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Above the Fold

Health and health care in 2009 – a year of managing risks and wild cards

Dec 30, 2008

By Jane Sarasohn Kahn

As we inevitably do this time of year, we prognosticate about the new year. This time around, it’s a toughie: there are too many uncertainties that preclude us from doing a straight-line forecast for 2009, especially in health and health care.

Here are some trends and wild cards to keep in mind for 2009: the year of managing risks.

How will the macroeconomy play out against health care in the new year? Keep in mind the Kaiser Family Foundation’s metric on unemployment: an increase of 1% unemployment leads to 1.1 million uninsured, and 1 million more people added to Medicaid. This was the math that worked in 2007-8. The metric will probably change in 2009 as Governors struggle to balance budgets while providing medical services, education, and safe streets to citizens. The National Governors Association, and the individual state heads, have all warned that Governors will inevitably cut services in 2009 and into 2010 if tax receipts continue to decline.

My Health Care Reform House Party

Dec 29, 2008• 6

By Michael L. Millenson

The Obama-Biden Transition Team has encouraged individuals across the country to gather in small groups with friends and neighbors to discuss their ideas for health care reform. The team provided a background paper, discussion guide and a specific list of questions as a framework within which citizens could provide feedback to health reform czar-designate Tom Daschle. More than a thousand would-be hosts have officially registered on the change.gov website, and my wife and I were recently invited to one such gathering in a small village (yes, that’s the official designation) north of Chicago. My report below is not the official one.

‘Twas three nights before Christmas, and despite cold and stormWe’d gathered together to talk health care reform.Clutching Team Obama’s brief questionnaireWe went over each item with scrupulous care.Middle-class, middle-aged and in the MidwestWith our host’s college kids for reality test.O’er the country many thousands had signed up for the sameDespite fear “special interests” would come rig the game.But as we plain folk gathered by the living room fireWe closely read instructions, then vented our ire.

“Get Well Soon” Wishes for Health Policy Pioneer Paul Ellwood

Dec 28, 2008• 1

By Michael L. Millenson

Here’s a greeting card conundrum. What exactly do you say to an 82-year old man who, emailing you about a joint project you were working on, notes that he has just survived “a 12-foot backward fall into a jagged confined space. Result at least 6 smashed cervical and thoracic vertebrae. [But] no paralysis! In a halo and off full duty for a while, but eager to rejoin the hunt.”

“Get well soon” seems so pallid a reply.

Paul Ellwood, who survived this most recent harrowing accident, is best known as the man who originated the term health maintenance organization and then got the federal government to support the concept. He was also one of the first policy thinkers to push vigorously for patient-centered measures of care quality, through his Jackson Hole Group and, since the mid-1990s, on his own.

He’s also one tough hombre.

Merry Christmas & Happy Hols

Dec 25, 2008• 4

By Matthew Holt

Thanks for reading THCB this year. Thanks to to all the authors who we’ve featured and thanks to John and Sarah for keeping the train on the tracks. And thanks to all who commented and made THCB a great place for educated debate about health care issues.

We’ll be posting a little over the next week with some forecasts for 2009–-which is shaping up to be an interesting year in health policy at least. And there’ll be a new look for THCB early in 2009 too.

But for now enjoy the holiday!

I’m in Tahoe where there was 2 foot of powder last night, which I’ll be heading out to enjoy on my snowboard soon!

Naive policy makers need not apply

Dec 24, 2008• 5

By ROBERT LASZEWSKI

The Congressional Budget Office (CBO) has released two comprehensive papers detailing the policy and
financial options for health care reform: Key Issues in Analyzing Major Health Insurance Proposals and Budget Options, Volume I: Health Care.I can’t overestimate the importance of these documents to health care reform. I recently did a post as sort of an open letter to the CBO: To the Congressional Budget Office: Please Keep Playing it Straight!After reading these two reports, totaling more than 400 pages of some of the most valuable health policy analysis I have ever seen, I now know that I had no reason to worry that the CBO would just tell the politicians what they wanted to hear.Any Congressional health care reform proposal will need to be “scored” by the CBO and, by preempting the coming proposals with this report, the career CBO health care experts
have now made it very clear they will not be an easy touch. Reformers
are going to have to play the game on the up and up—show real savings
or find the money elsewhere. CBO Director and incoming Obama Budget Director, Peter Orszag, also deserves a lot of credit for supporting his staff and issuing this report.It is also clear that, whoever the Congressional Democratic leadership appoints to succeed Orszag, a marker is down. The CBO is
on the record about what the likely reform options will cost before
anyone had a chance to bring political pressure to bear. And, that just
might have been intentional.The work contains an inventory of about all of the health care reform options being discussed complete with a thorough cost/benefit analysis detailing their impact on federal
spending. There would certainly be impact on private spending from many
of these options but this at least gives us a relative cost index to
compare the many health care reform ideas. This is also a financial report and did not attempt to measure quality improvements.

