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17 posts from October 2007

October 25, 2007

Rhetoric vs. reality, or, the not-yet-ready-for-prime-time universal health plans: Britain's NHS, Medicare (for All), and the FEHBP

Three examples of health plans are often touted by proponents of universal health care coverage: the Federal Employee Health Benefit Plan (FEHBP), Medicare and Britain's National Health Service (NHS). 

Access to "the same health care choices as members of Congress" (the FEHBP) is an ever-popular populist mantra on the stump.  Low-overhead Medicare is likewise promoted as a panacea.  And the pointy-headed liberal crowd (OK, sometimes including me) looks across the pond to a reinvigorated NHS as a potential model for at least part of what needs to happen here.

Today's question:  Do these solutions measure up?

Today's answer:  Not really.  That doesn't mean I'm joining the ranks of the Anti-Universal Coverage Club (see manifesto at Cato@Liberty), but while I recognize the difficulty of getting these things across in campaign-season sound bites, the candidates need to recognize the limitations inherent in these potential solutions and be a little more explicit about ways in which they would improve on them.

All this is brought to the fore, again, as the BBC reported on NHS bookkeeping yesterday:

NHS trusts have a £4bn backlog of key maintenance repairs which range from fixing heating to meeting fire safety rules, government figures suggest.

The figure is eight times this year's much-heralded NHS surplus, which was achieved by making a variety of cuts.

Shadow Health Secretary Andrew Lansley, who obtained the figures, said they showed the surplus was a "sham".

For me, this echoes the reality that "Medicare for All" would not, in fact, represent that great a savings on administrative overhead, because much of Medicare's overhead is off-budget (real estate occupancy costs, contractor operations, its own employee health benefits, etc.), and the emerging sense that FEHPB isn't really built to handle a gajillion more subscribers.

So, my sage advice to the candidates (OK, to the Democratic candidates) today:  acknowledge these limitations and offer some concrete options to overcome them.

I know there are several other hurdles to overcome --  getting medical inflation in check, ensuring that prevention gets more attention (e.g., anti-obesity programs, which among other things might even include an adjustment to the federales' subsidy of corn production in this country -- but that's a whole other story).  But on the financing of health care coverage side of things, a nod to the fact that the solution is not so simple might give the public greater confidence.

-- David Harlow

October 23, 2007

HealthVault: The end of the world as we know it?

Fred Trotter has thrown down the gauntlet: he says Microsoft's HealthVault privacy policy doesn't pass muster.  He chides Deborah Peel, director of the Privacy Rights Foundation for endorsing its privacy protections.  Martin Jensen at the HIT Transition Weblog, among others, is in agreement. 

Bottom line, they're right, but so what?

Whose privacy policy really works these days anyway?  And we're talking about medical records, right?  Those mostly paper records that get slogged around medical offices and hospitals and nursing facilities and imaging centers . . . . It's not as if their security has never been subject to compromise before being locked up in the HealthVault.

Fred recoils in horror upon learning that Microsoft's posted privacy policy is subject to change.

He wonders what might happen if Microsoft isn't around when his great-great-great-great-grandkids need to review family medical histories.

Again, while it would be nice to have perfect privacy policies and practices to go along with the brand-spanking-new HealthVault, I think we are asking too much of new technologies if we expect the old wine to be transformed simply by being decanted into new bottles.

First of all, as many others have observed, there are plenty of other hurdles that Microsoft will have to vault over before facing this one head-on.  For example: (1) likelihood of individuals bothering with complete data entry and maintenance is low, so (2) use of data from the vault by other health care providers is relatively unlikely because it will not be viewed as reliable.

A panacea offered by some to the problem of sharing patient health information across providers is the RHIO.  Unfortunately, we have witnessed the failures of numerous RHIOs, big and small (e.g., Santa Barbara and Northeast PA, to name but two); and, in fact, one limitation of the RHIO is its first name: "regional."  The perceived demand HealthVault seeks to tap into is the demand for portability of personal health data, not regionally but nationally and internationally.  RHIOs seem to be able to tackle the problem locally on a technical level (witness MAeHC; see also MAeHC CEO Micky Tripathi's blog), but long-term viability is far from assured given the struggle RHIOs have had with settling on a sustainable busniess model -- and privacy issues are a concern for RHIOs too.  HIPAA does not apply to RHIOs, and while there is legislation pending that would extend HIPAA privacy protections to RHIOs (Wired for Health Care Quality Act of 2007), it is stalled in committee and is opposed by HIMSS.

The challenge remains the same: timely development of workable interoperability standards -- and products that adhere to those standards and allow for real-time access to organized health records by all providers caring for a patient.

Fred and others point to Indivo, an open source solution with perhaps greater transparency than HealthVault (auditable, etc.); however, it is ultimately subject to many of the same concerns.  Unless I'm missing something, maintaining a personal health record that is complete, and up to date, and subject to HIPAA-type protections, is still little more than a pipe dream.

-- David Harlow

October 22, 2007

OIG advisory opinion OK's certain ambulance service support for county expenses

Last week, the OIG posted an October 12 advisory opinion regarding private ambulance service support for county expenses incurred in connection with prehospital care and transportation provided under exclusive contracts with the ambulance services providing the support.

Most municipalities no longer ask for -- and most ambulance services no longer offer -- vehicle donations and other goodies in return for exclusive contracts.  This advisory opinion serves to remind us that while freebies not closely related to the contract in question are a no-no, some closely-related financial supports are, in fact, permitted.

