Remember the Sustainable Growth Rate, that congressional hedge against inflation of health care costs, specifically payments under the Medicare Physician Fee Schedule? Well, the CY 2010 MPFS went on display yesterday, and is due to be published in a couple weeks. As written, the rule would (among other things) fully implement the SGR by cutting physician payments 21.5% (see the press release). That's because Congress has overridden every other cut mandated by the law since 2002, yet has not taken the time to rethink it -- even though it called for a review in 2005's DRA, and MedPAC obliged in 2007. To cut to the chase, MedPAC recommended that Congress either (a) come up with another cockamamie formula or (b) repeal the SGR and develop incentives for providers to provide higher quality care at lower cost. Yes, they've done a fine job so far . . . .
So, we all know that Congress will step in before the rule takes effect January 1, 2010; perhaps it will be in a systematic way this time, however, with a real replacement for the SGR wrapped into a broader health care reform bill. The Tri-Committee bill in the House (see sec. 1121, p. 181) is the only leading bill that addresses this issue head-on, as far as I know (please let me know if I'm missing something), though it does not include a radical enough reformation and seems to fall in line with MedPAC recommendation (a).
As the WSJ Health Blog notes, another part of the crazy logic at work in the draft rule is a CMS proposal to carve out reimbursement for physician-administered drugs ($87.5B over ten years, per the CBO) from that which is subject to the SGR. That would help with the narrow issue of how-many-percentage-points-of-the-SGR-can pass through the eye of a needle, but obviously doesn't address the fundamental systems issue. (I'll take (b) for $2.4 trillion, Alex.)
There's plenty of other goodies in this draft rule -- especially around imaging -- but the big across-the-board cuts certainly deserve the headline. For example:
Capital reimbursement for physician-office diagnostic equipment was originally calculated by CMS based on the assumption of a 50% utilization rate. Since the actual utilization rates are much higher, that assumption is now being formally thrown out the window.
Under MIPPA, imaging providers will be subject to new accreditation requirements as of January 2012; accreditation organizations are identified in the rule, and additional controls will be forthcoming in separate rulemaking.
Finally, more measures are being added to the PQRI set, and automatic EHR-to-CMS reporting is being explored (as is the case with hospital RHQDAPU reporting), as pay-for-reporting (in lieu of meaningful pay-for-performance) continues at the Federal level.
Bottom line: This is a complicated set of issues, but it is only one of many that Congress and the President hope to have all wrapped up neatly by November. Perhaps a post-SGR approach to physician payment will help build the coalition necessary for meaningful systemic reform.
I had the pleasure of discussing the current crop of health care reform policy options with Gregg Masters and a number of callers today on Blog Talk Radio. The hour-long show is available for your listening pleasure here (streaming or download). Please let me know if you like the content and/or format. Gregg (aka @2healthguru on twitter, where we first met) and I plan to produce future shows and are interested in your comments and suggestions on focused topics for discussion.
June is bustin' out all over . . . . Lord knows my nose knows it, thanks to all the pollen in the air these days. Check out the classic movie rendition of this set piece (well worth the eight-minute investment), let your coffee and/or antihistamines kick in, and then let's dive into the past week's medblogging, loosely categorized into insights of patient bloggers, provider bloggers, bloggers I've met in real life (the number keeps growing), bloggers following the money trail through the health care thicket, and bloggers who are or should be dancing and/or shirtless (watch the whole movie clip . . . on second thought, let's leave it at dancing).
Last time I hosted Grand Rounds, we delved into the origins of Valentine's Day, so even though we're a couple weeks shy of the vernal equinox, since June is bustin' out all over, the historian in me feels the need to touch on an ur-Spring nugget or two before we get going. Where do these celebrations of Spring come from?
Attis was a Phrygian god, whose annual death and resurrection were mourned and celebrated at a Spring festival. (On the other hand, the death and rebirth of the Sumerian Tammuz was a summer solstice thing rather than a vernal equinox thing.) James Fraser, in The Golden Bough, wrote:
The annual death and revival of vegetation is a conception which readily presents itself to men in every stage of savagery and civilisation: and the vastness of the scale on which this ever-recurring decay and regeneration takes place, together with man's most intimate dependence on it for subsistence, combine to render it the most impressive annual occurrence in nature, at least within the temperate zones. It is no wonder that a phenomenon so important, so striking, and so universal should, by suggesting similar ideas, have given rise to similar rites in many lands.
