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Above the Fold

Commentology

Feb 24, 2009• 1

Michael Millenson had this response to a commenter in the thread on his recent post looking at web sites that offer the public data about provider performance. (' Just OK Quality or the Best? ')

"Why does HealthGrades get so many more visitors than HospitalCompare? I think you're correct that it's because of promotion, but the context is the magnitude. HealthGrades constantly promotes, via Google-sense ads, via press releases to the trade and mainstream media, via the ads taken out by hospitals touting their ratings and via search engine maximization. And they've done this for many years, acting as if their economic future depends on it (which it does). The government promotes its site kind of the way you see those "stop smoking" public service announcements.

Getting “the CCHIT question” wrong

Feb 24, 2009• 8

By Matthew Holt

Matthew Holt

There’s been a lot of blather from one commenter (who may or may not be a front for a group of malcontents) on the WSJ Health Blog and lots of other blogs about CCHIT and whether it was doing business without a license in Chicago, and/or was a front organization for HIMSS or EHRA. All summarized on Neil Versel’s blog. Indeed I did get a call from one well known blogger telling me that HIMSS’ lawyers had asked for him to take those comments down—not too bright a piece of PR on HIMSS’ part IMHO.

MrHISTalk thankfully did what I certainly could not be bothered to and actually looked into the “CCHIT is not a licensed corporation” situation and figured out that it’s basically being run legitimately. I myself cracked the joke privately that if CCHIT/HIMSS/EHVRA/Leavitt et al had only managed to get $2m (or $7m for that matter) out of the Bush Administration, they needed to go to the Haliburton school of “how to stick it to the taxpayer properly.”

The other wisecrack I’ve heard is that the way to determine the list of functions an EMR needs to have to get CCHIT certified was to copy the feature set of Allscripts TouchWorks. (Of course you can insert the name of any of the other big EMR vendors here too).

OK, so we’re kidding around here, but underneath this discussion are some serious points. And those serious points have got little to do with what has indeed been a pretty close relationship between the powers that be at HIMSS,EH(V)RA, CCHIT & HITSP.

In any case I assure you that the back room dealings and conflicts of interest are nothing compared to how the rest of the Federal government has colluded with industries it regulates for the last 8 years. The money given from ONC to CCHIT wouldn’t even be a rounding error on what’s been completely lost in Iraq in cash in suitcases. let alone what Blackwater, Halliburton et al have stolen, And there’s no evidence that the Feds didn’t get what they/we paid for from CCHIT, which is a certification process.

So if this is a non-story, what are the actual issues?

1) Part of the justification for a certification process is that there is a great deal of fear and trepidation among physicians who have heard the horror stories about EMR implementations, and are now being bribed (and later to be threatened) by the Federal government into installing EMRs. Given the plethora of vendors out there, and the fact that these providers are more or less Federal contractors who tend not to understand IT, it’s not unreasonable to suggest that the Federal government (or someone) gives authoritative guidance as to what’s a robust system that has the right features and functions. Remember that the nation’s biggest and richest integrated provider organization trashed not one, but two national investments in EMRs before getting it right at try three. Having recalled that it becomes reasonable to agree that most providers need some help. And of course there is some slight protection for the taxpayer if the providers who are about to get their $40K have to do more than just claim that they bought an EMR from Sonny on the corner.

2) Of course once you say that the Federal government will pay out only to those purchasing certified products you then run into two other problems. First, the certification process is going to get somewhat politicized. Despite all the yakking about “volunteers” on all these committees, what we’re talking about is the people with a deep interest in EMRs et al being those “volunteers” and of course they are mostly from the vendor side or users who know the vendors well. I don’t see a way around that unless we really want to develop a civil service that has expertise in health care IT and also is prepared to stay in the job for 30 years like they do in Japan. Second, by its very nature the certification process is likely to run behind the development of technology, which means that vendors building for the certification process are like teachers prepping students for tests, not creating innovations. Again that may not be a terrible thing, but it’s not how innovation works in most other industries. (John Moors at Chilmark has a rather blunter, bleaker assessment of how this might work out)

3) And of course, the reason that you don’t see Federal certification of, say, MP3 players or automobiles is that there’s a somewhat effective market there that means that innovation and user experience gets rewarded. Make a confusing MP3 player, you don’t move the needle much. Figure out how to make it easy and elegant and you’re called Steve Jobs and you sell a gazillion iPods a year. Health care doesn’t have such a market, or even rationally managed incentives from its Federal paymaster.

So I don’t have the answer, but I do have the question. And it’s the same one being posed by the Dogs, in response to the Cats. Can we realistically expect CMS and the rest of the big payers to start rewarding providers for producing the correct outcomes. If we paid for outcomes, providers would change their organizational structure, and their processes, and the technology they use. The ones that worked would succeed and the others would go away. That’s how a market works. And that would create lots of interesting technological innovation of the type that is already happening in the consumer health arena in Health 2.0.