In this case, partial reimbursement for administrative and dispatch expenses, and free care for uninsured -- all related to the county inmates whose transport was the subject of the contract (and which was billed to third parties) -- were found by the OIG to be permissible.

The grounds for this decision were as follows:

  • The arrangement was part of a comprehensive municipal program to secure transport services
  • Payments for administrative and dispatch expenses will not cover their full cost
  • Even though payments will vary with volume, the payment will not induce referrals, as most volume is 911 volume
  • The arrangement in this case is with providers that have been contracting with the county  government for over 25 years
  • The remuneration in this case would inure to the public benefit
  • The arrangement was developed by the county government
  • "Importantly, there is no ancillary or unrelated remuneration offered or paid by the Ambulance Services to the County . . . .  We might have reached a different result if the Ambulance Services had offered the County . . .  some remuneration not directly related to the provision of the emergency medical transports covered by the contracts including, by way of example, free or reduced cost equipment for . . . County agencies."

Expect a proliferation of carefully-constructed support programs in the wake of this advisory.

-- David Harlow

Blawg Review is up

Check out the latest Blawg Review hosted this week by the ever-incisive David Maister.

-- David Harlow

October 18, 2007

Guns and butter: Health Wonk Review is up at Healthcare Economist

In today's health-wonk-o-sphere news, Jason Shafrin is hosting the current Health Wonk Review at Healthcare Economist.  Check out his lively digest of everything from P4P to SCHIP to HealthVault and beyond. 

Not surprisingly, what ties together many of the posts Jason selected is a concern with competing interests and values -- the guns vs. butter, or pizza vs. beer issues of the health care economy.

-- David Harlow   

October 17, 2007

KFF posts comparison tool for the presidential candidates' health plans

For a useful primer on the presidential candidates' health care platforms and more, check out the Kaiser Family Foundation's Health08.org site. 

Among other things, you can build a side-by-side comparison of the candidates' health care plans, with links to source materials, and check out webcasts (live and archived) of candidate forums on their health plans.

-- David Harlow

October 16, 2007

Stem cell research in Massachusetts

The Public Health Council is dead!  Long live the Public Health Council!

Following statutory changes and subsequent repopulation of the Massachusetts Department of Public Health's PHC earlier this year by Gov. Patrick, the stem cell research regulations implementing the biotech act adopted last year -- and foisted on the Department by former Gov. Romney -- have been revised significantly.

Last week, the PHC voted to amend those regs.  Just a few words actually changed, but the import of the regs now tracks the legislation, instead of standing in opposition to it.  The original reg was explained by DPH staff thus: 

In essence, researchers may not create fertilized embryos solely for donation to, or use in research.

Now, MA researchers may use stem cells that were developed solely for use in research without being subject to state sanctions, including criminal penalties.

(TOH: A Healthy Blog)

-- David Harlow

October 14, 2007

CMS announces home health pay for performance demonstration

P4P is moving into the home health arena.  Later this month, CMS plans to roll out a two-year HHA P4P demonstration project in seven states: CT, MA, AL, GA, TN, IL and CA.  The key indicators to be tracked as part of the demo are drawn from standard quality measures already included in the CMS HHA Outcome-Based Quality Improvement (OBQI) data set.  They are:

  • Incidence of Acute Care Hospitalization
  • Incidence of Any Emergent Care
  • Improvement in Bathing
  • Improvement in Ambulation/Locomotion
  • Improvement in Transferring
  • Improvement in Status of Surgical Wounds
  • Improvement in Management of Oral Medications

Payments will be tied to both high performance (a la HQID) and performance improvement.  Unlike other P4P demonstration projects (e.g., the gainsharing demos), for this project, there's talk of random assignment to control vs. study groups.  Also, payment will be conditioned on reduced overall Medicare spending.  Thus, unlike participants in the gainsharing demos, HHAs will not be put at financial risk by implementing higher-cost program modifications designed -- but not guaranteed -- to yield performance improvement and/or cost savings.

Abt Associates has been in involved in the demo design, and an Abt presentation at an HHA P4P open door session is up on the CMS website (click on open door ppt download).

The HealthBlawger stands ready to assist HHAs with the demonstration application process, as I have with hospital and physician group clients in the MMA 646 and DRA 5007 demos. 

-- David Harlow

October 11, 2007

Medicare fraud attracts South Florida drug traffickers

Here's the lead from today's Morning Edition story on Medicare fraud:

There's a nationwide crime epidemic going on that rakes in $35 billion or more each year. Exactly how much is being stolen is impossible to say, because the federal government doesn't try to measure it.

It's Medicare fraud. The $368 billion federal program is a tempting target for crooks, and there are signs the problem is growing. It is particularly acute in South Florida, where it seems to be replacing drug trafficking as the crime of choice for those who want to get rich quick.

We all know about Medicare fraud, and the fact that enforcement is woefully underfunded. But that $35 billion figure in the lead caught my eye . . . just what el presidente vetoed on the SCHIP front last week. Hmm.

-- David Harlow

People with chronic illness more likely to actually use online health care info

Not surprisingly, the Pew Internet and American Life Project recently issued a report on e-health finding:

Those with chronic conditions are more likely than other e-patients to report that their online searches affected treatment decisions, their interactions with their doctors, their ability to cope with their condition, and their dieting and fitness regimen.

Check out the NPR story on this as well.

Something for the Health 2.0 crowd to consider as they build out their products and platforms: the most robust market is a public that is older, more chronically ill or disabled -- not the the early-adopter target demographic of other Web 2.0 ventures.

-- David Harlow