What I best remember from The Golden Bough, though, is the tale of the king-for-a-year, who ascends the throne as a result of a cultic regicide, and ends his term the same way. Great stuff.
For further reading linking The Golden Bough, The Holy Grail, Wagner's Parsifal, and T.S. Eliot's The Waste Land, check out Derrick Everett's article on The Waste Land.
I'm not certain that Rogers and Hammerstein had these themes in mind when writing Carousel. Heck, who knows what they had in mind; they threw in a happy ending that wasn't in their source material (but hey, that's show business). You, dear reader, certainly didn't have these themes in mind when you tuned in to today's edition of Grand Rounds. Nevertheless, on with today's show.
Provider Bloggers
At Musings of a Distractible Mind, Dr. Rob discusses Atul Gawande's recent New Yorker piece on health care cost variations across the country
(a good read, well worth the time), which focuses on McAllen, TX, a
small border town that consumes far more than the average annual per capita
amount of health care services. Gawande loops in the Dartmouth Health
Atlas folks, asks the hard questions about physician-owned facilities and financial incentives, and concludes that outfits like Geisinger, Intermountain, Kaiser Permanente and Mayo -- not-for-profit integrated delivery systems with salaried docs -- have the model we should strive to emulate systemwide. Dr. Rob recounts his own experience with physician-owned
facilities. His conclusion is a folksy twist on Gawande's:
How
do we fix it? There are lots of good answers, and lots of dumb ones as
well. The bottom line is the bottom line, though. How you pay docs
will determine what happens. It’s America, after all. It’s what makes
us great. Right?
Right. The thing is, guys, we've known this for at least forty years.
ACP Hospitalist reports on Sid Wolfe's new Public Citizen campaign to get hospitals to step up reporting of physician wrongdoing. Bob Wachter, at Wachter's World, delves deeper into the problem, and says:
I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.
Bongi, at other things amanzi, recalls a suboptimal experience in his training, when the "see one, do one, teach one" approach was reduced to "read an article about one, do one immediately afterwards."
At Providentia, Romeo Vitelli looks at the historical precursors to Jenny McCarthy and the current crop of anti-vaccinationists.
NurseAusmed recounts difficulties in handling patient communications and managing patient expectations at Nursing Handover.
How to Cope With Paintakes
a page from a book offering guidance to those who have lost their
spiritual way and turns the advice to use for those facing physical,
rather than spiritual, pain.
Web 2.0 meets the health care establishment, and KevinMD [IRL] observes that since health care is largely a business, this should not be surprising. For a window into social media use by health care provider organizations, check out healthsocmed.
The anonymous author of Notes of an Anesthesoboist says it's hard for women doctors to make friends . . . perhaps they should introduce themselves as drug pushers instead?
Big Pharma also always follows the money, and David Williams, at the Health Business Blog, remains perplexed over Pharma's failure to engage with the public via twitter. (GSK has already responded to David's post, but in a way that doesn't exactly undercut his point.) For a window into Pharma's engagement with social media, look no further than Shwen Gwee, who organized the Social Pharmer unconference in conjunction with the HealthCamp Boston unconference I co-organized in late April. Speaking of social media, feel free to follow me on twitter: @healthblawg.
Last week, I took a look at the proposed Medicare Inpatient Prospective Payment System (IPPS) updates for FFY 2010. Among other things in the rule (including payments cut to the bone), I was surprised to see tucked away in there a tacit acknowledgement that the whole "no pay for never events" thing isn't really saving anybody that much money.
Lots of hospitals are touting new private rooms these days. Seems to help patient care (lower infection rates, better sleep, more privacy), but despite the benefits, Jeffrey Seguritan at nuts for healthcare observes that the private room is being pushed by the AIA, and wonders whether health care dollars really ought to be spent these days on capital projects such as these. (My brief response: these days, they really aren't, given the tight financial markets).
How do you [reduce health care costs dramatically]? Here's my theory. You can do more to affect health care costs by getting 10,000 people to change their lifestyle habits than you can by getting a few hundred docs to change how they document and collect data and prescribe some pills.
