doctors Raise Doubts on Digital Health Data”. The New England Journal of Medicine just published two articles outlining the challenges with making the electronic records dream a reality.

In a recent post on this blog entitled, “Better Records on Our Cars Than Ourselves“, we discussed the critical importance of better connecting consumers to the healthcare decision-making and delivery process. Without engaging consumers effectively, it will be difficult to drive meaningful changes in healthcare consumption, healthcare effectiveness and ultimately, healthcare cost.

While the recent flurry of media coverage on the subject of electronic health records points to many of the reasons why the Government’s plan cannot or will not succeed, let’s take a minute to focus on why it should succeed:

1. Health information belongs to the consumers whose health is in question. While the information may be generated by doctors and other members of the delivery system, it is generated on patients and generally paid for by the patients themselves or their insurers (private or government).

2. Patients can and should be able to access and share their health information. Is it really appropriate, as some have argued, for some doctors or other members of the delivery system to decide if we, as patients, are “qualified’ to have access to our own health information ?

3. Getting health records into a more standardized, usable and transferrable format will surely take time and cost a lot of money. One potential benefit of this investment of time and money may be a new partnership between those who deliver healthcare and those who consume heathcare. In an industry which is today characterized by battling between constituents over who gets what care and who pays for that care, a bit of partnership might go a long way. Cal it a pollyanna-ish view, but without a vision to make things better we are may well be destined to mediocrity.

Why not focus on what we can accomplish vs what we cannot ? Why not begin architecting a plan to migrate from reliance on proprietary systems and paper records to an open, electronic solution that brings healthcare information together vs keeping it in protected silos ?

In closing, as the New York Times and New England Journal articles discuss, it seems appropriate to debate how the new electronic information will be used to improve healthcare quality. But, this debate can proceed in parallel with an effort to make the information more readily available in the first place. Without substantive changes to how we collect, store and transfer health information, the healthcare quality debate may stay just that – a debate.

Doug Klinger serves on the board of MedCommons. Before joining MedCommons, spent ten years with CIGNA, where he served as CEO of CIGNA Dental, among other roles. His resume includes a stint with Monster.com, where he led the company’s North American unit.

Health 2.0 NYC Chapter, has meeting, needs a place!

Apr 1, 2009• 2

Health 2.0’s NYC chapter is having a meeting this Thursday 4/2–-around 50 people are due to attend and it’s set to be a great session.

There is one minor problem though. Due to a last minute cancellation by the existing conference room sponsor the meeting needs a new venue. Please contact eugeneATnyhto.org if you can fit ~40-50 people for tomorrow evening from 6.30pm on.

(Eugene does have a back up, but it’s not ideal! And no this is not an April Fool’s joke)

BIDMC, Google Health and the data transfer problem

Apr 1, 2009• 15

By Matthew Holt

e-Patient Dave on the real world issues of moving data around in health care. The punchline—claims-based data without dates is not very useful, which requires those using the aggregators (Google health et al) to do a whole lot more work.

A really, really important article. Go read.

Imagining the Possible

Mar 31, 2009• 18

By Bruce Pyenson, Sara Goldberg and Kate Fitch

The emperor we call American healthcare is wearing no clothes—or perhaps too many clothes. The United States spends too much on healthcare. More than 25% of our healthcare dollars are wasted on unnecessary utilization. With this in mind, we recently completed research that identifies where that waste resides. Our analysis offers a target for how far the country might go in weeding out waste. We used the top-performing health systems as a basis, employing actuarial models to extrapolate results for the entire country. Our “16 to 12” model is a standard you can use to measure healthcare reform proposals. It can help you quickly identify defenders of different pieces of the status quo—and defenders of the absurd. In the few weeks since “16 to 12” came out, we’ve heard an almost universal reaction: “Of course you’re right, but [fill in special interests] won’t let it happen.” That’s amazingly positive—maybe we can actually reach consensus on fixing the system.

Framing the vision

In 2006, approximately 16% of the gross domestic product was spent on healthcare. Even if the United States were to reduce its healthcare expenditures to 12% of GDP, we would still spend far more than any other country. Is this possible? Our reduction is less than many estimates of healthcare waste. It’s also more than the annual spending on motor vehicles—4% of GDP could power a new American century.

Numbers for a growing consensus

Opposition to waste seems universal, from President Obama to Senator Max Baucus. They join a chorus of other voices, from CEOs and medical trade organizations to employer groups. Let’s take them all up on this point by quantifying opportunities for reductions in waste.

The table below offers a detailed inventory of efficiencies by service category, for one year’s costs. For example, inpatient services in 2008 cost an estimated $500 billion. Our working efficiency model reduced that by 38% to $311 billion.

These reductions are based on evidence-based best practices, including reducing unnecessary imaging and surgeries, better managing inpatient admissions, increased reliance on generic drugs, embracing primary care and certain electronic transactions, and other 20th-century (not even 21st-century!) management practices.

We’re proposing that healthcare payers (governments, employers, and individuals) could reallocate more than half a trillion dollars each year to other priorities.

The saved money could be used in other sectors, such as increased wages and infrastructure investment initiatives, and possibly even toward deficit reduction, reduced taxes, funding Medicare, etc.

The money saved could also stimulate the economy. And even though we’re working with 12% as the target model, we think it can get even lower than that.