But (beware: run-on sentence coming up so take a deep breath) if we realistically can’t get to some massively enhanced version of pay for performance very soon, and instead are going to insist that providers use EMRs or something like them and the Feds will pay them for it, and we are happy to declare that that solution is as good as we’re going to get while we work on wider health system reform later, then I don’t think that we can complain about the CCHIT process too much. We have to accept that the Feds are going to put a stake in the ground somewhere as to what is an acceptable technology to reward. And those rewards are not going to be market or outcomes-based yet.

So the ultimate question, is what’s the time-scale for junking our stupid current health care incentives and finance system? And the answer is, not in the next 2–3 years.

Which means that if we’re paying directly for technology (which we are as the law is now passed), a certification process is a necessary evil to help providers and to make sure that the tax payer isn’t being defrauded (see we’re back to Iraq again!).

Of course, this doesn’t mean that the certifiers shouldn’t be made to appear to be (as we;; as actually be) completely above board and be watched like hawks to make sure that they’re not putting too many restrictions on smaller companies or discriminating against them. And maybe that kind of oversight demands that we see greater separation between the HIMSS/EHRA/CCHIT/HITSP/ AHIMA players, which would fit in with Obama’s “no lobbyists in the Administration” line.

But I can’t see that this is an issue for anyone to go to the barricades about. And in the end if CCHIT helps providers get better tools than they have now, it’s probably a net positive—even if it may prevent greater innovation happening faster.

Health reform for health’s sake

Feb 24, 2009• 3

By Sarah Arnquist

If the goal of health reform is to improve Americans' health, then the debate needs to broaden to focus on issues outside the medical system that often play a greater role in determining health.

That’s the message Susan Dentzer, editor-in-chief of the health policy journal Health Affairs, gave to an audience Monday at the Johns Hopkins Bloomberg School of Public Health.

Dentzer began her talk by quoting New York Times Columnist David Brooks, who wrote in a column last fall about a “tide of research in many fields, all underlining one old truth — that we are intensely social creatures, deeply interconnected with one another and the idea of the lone individual rationally and willfully steering his own life course is often an illusion.”

Her point was that communities and social networks play a huge role in
setting social norms and determining health status of the population. And Improving population health should be the goal of any national health
reform effort, she said, and accomplishing that requires a focus on determinants
of health outside the medical care system, such as smoking, obesity,
poverty and social networks.

Finding a Faster Route From Patent to Patient

Feb 24, 2009• 4

By Wendy Everett

As the health reform debate intensifies, the rightful role of medical technologies is stuck squarely in the
middle, caught in a simplistic tug-of-war over whether these innovations raise or lower health care costs. Instead of this argument, we should be focused on how to best identify the truly valuable technologies – those with potential to save both lives and money – and get them into the health care marketplace.

So how can we ensure that the U.S. is making smart investments in innovative technologies that pay dividends for patients and the system, something Europe, Canada and many other countries are already doing?

Answering this question would give us a shot at fixing some of the most broken parts of health care. Technologies can play a key role in the redesign of the ailing primary care system by providing quality patient data, assisting in preventive practices, and taking the burden off the backs of primary care physicians. Similarly, technologies can help combat and manage the massive burden of chronic disease, and they can help reduce the costly clinical waste and inefficiency plaguing the system.

Making Price Competition Work

Feb 24, 2009• 12

By ROGER COLLIER

Wall Street Journal editorial writers and other folk with touching faith in classic economic theory wonder from time to time why competition doesn’t work better in the health care system. (Actually, the WSJ people are sure that it could, if it were not for government bureaucrats and their spendthrift liberal friends).

It does seem as if Adam Smith’s “invisible hand” is affected by a strange palsy as it nears the realm of health care. But why, given the legions of insurers and providers all apparently eager to edge each other out in the race for our dollars?

Economic Forces Reshaping Medicare Drug Benefit

Feb 23, 2009• 1

By Bonnie Washington

After years of relative consumer inertia in the Medicare drug benefit plan selection process, the economy
created the first real test of Medicare drug plans' stickiness. Would seniors stay loyal to their last drug plan choice, or would they be more willing to shop around to chase savings?

New data released today by Avalere Health shows that 1 of every 3, or more than 9 million, Medicare beneficiaries has picked a Medicare Advantage plan with prescription drug coverage (MA-PD plans) as their way to access medications. Growth in MA-PDs far outpaced enrollment in standalone drug plan, or PDPs, for 2009. MA-PDs; picked up about 730,000 people relative to mid-2008 levels, while total enrollment in standalone prescription drug plans, or PDPs, increased by about 140,000 individuals over the same period.

How to explain MA-PDs newfound popularity? It's the economy, of course.