So here's what you do. You bribe the public. People are inherently lazy, but they respond well to piles of money.
For a fuller introduction to the X Prize competition: Scott Shreve [IRL] posted his twitterview on the X Prize with Bertalan Mesko (@berci) at Crossover Health. Learn more about it there.
The big HITECH Act pot of money that everyone in health IT is itching to get their hands on is going to have some strings attached: chief among them are going to be definitions of "meaningful use" and "certified EHR." Them that are likely to be certifying -- CCHIT -- have been the target of some possibly well-deserved pot-shots, and the gloves have come off. See Gilles Frydman's [almost met IRL at the Health 2.0 conference in
Boston a month or so ago] framing of the debate at e-patients.net and John Moore's [IRL] take at Chilmark Research.
Health technology research and development yielded two bits of news this week: FDA approval of a handheld ultrasound unit, via Vijay Sadasivam's scan man's notes, and Ves Dimov's post at Clinical Cases and Images on the Rovio - a WiFi-enabled mobile webcam, which may be more attractive to medical users given the recent study that found patient satisfaction, physician satisfaction and diagnostic agreement (measured both between face-to-face and virtual vists, and between two face-to-face visits) to be similar for face-to-face and virtual visits. (Yesterday's Boston Globe took a closer look at this study, virtual visits in general, and American Well in particular.)
The health IT crowd is working on interoperability and portability of health information. Google Health is one of the platforms that may enable folks to reach this holy grail. Brian Dolan at mobihealthnews says that Google Wave, an open-source tool for communication and collaboration, looks like a killer tool for enabling Google Health to do more in terms of provider-provider and patient-provider collaboration.
Evan Falchuk's observation at See First on prevention: it ain't cheap; treatment of preventable disease is more expensive than the savings from avoided disease and complications, so we need to be talking about more than cost-effectiveness.[Supposed to meet IRL soon.]
Patient Bloggers
For
some reason, diabetics are very well-represented among Grand Rounds'
usual suspects. This week, they're turning into media critics as well,
following President Obama's nomination of Sonia Sotomayor to the
Supremes. Amy Tenderich [who I also almost met IRL at Health 2.0] touched on the media frenzy regarding the
nominee's Type 1 diabetes at The Diabetes Mine, as did Six Until Me's Kerri Morrone Sparling. Not to leave Type 2 diabetes unattended, Rachel Baumgartel offers tips for the newly diagnosed Type 2 diabetic at Diabetes Daily. (For those who care to immerse themselves in The Politics of the Sotomayor Nomination, the good folks at SCOTUSblog say come on in, the water is fine.) For a taste of the difficulties faced by some diabetics traveling through airports with needles and curious liquids, head on over to Tim Brown's post at Shoot Up or Put Up.
At Getting Closer to Myself,
Leslie offers her reflections as a twentysomething with auto-immune
disease, specifically a feeling of how she can't go home again to an
idealized summer retreat.
Barbara Kivowitz describes a good day at In Sickness and In Health, and invites all of us to do the same.
Bloggers Who Are or Should Be Dancing
Val Jones [IRL] is pretty pleased with her high-deductible health plan (HDHP) - cash-only PCP combo. I hope her husband is dancing after the office procedure scheduled on a dime last weekend . . . and I hope Dr. Val has all the releases for those photos stashed away somewhere. It's a good solution for those with no chronic conditions, young kids, or other sources of regular interactions with the medical-industrial complex. And no less a luminary than Clay Christensen says we're 5-6 years away from the tipping point (to mix metaphors) on HSA/HDHP combos, at which time we're likely to see a significant change in the economics of healthcare (with or without significant movement in DC). For one example of where this may play out, see my recent post on retail health clinics.
InsureBlog's Bob Vineyard shares good news for Cuba's pre-op transsexual population: coverage is here. Surely cause for someone (patients, if not bloggers) to dance.
Well, that's the last dance . . . for this week. See you around the medblogosphere, and next week at the next edition ofGrand Rounds.