AARP, online trends health IT and fixing US Healthcare

Dec 24, 2008• 5

By Val Jones MD

Valjones
I had the chance to speak with John Rother, Executive Vice President of Policy and Strategy for the AARP
about the intersection of online health, information technology (IT),
and the baby boomer generation. Find out what America’s most powerful
boomer organization thinks about the future of healthcare in this
country. > Listen to the podcast

Dr. Val: Recent studies suggest that Americans age 50 and
older are more Internet savvy than ever before. How are AARP members
using the Internet to manage their health?

Rother: People over the age of 50 are the
fastest growing set of online users, and healthcare is the major reason
why they’re going online. They’re looking for health related news, help
with diagnosis, and finding appropriate healthcare providers.

Dr. Val: What role can online community play in encouraging
people to engage in healthy lifestyles that may prevent chronic
disease?

Rother: Our experience is that online
communities can be extremely helpful in several ways. First, it
provides emotional support for people who have a shared experience,
whether it’s as a caregiver, or being recently diagnosed with a disease
or condition. Second, people seem to feel more comfortable asking
questions of others with their condition than they do their own
physicians. And third, online communities can reinforce needed behavior
change. Whether it’s weight loss, exercise, or quitting smoking –
online communities can be just as effective in encouraging behavior
change as a face-to-face community.

Dr. Val: Tell me a little bit about the communities on the AARP website.

Rother: Currently our communities are organized
around medical topics, but in the future I think the communities will
become more geographical. An online community designed to serve the
needs of people in a given location can facilitate information sharing
about how to navigate a particular hospital system, for example,
instead of just general information about coping with a disease or
condition.

Next Steps for Interoperability

Dec 23, 2008• 9

By JOHN HALAMKA

There are some folks in Washington who have made statements that we
should delay investments in EHRs because current vendor products lack
the functionality needed to support a coordinated healthcare system.
Others have said that we lack the standards or security framework to
implement interoperability. Here are my thoughts.

Take a look at
the successes in Massachusetts and New York with commercial EHR
products. We’ve implemented eClinicalWorks, which includes decision
support, e-prescribing, administrative transactions with payers,
clinical summary sharing across the community, and quality measurement
(all the National Quality Forum high priority measures). It’s
web-based, using a service oriented architecture in a cloud computing
environment. By implementing this product at BIDMC, we’re meeting all
the payer guidelines for delivering appropriate, coordinated, high
value care. Vendor products from Epic, Allscripts, NextGen, GE,
Meditech, eMDs, MedSphere, and other CCHIT certified vendors have
similar features.

Should we wait for something better that has more interoperability?

Do
you drive a car? Why? It pollutes, costs a lot, and generally is not
very efficient in traffic. You’d be much better off asking Scotty to
beam you up via the transporter. Should we eliminate all cars, planes
and trains until the transporter is invented? The same can be said of
EHRs and health information exchange.

An EHR We Can All Agree On

Dec 23, 2008• 6

By Eric Novack

This is a modified post from one I wrote in Nov of 2007. I report this as a part owner of a small business whose costs are increasing every year while revenues are decreasing.

Therefore, I present to you all the new, improved EHR: Effective Hourly Rate.

With the absurdity of bailouts and the apparent transition from a constitutional republic to an elected monarchy, let’s see if the powers that be require us to ‘move from a 20^th century economy to a 21st century economy’— by making the change from the worthless concept of ‘wages and tips’ on the W-2 to the concept of ‘total compensation’.

Should I suspect that both parties will be unable, and unwilling, to make such a tiny change in reporting that would benefit the people of the United States with real, you know, information.

The EHR should be given to all employees of all companies. What it will consist of is simple: all of the total compensation divided into what that rate would be on an hourly basis.

Let’s give an example:

JSK on Health IT in 2009

Dec 23, 2008

By Matthew Holt

Savvy stuff, of course. Go read.

The Connected Medical Home: Health 2.0 Says “Hello” to the Medical Home Model

Dec 22, 2008• 21

By David Kibbe & Joe Kvedar

The concept of participatory medicine is taking hold, fueled, at least in part, by what we see as two complementary forces, these being the patient-centered medical home (PCMH) and Health 2.0. Health 2.0 is very much a grass roots phenomenon, dominated by a small but significant group of patients who are testing the hypothesis that the wisdom of the crowd can rival the wisdom of physicians. The PCMH is a concept, not new, but gaining tremendous traction in the provider sector now as a best-try effort by some providers to be truly patient centric in their approach. The two should be complementary and mutually self-supporting. One might even suggest their respective champions should be collaborating right now, when the scent of health reform is in the air in our nation’s capital. But they are not. Lets examine why and explore ways in which to create a natural bridge between these two concepts and their champions.

The medical home concept was first introduced by the American Academy of Pediatrics in the 1960s. But several factors are now converging to update this original concept for today’s health care environment. The growth in chronic illness, the emergence of new reimbursement models designed to improve quality and control costs (e.g. pay for performance), and the greater availability of monitoring and messaging technologies have providers, payers and patients taking a fresh look. This is a good thing, in that it is an effort by organized medicine and large corporations to get into the reform conversation.

But the aspects of the medical home that are getting the most airtime are largely focused on rounding out office staff, adding new roles that take work away from the physician so that the physician can tend to more patients, and taking a population view of the patient panel. This vision is idyllic, but several challenges suggest that as conceived it will be tough to get it out of the womb.