Economic stimulus programs will likely increase healthcare spending, especially by federal and state governments. The 12% target may have to fight that surge, but we’re not talking about speculative long-terms gains, such as getting all Americans to exercise and reach a healthy weight.

What will the new system look like?

Although the healthcare system is typically divided into three categories—physicians/healthcare professionals, hospitals, and prescription drugs—our vision directly benefits patients.

We point to patients consistently receiving attention and care, according to treatment plans based on evidence-based medicine. All patients’ interactions will be streamlined through administrative systems, along with expanded hours via e-mail and phone access. We also suggest that the average patient will be more informed about choosing the appropriate care due to the reduction in costs; in turn, fewer medical errors should occur.

Another big change in the desired model is the re-engineering of hospital care.

Hospitals would operate on a 12/7 (12 hours a day, seven days a week) or 24/7 basis. While many hospitals currently don’t provide diagnostic treatment services on weekends or after standard business hours, that would change under this vision.

We believe hospitals can do a much better job lowering their readmissions. A separate report estimates that 18% of Medicare hospitalizations result in readmission within 30 days. A majority of those are potentially avoidable.

Our report didn’t delve deep into prescription drugs, but we suggest that there are efficiencies to be found in improvements to the FDA approval process and in a more widespread embrace of generic drugs.

It’s important to point out that we can become even more efficient than this vision. For example, we can dramatically improve end-of-life care, fix medical malpractice, and reduce administrative costs on better than a pro-rata-with-claims basis—all things that could push healthcare spending below 12% and improve the patient experience.

Winners and losers

Given this demanding vision, hospitals and other providers who don’t adapt to an efficiency- and quality-driven system will lose out.

For the nation, this vision offers more winners than losers. Patients and consumers would be the biggest winner and the U.S. economy overall would benefit. Employers would minimize the yoke of expensive benefits that has made it difficult to compete with leaner companies in other countries.

Proposals for healthcare reform now have the glamour of springtime fashions. Our 16% to 12% vision measures what’s under these emperors’ new clothes.

Pyenson, Fitch, Goldberg, Imagining 16% to 12%. 2009. Available online at http://www.milliman.com/expertise/healthcare/publications/rr/pdfs/imagining-16-12-RR02-01-09.pdf

Lead author Bruce Pyenson, FSA MAAA, is a Principal and Consulting Actuary with Milliman, an actuarial and consulting firm with offices worldwide. Kate Finch RN serves as a Principal and Management Consultant with Milliman. Sara Goldberg, FSA, MAAA serves as Consulting Actuary with the firm.

So what’s the real usual, customary and reasonable price of care?

Mar 31, 2009• 43

By Matthew Holt

The Ingenix mess apparently won’t go away. Sen. Jay Rockefeller is now going after the health plans for using Ingenix’ database. Ingenix and some of its customer health plans have already settled with several states, but apparently it’s not enough. Now Rockefeller is after them. And the words are tough. “Fraud”, for one.

Now, health plans don’t exactly have much credibility. And when the politicos find out that Ingenix a) sells tools to help health plans cram down the amount they pay providers, b) sells tools to providers to extract more money from health plans, and c) is owned by the biggest (and not too long ago) baddest insurer on the block, this may get a little more interesting. After all, it’s kind of an arms dealer arming both sides.

But there is one thing that troubles me. I’m quite prepared to believe that Ingenix’s view about what was UCR was different from the local medical society’s view of what was UCR, and therefore that the plans were “under-paying” the consumers and the doctors who serve them.

But let’s remember what Usual, customary and reasonable fees are.

Will CIGNA Remake The Health Plan Marketplace?

Mar 30, 2009• 17

By BRIAN KLEPPER

America’s health plans are floundering. If their job has been to provide the nation’s mainstream families
with access to affordable care (let’s leave quality out of it for the moment), they have failed miserably, though they were very profitable along the way, at least until Q1 2008. In 2008, the Milliman Medical Index – an estimate of the total cost for health coverage premium and out-of-pocket costs for a family of four – was $15,609. Now it is almost certainly above $17,000, more than the total income of more than one-third of American households.

To many health plan execs, these are simply market dynamics that must be accommodated through new product and service designs. I just attended a health plan conference where the overarching themes were the transition away from group to individual coverage, and the use of incentives and touch points like texting, email, and ergonomic Web interfaces to cultivate member competency, loyalty and retention.

There are important steps forward but, to me, the discussion tiptoed
around the more glaring problem – costs this high have exhausted many
purchasers’ ability to pay, and are rapidly shrinking health plans’ commercial market and profitability.

Sustainable Healthcare Reform

Mar 30, 2009• 24

By ROBERT LASZEWSKI

Last week Senate Majority Leader Harry Reid was quoted as raising the possibility
we could take the $600 billion in new revenue projected from a
"cap-and-trade" plan to cut green house-gas emissions and use some or
all of it to help pay the estimated $1.5 trillion cost for
comprehensive health care reform.

Energy and climate change issues aside that would be a bad idea–a really bad idea.

The biggest health care challenge we face in America is the cost of health care. To really reform the system we have to bring its costs under control. The only way we can achieve sustainable health care reform
is to pay for most of the cost of any reform plan out of the savings we
achieve fixing the system and its perverse incentives to spend more
without regard to what we receive.