CMS published the FY 2010 IPPS (hospital inpatient prospective payment system) rule and rates on Friday May 22. I'll offer just some highlights of the 608-page monstrosity here, focusing on the short-term acute care portion; the long term acute care hospital (LTACH) rates are in here, too.
First and foremost: Acute care hospitals will enjoy just a 0.2% increase in DRG payments for the year beginning October 1, 2009. The rule provides for a 2.1% adjustment for all hospitals reporting RHQPAPU measures (which is virtually everyone); 0.5% if not reporting. The sucker punch: a 1.9% negative adjustment to adjust for the shift to the severity-adjusted MS-DRG system in FY 2008-09 and the concomitant attention to reporting, which the federales say resulted in higher reimbursements without a change in acuity. There is a total 8.5% negative adjustment to be made which CMS is deferring so as not to whack the industry excessively just now. Congress has come to the rescue once, reducing the cuts and deferring the day of reckoning, but that day has now come. It remains to be seen whether Congress will seek to defeat or defer these cuts again (and again)
a la
the SGR. Comments are invited; the AHA and others are already steamed.
One bright spot: orthopedic MS-DRG codes are bucking the trend and see a more significant increase.
A note of caution for hospitals: Even though complete documentation and coding led to the negative adjustment, folks need to continue to do a good job of documentation and coding, since that's what the MS-DRG system is all about.
On the RHQDAPU front: the federales are taking baby steps towards automating the reporting process, testing the transmission system direct from hospital records to a central repository with three measures not currently used for payment incentives.
This year the proposal is to add two new measures to the 44 currently in use (for FY 2011) (see chart in linked Federal Register document, 74 FR 24171-72, pp. 93-94 of pdf) , and 69 additional measures are identified that might be used in the future (74 FR 24172-73, pdf pp. 94-95). Also interesting is the fact that one measure is being taken off the list based on research tying IV beta blockers to elevated mortality risk in certain populations, and related practice guidelines evolution. In addition, other measures may come off the list if they've "topped out" with near-universal compliance -- like a pneumonia oxygenation assessment measure. Comments are invited on determining when to retire criteria and also on the criteria for establishing new criteria. These criteria are significant, so I quote this section of the commentary in full:
In the FY 2009 IPPS proposed rule, we solicited comments on several considerations related to expanding and updating quality measures, including how to reduce the burden on the hospitals participating in the RHQDAPU program and which approaches to measurement and collection would be most useful while minimizing burden (73 FR 23653 through 23654). In the FY 2009 IPPS final rule, we responded to public comments we received on these issues (73 FR 48613 through 48616). We also stated that in future expansions and updates to the RHQDAPU program measure set, we would be taking into consideration several important goals. These goals include: (a) Expanding the types of measures beyond process of care measures to include an increased number of outcome measures, efficiency measures, and patients’ experience-of-care measures; (b) expanding the scope of hospital services to which the measures apply; (c) considering the burden on hospitals in collecting chart-abstracted data; (d) harmonizing the measures used in the RHQDAPU program with other CMS quality programs to align incentives and promote coordinated efforts to improve quality; (e) seeking to use measures based on alternative sources of data that do not require chart abstraction or that utilize data already being reported by many hospitals, such as data that hospitals report to clinical data registries, or all-payer claims data bases; and (f) weighing the relevance and utility of the measures compared to the burden on hospitals in submitting data under the RHQDAPU program. Specifically, we give priority to quality measures that assess performance on: (a) Conditions that result in the greatest mortality and morbidity in the Medicare population; (b) conditions that are high volume and high cost for the Medicare program; and (c) conditions for which wide cost and treatment variations have been reported, despite established clinical guidelines. We have used and continue to use these criteria to guide our decisions regarding what measures to add to the RHQDAPU program measure set.
The goals of the RHQDAPU articulated here bear close reading. These are core values that CMS is seeking to refine further -- comments are welcome -- and it seems to me that these core values will continue to inform quality measurement and value based purchasing initiatives of the agency in the future. The main problem I have with the approach taken to date (and I've been saying this for quite a while) is that the federales -- and other payors -- are asking providers to track too many indicators. It is possible to track a small number of indicators that are predictive of other quality performance measures. (Two key people who agree with this perspective are Don Berwick of the Institute for Healthcare Improvement and Leah Binder of the Leapfrog Group, each of whom I've had the opportunity to talk with about this issue, among other things.) My other problems with the approach are that too little of the total payment is at stake (2%), and that the system is set up as a pay-for-reporting system, not a pay-for-performance system.
