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Above the Fold

Jonathan Cohn on the internal politics of Obama’s health care plan

Mar 18, 2009• 7

By Matthew Holt

Jonathan Cohn has started blogging almost daily on the politics of health care at The Treatment. And it's a treat to read. Jon is a member of the recently exposed vast left wing conspiracy (so am I, but that’s because Ezra’s soft), but the difference is that instead of being a San Francisco based ranter with an unfocused cynicism, Jon actually knows the inside Obama players and cares what they do. And he’s an optimist.

His latest piece at TNR, Stayin' Alive describes the inner story of why the Administration decided to come up with the $65bn a year number in the budget for health reform, rather than just brushing it under the rug. And the somewhat surprising (to me) answer is that the member of the Obama team who would not let health care die was Obama.

Now I know I’m very cynical about both the chances of any reform passing and the value of said reform, but there is the (ever so slight) chance that I might be wrong. So paying attention to Jonathan is a smart idea.

CODA: BTW, why are health care reform costs always quoted as “$1.5 trillion” or whatever. Why are they not quoted like everything else, in annual terms?. After all $1.5 trillion over 10 years is a pretty small fraction of the $30+ trillion we’re going to spend on health care in the next 10 years.

For whom the HITECH Bill Tolls?

Mar 17, 2009• 18

By MARGALIT GUR-ARIE

As part of a sweeping effort to address the woes of the current US economy, the government has placed $19 billion on the table for HIT, aimed at containing healthcare costs and creating new jobs. The ultimate instruments for implementing this HITECH bill are America’s physicians and there is much confusion and apprehension in the physician community regarding the net effects of this bill on doctors in particular and healthcare in general. The HIT stimulus effort will not reach its stated objectives without voluntary adoption by our doctors. The government and the HIT community must find a way to draw physicians all over this country into the process of defining and implementing the stimulus package.

In very broad terms, interoperability standards will be defined, Electronic Health Records (EHR) technologies will certify compliance with the standards and physicians will be provided financial incentives to acquire, and meaningfully use, those EHR technologies. The assumptions are that use of these standardized EHRs will reduce costs by reducing medical errors, reducing duplication of tests, improving quality of care and encouraging evidence based clinical decisions. Jobs will be created as the EHRs are deployed across the nation. Experts are already at work “on the Hill”, in the White House, in the boardrooms of HITSP, NIST, CCHIT and other acronym organizations. Technology vendors are feverishly doing their part, from creating websites devoted to the HITECH bill, to making products available at Wal-Mart, to sudden revelations that HIT is really their main business. Everybody is actively involved in making this bill a success. Well, maybe not everybody.

Bill Maher explains why government-run health care is a good idea!

Mar 16, 2009• 41

By Matthew Holt

Maher’s being funny (at least he thinks he is!), but he’s tapping into a meme that I think that many in DC including any Democrats are missing. I was watching CNN on Sunday and Sanjay Gupta brought up the question to Bill Clinton and (and Bill Frist, John Podesta & Mehmet Oz) about whether single payer was really off the table. The answer is, it’s not if they get this wrong (and they will). If we have a mealy mouthed reform this time (a la Massachusetts) then single-payer will be back with a vengeance in a few years.

A Sticky Solution to a Sticky Problem

Mar 16, 2009• 23

By ALISTAIR ROCK

“Don’t pull the knot tight,” the philosopher Ludwig Wittgenstein once warned, “before being sure you have got hold of the right end.” Those who hope to sort out the tangle of health care spending would do well to heed his advice.

Clearly, there’s been no lack of solutions put forward since the Clintons first put health care atop the national agenda more than a decade ago. But with health care spending still rising at twice the rate of inflation, few have made any real and lasting impact.

Employers (who still pay the lion’s share of health insurance premiums here in the U.S.) know, of course, that keeping employees from getting sick in the first place—and minimizing the severity and duration of their illness when they do—is the first step in reducing this unwelcome “growth sector” of our economy. They understand, for the most part, that healthier employees equal not only lower healthcare costs but reduced absenteeism and greater productivity for the economy as a whole.

I shake my fist at Clay Shirky!

Mar 15, 2009• 9

By Matthew Holt

Last week (Tuesday to be precise) Chris Rauber, the health care journo at the SF Business Times calls me to talk about health care IT. But he ends with a question that’s not about Health care or IT, but aimed at me as a blogger. He says “what do you think is the future business model for journalism”

I’ve been mulling this a little bit and my response went something like, media is now disaggregated. Craigslist and Google have destroyed the advertising model for most media, and blogs and social networks have democratized the commentary/opinion playing field (to some extent—I’m not as rich as Tom Friedman yet!). The problem is that not many “new” media outlets—such as THCB—can afford to take on the interesting part, which is paying real investigative journalists to investigate. Something I would love to be bale to do—as there’s lots of muck to be raked in health care.