Open Source Health Research

Feb 23, 2009• 3

By Matthew Holt

I'm doing a first for THCB which is a IM chat interview. On the other side of the keyboard (so to speak) is Alexandra Carmichael who is the CEO of CureTogether.com. Hi Alex!

Alexandra: Hi Matthew, nice to IM with you!

Me: So we're trying this out and we'll talk about Repetitive Stress Injuries later!!

Now CureTogether was a late add to a panel at Health 2.0 last October, but to be fair you are very early in the process of what you're calling Open Source Health Research. Before you tell us what that is, can you tell me a bit about your background.

Alexandra: Sure, you can add Repetitive Strain as a condition on CureTogether.

I started out in molecular genetics, actually, at the University of Toronto, Canada. I left grad school to co-found Redasoft, a molecular biology software company, with Daniel Reda. We grew the company over 10 years to having customers in 37 countries, then sold the technology we developed to Hitachi Software in 2005. We moved to California, consulted with Hitachi for a couple of years, and then were ready to dive into a new project.

Commentology

Feb 23, 2009

Joe Flower had this to say in response to criticism of comparative effectiveness research in the comment thread on his post ("Fear and Loathing Over the Stimulus Bill") examining the backlash against the Health IT provisions in the stimulus package …

"No one that I can see is saying that doctors and patients should not
be allowed to choose the best treatment. But there need to be some
bounds, some incentives to pay attention to what the best evidence
shows. Why don't doctors do bloodletting, as they routinely did 200
years ago? Why don't they whip out every kid's tonsils, as they did
when I was a kid? What happened to the idea that radical mastectomy was
the gold standard treatment for breast cancer? What about the fad for
high-dose chemo and bone marrow transplants for breast cancer, all
before studies showed little benefit and great risk? What about all the
routine things that are still done that have shown little benefit in
studies (like routine episiotomies, brain bypass surgery for patients
with warning signs of stroke, or HRT to prevent a second heart attack
in women)? What about the hundreds of thousands of spinal fusions still
being done, not for tumors or spinal fractures or congenital problems,
for which the surgery shows great benefit, but for chronic back pain,
for which repeated studies show little long-term advantage over
non-surgical techniques?

What do we do with such information? Do we just shrug our shoulders
and do nothing about it? Do we wonder whether such over-treatment with
unproven or even disproven therapies has anything to do with the fact
that we spend roughly twice as much per capita as every other major,
medically modern economy, whether socialized or mixed, for worse
outcomes, and still can't seem to afford to offer even basic care to
all Americans?"

Raising the Price Before You Put It On Sale

Feb 23, 2009• 3

By ROBERT LASZEWSKI

The Obama budget team has made it clear they are going into the next federal budget process playing it straight on many fronts that the prior administration had fudged on. The
cost of the wars, the cost of adjusting the alternative minimum tax
each year to keep the middle class from falling into it, the cost of
disaster relief, and the cost of avoiding the otherwise automatic cuts
to Medicare physician fees because of the Sustainable Growth Rate (SGR) formula were all conveniently left out of the Bush budgets making them look a lot better than they really were.

Facing a $1.5 to $2 trillion deficit this year
you might as well throw the lot on the pile, get it over with, and
create an even greater imperative for change—a trillion here a trillion
there "and pretty soon it gets to look like real money."

In the end an honest accounting is all to the Obama administration’s credit.

But on the health care front anyway, it may also be very shrewd politics.

Betsy McCraker misses the point, again

Feb 23, 2009

By Matthew Holt

Not content with being the catalyst for the unleashing of a torrent of vitriol in the direction of those Milquetoast individuals who are in favor of better information systems in health care, in the mild expectation that it might improve care delivery, Betsy McCracker is back at it again. This time the NY Times prints her letter. And in it she says:

These changes will affect all of us, at the least by requiring that our treatments be recorded in a federally mandated electronic database and guiding the choices our doctors make. Yet no hearings were held, no expert witnesses called, no opinions gathered from patient advocates, doctors’ groups, the elderly or other stakeholders.

Apart from the fact that there’s no evidence of one “electronic database”, she’s missed a couple of things.

First, hearings, witnesses, etc, etc, have been held for on this topic for years, and witnesses were called in the weeks before the stimulus bill—Microsoft’s Peter Neupert among them. Peter may not be an expert in Betsy’s eyes, but I think most of us would concede that he knows something about the topic (even though much of his advice was ignored).

Secondly, Betsy McCracker seems to be missing a minor point. The Obama campaign was not shy about telling anyone who listened that they were going to spend up to $50 billion on health IT in the next five years. It was on their website, and talked about by their health care advisers non-stop, as the WaPo noticed in early December.

Why are we supposed to be surprised that they did what they said they were going to do? Isn’t that the point of democracy? So Betsy, who won the election?