No new hospital-acquired conditions (HACs) are being added to the no pay for never events rule this year. A very significant fact was tucked away near the very end of the publication (74 FR 24669; pdf p. 591): The no pay for never events rule is only expected to save the federales $21-22 million a year, because most cases with HACs have other comorbidities that result in higher MS-DRG payments anyway. Sounds to me like this is a rule crying out to be rewritten: All the hoo-ha over hospital-acquired conditions and no pay for never events and the federales are saving just a measly $21 million a year??? Either tighten it up so that real savings can be achieved or toss it.
There are many more proposed changes and updates in this reg, but the last I'll touch on here is the EMTALA sanction waiver, which would essentially provide a 72-hour waiver of EMTALA (except for patient dumping based on source of payment) in case of implementation of a hospital disaster protocol. There is, of course, a pandemic infectious disease exception (for all you swine flu eschatologists out there) extending the 72-hour waiver til the end of a declared public health emergency.
The comment period is open through June 30; a final rule is expected by the end of July, and new rules and rates will be effective October 1.
AHA, AMA, AHIP, SEIU, AdvaMed and PhARMAtold Obama yesterday that over the next ten years they stand ready to "do our part to achieve your Administration's goal of decreasing by 1.5 percentage points the annual healthcare spending growth rate -- saving $2 trillion or more." The details include nostrums that appear in the President's budget proposal as well.
Setting aside for a moment the creative accounting built into that pledge, why don't they start by pledging to eliminate the $700 billion or so a year of waste in the system? It is a commonplace that 1/3 of the costs incurred in the U.S. health care system are unnecessary.
Frankly, these groups are destined to decrease health care spending by even more, given today's Medicare Trustees' report (the doomsday clock gives the Hospital Trust Fund about 8 years) -- so 1.5% a year is bupkes.
It also bears noting that a careful reading of the letter yields a pledge to "do our part" to achieve the federales' goal -- not a pledge to reach the $2 trillion mark on their own.
While they doth protest otherwise, these groups are likely eager to forestall the public plan option (see one exposition of what that could mean in an earlier HealthBlawg post) and perhaps believe that by being inside the big tent this time around, instead of throwing stones (to mix a metaphor) a la Harry and Louise ads in the HillaryCare era, they have a better shot at steering things their way.
Update May 13, 2009: Bob Laszewski sums up the issues with yesterday's fantasy health care reform exercise nicely.
Update May 18, 2009: The alphabet soup of organizations standing behind Obama at the White House last week have now been distancing themselves from his message, which went a bit further than the groups' actual commitments (as noted above). Not to be the bearer of wet blankets or anything, but the announcement now starts to look like a backfiring White House media event ginned up while not-ready-for-prime-time in order to deflect attacks on the unfinanceability of the Obama health reform plan.
This Great Leap Forward approach by industry is also exemplified by GE's healthymagination gobbledegook, rolled out last week with similar fanfare. The proposal: all GE's health-related businesses will roll out product and service upgrades that will cut costs while increasing access and improving quality. While a $6 billion commitment to health care, addressing cost, access and quality is generally a good thing, GE was a little short on details. Also, monopolists and near-monopolists don't talk about lowering prices unless something is really wrong. See doomsday clock, above. (For more cynicism, see John Moore's take on GE as well.)
Welcome to Health Wonk Review, where everyone is above average. We enjoy above-average
health care costs per capita, above-average uninsured rates, and above-average
obsession with health care reform. That's what it's like today in
America. Our president has said, Change has come to America. In the
words of Robert Hayden's [American Journal]:
america
as much a problem in metaphysics as it
is a nation earthly entity an iota in our galaxy
an organism that changes even as i examine
it fact and fantasy never twice the same
so many variables
LikeSchrodinger's cat, America's
health care system seems to change in the changing light as we examine it; one
thing we can all agree on is that it needs some work.