Op-Ed: Pathway for FOBs Should Balance Need for Competition and Need for Innovation

Mar 14, 2009• 5

By JAMES BIANCO MD

President Obama's first budget calls for the creation of a regulatory pathway for the creation of follow-on, or biosmiliar, biologics. This is obviously now the most high-profile call yet to move forward with a system that will provide the benefit of biotech drugs to patients who need them the most.

The biotech industry has done an outstanding effort in the last 10 years producing some of the most high-tech but also the most expensive drugs on the market. Some biotech medicines cost hundreds of thousands of dollars each year. Many of these products face no competition, because there is no legal way for a generic version of the product to get on the market. Individual patients as well as the healthcare system generally simply cannot absorb these continually rising costs.

To date, the debate over follow-on biologics has been mostly political posturing between the trade groups that represent the generic drug industry and the pioneering companies. The generic industry wants biotech companies to have only three to five years of market protection after bringing a new drug to market. The industry counters it needs up to 14 years of exclusivity to recapture its investment costs, which can reach over $1 billion for a single product.

Another Look: The Wal-Mart and E-ClinicalWorks Deal

Mar 13, 2009• 14

By David E. Williams

The New York Times reported this week (Wal-Mart Plans to Market Digital Health Records System) that
the company’s Sam’s Club division will bundle eClinicalWorks
electronic medical record software, Dell computers, installation,
maintenance and training to offer to small physician practices. Pricing
is about $25,000 for the first physician in an office, and $10,000 for
each subsequent physician. Annual maintenance and support costs will be
about $4,000 to $6,500 (though it doesn’t say whether that’s per
physician or per practice).

Wal-Mart says its package deal of hardware, software,
installation, maintenance and training will make the technology more
accessible and affordable, undercutting rival health information
technology suppliers by as much as half…

Dell will be responsible for installation of the computers, while
eClinicalWorks will handle software installation, training and
maintenance. Wal-Mart is using its buying power for discounts on both
the hardware and software.

This program has promise, but it isn’t revolutionary and is by no
means certain to succeed. Interestingly, the Wal-Mart PR people, who
usually send me a heads up about any new Wal-Mart move in health care,
didn’t tell me about this one. It makes me wonder what’s really going
on. There are a couple of very promising aspects of this program:

Today’s NEJM Hospitalist Study: What’s the News?

Mar 13, 2009• 8

By Bob Wachter

A paper in today’s New England Journal
proves what we all know – the hospitalist field is the only thing
growing faster than the national debt. Even though that’s not news,
this elegant biopsy of the Medicare database offers some new insights
about our field, the fastest growing specialty in medical history.

Briefly, the study used a methodology developed
by Sanjay Saint a decade ago: by examining evaluation and management
(E&M) codes submitted by general internists to Medicare, one can
determine which physicians do virtually all their E&M work in the
hospital, which have traditional general internist practices
(part-inpatient, part-outpatient), and which do virtually no inpatient
work (“ambulists” or “officists” – somebody will ultimately need to
settle on a term).

Controlling Health Care Costs by Seduction

Mar 13, 2009• 26

By PETER NESBITT

The past failure of insurers and care providers to control medical costs challenges the Obama health care team to redesign health care to provide broader coverage while managing costs. If the past is any guide, they will fail just as certainly as those who went before. The problem is that those working on the new health care plans do not fully understand why existing plans failed over the past 30 years. The panoply of managed care ideas; HMO’s, rationing, pre-approvals, denial of benefits, denial of service, reduction in fees have all failed to reduce medical costs. If we wish to get past these failures, we need to think about seducing those who control the costs.

The phenomenology of health care shows that medical costs are a function of fees and utilization. Fees are what we pay for a medical service. Utilization denotes the variety of services available. Almost all medical services are performed or ordered by physicians. The ever spiraling cost of medical care amply demonstrates that coercive methods used by insurers and managed care proponents against physicians have failed to bring about the desired results.

If physicians cannot be coerced into cooperating, perhaps they can be seduced.

ARRA: A New Era for Health IT, and for CCHIT – Part 1

Mar 12, 2009• 10

By MARK LEAVITT

When President Obama signed the American Recovery and Reinvestment Act (ARRA) into law, health IT
was catapulted into a new era. I believe this is — and forever will be — the biggest milestone in the history of health IT. I’d like to share my perspectives on it, but it will take several blog posts to cover such a big topic. Today, I’ll start with a high level view of the significance of this event, and talk about some of the confusion that has resulted from the injection of so much new money – and with it, some new politics – into the world of health IT. Then I’ll follow up with posts that delve into the details of how I believe CCHIT will need to evolve in this new environment.

I’m personally struck by the parallels to a historical event still vivid in my memory: Project Apollo, President Kennedy’s incredible national goal of achieving manned spaceflight to the moon.

Apollo cost $22B (in 1969 dollars, now worth five times that) and took 8 years to achieve the first moonwalk. NASA, a new government agency, spearheaded the effort, but the technology was developed by private sector contractors.