We begin with some broad brush strokes on form and amount of spending:
One cost, no matter what the payment system, is labor. Lynn
Nicholas, President of the Massachusetts Hospital Association writes about some pending changes to labor laws that might make it easier for labor to unionize,
presenting the favored position of a non-union shop as one of worker, rather than employer, preference. See Keeping Communication Lines Open
in the Healthcare Labor Debate at CommonHealth, the Massachusetts health care reform blog of WBUR (a Boston NPR affiliate).
Who Will Pay for Prescription Drugs? asks Adam Fein at Drug Channels. CMS projections show that the government will have a very strong hand in managing retail drug spending and shaping the future of drug channels. How will that affect pricing and R&D? Richard
Fogoros (DrRich)presentsA Brilliant Plan For Preserving
Pharmaceutical Progressat The Covert Rationing Blog, saying, The title says
it all. Can we have our cake (drug price controls) and eat it too (continue
drug innovation)? DrRich says, yes we can! Check out his proposal.
My dad used to say he wanted to listen to a radio station that broadcast only good news (not Good News, just good news). Merrill Goozner, of GoozNews, suggests this week that there ought to be a journal dedicated solely to publishing negative results -- as soon as they're known -- as he is all hopped up due to delayed publication and/or suppression of data on adverse effects of drugs. These issues in general, and a couple of current cases he discusses, have policy implications for the new leadership at the FDA.
At InsureBlog, Mike Feehan has a piece on
Wellpoint's recent spinning off of its in-house PBM, About Wellpoint's PBM Auction, and future implications for prescription costs.
At the other end of the spectrum, Health Access WeBlog's Beth
Capell
asks What are gold-plated benefits
anyway? An interesting question, now that the president has indicated that he is open to signing a bill including taxation of health benefits. (As an aside, Obama's approach -- White House Health Care Summit with stunning transparency, concluded with an invitation to Congress to send him a bill consistent with the policies he articulated throughout the campaign -- is both a refreshing change from the Clinton years and a strategy likely to insulate him from criticism on the exact contours of the plan when it reaches his desk.)
Jared
Rhoads
presents Less government, not more at The Lucidicus Project, discussing the recent report by Physicians
for a National Health Plan (the single payor proponents). I spoke with PNHP's David Himmelstein a little while back, and while he has a compelling argument for adopting a single-payor plan in this country (the savings would be impressive), I still believe that the more pragmatic approach is to make incremental changes in the system before us.
Taking our cue from Dr. Himmelstein, we begin a bit of a grand tour by visiting our neighbor to the north.
At BNET Healthcare, Ken Terry writes that Massachusetts Needs to Deal With Primary Care Crisis, saying that while proponents of the healthcare reform program in Massachusetts tout it as a model for the entire country, and detractors point to the program's rapidly rising costs, neither side is really focusing on the need for better access to primary care in the state. He also observes that retail clinics are expanding in Massachusetts, and community health centers are pulling in federal cash for expansion. One observation: retail clinics in Massachusetts are not currently expanding as they cannot find nurse pratitioners to hire. Also, on a national level, Minute Clinic recently shuttered 90 sites for the season. Even if they were growing, they are no substitute for primary care.
Here at HealthBlawg, I recently interviewed the CEO of Satori World Medical, a medical tourism company that offers a twist: through an HRA, it funds patients' future years' insurance premiums with a portion of the savings their employers or insurers enjoy as a result of their overseas medical procedures.
Closer to home, many doctors are now leery of online ratings sites, and have started using a service, Medical Justice, to get patients to agree not to post negative reviews as a condition of being taken on as patients. Dmitriy at Trusted.MD has been following this issue for a while and offers some insights.
Care management is also the theme of Julie Ferguson's post on The effect of obesity and other comorbidities on workers comp at Workers' Comp Insider. In light of a new report which shows that workers comp medical claims can cost three times as much when the injured employee is obese, she makes the case for breaking down the silos between employer-based occupational health and general health programs.
Using the cost per doc put out by Wal-Mart, John
Moore does some calculations, and shows in his post The HITECH Challenge: Is $19B
Enough to Drive HIT Adoption at Chilmark Research that docs getting wired and getting HITECH incentive dollars will be engaged in a money-losing proposition -- they'd actually be better off financially not implementing EHRs and getting hit with the penalty a few years down the road.
Speaking of Wal-Mart, it bears mentioning that this day in history marks the anniversary of the Civil War Battle of Bentonville (No, not that Bentonville; the battle was in North Carolina.)
Shahid
N. Shah
presentsClient/Server vs. ASP/Web-Based in
Healthcare IT posted at The Healthcare IT Guy, since with the HITECH Act and stimulus bill making news,
many users are asking if they should purchase software and use it on premises
or if they should use a "cloud" package or an ASP/web-based solution.
In addition to jump-starting HIT, current legislation is giving a boost to research funding. One pot of funds is time-limited; Glenn
Laffel looks at Beaker Ready projects ready for NIH funding at Pizaazz.
In The Color of Money: What Sort of School Doesn't Pay Its Faculty to Teach? Roy Poses at Health Care Renewal puts academic medicine on the spot, saying that some leaders have abandoned core missions in favor of collecting "taxes" from medical faculty, which makes faculty more dependent on commercial interests. Strong words indeed, and an issue that needs to be rolled out front and center together with other payment issues if there is to be a wholesale revamping of health care financing in this country.
Take some advice from the HealthBlawger in screening new employees. Check out some specifics in the current edition of DecisionHealth's Medicare Compliance Alert, offered in point-counterpoint format with tips from my friend Bill Mandell.
Humana purports to cut through all the jargon and traditional media with a new series of faux naif video clips on YouTube accessible through the managed care giant's Stay Smart Stay Healthy web site, which tells us:
In the old world, companies tried to explain health insurance through complex brochures or some other kind of traditional media filled with industry jargon and littered with “legalese.” This is one of the main reasons consumers fail to understand their health insurance. We, the industry, just don’t make it easy.
Today, consumers are increasingly filtering out complex messages, in favor of clearer, more relevant ones delivered through new, engaging mediums of communication. Recognizing this, Humana is now exploring non-traditional avenues to influence consumers’ mindsets and behaviors.
Stay Smart Stay Healthy is a Humana new-media venture designed to deliver guidance, and to support awareness and understanding of the healthcare industry. Our goal is simple: to educate consumers on the healthcare system by removing the usual complexities and replacing them with an informative and engaging series of videos.
Why read your subscriber agreement or a summary when you can watch a "new media" video?
The videos are undeniably clever and engaging, and they do contain some valid information. (I'm making this blanket generalization after watching only the latest addition to the series -- the tenth video, on Medicare.) However, at least this most recent video includes the managed care organization point of view slipped in -- not-so-subtly -- among the "facts." Specifically, the clip explains Medicare Advantage as managed care for Medicare beneficiaries that reduces cost and improves quality. Of course, Medicare Advantage is also a program that provides an essentially guaranteed profit margin to (mostly) for-profit managed care organizations.
The installment on "Why Is Health Care So Expensive?" was similarly deconstructed by Michael Miller at his Health Policy and Communications Blog, one of the other bloggers apparently getting the Humana email updates on this series.
It will be interesting to see whether this series of videos will spawn replies or parodies, as often happens on YouTube. Once "old economy" companies engage with "new media," they no longer control the discourse.
The indefatigable John Halamka makes a convincing case that "interoperability is implementable today with harmonized standards,
appropriate security, and a service oriented architecture using the
internet," and that the only thing barring the way to a fully interoperable national EHR system is resources, or incentives -- the technology is there.
(This conclusion begs the question: is GE's recently-announced foray into developing a new open standard for EHRs really necessary? The $200 million committed seems to be a drop in the proverbial bucket; as a recovering public health official, I always tend to ask: How many childhood vaccines could you buy with that kind of money instead?)
So, what sort of incentives would move providers to climb on board the interoperable EHR express? The federales have taken at least two approaches thus far:
First, the executive order giving hospitals a free pass for kicking in some dough when physicians in a position to refer business are buying EHR systems. (Not exactly doing land-office business, even after the IRS cleared up a little issue -- the executive order created a Stark exception and fraud and abuse safe harbor but hadn't addressed issues raised by tax-exempt hospitals forking over big bucks for the benefit of for-profit medical groups.)
Will these incentives move a lot of docs online? I'm not convinced. Frankly, the hospital community is not exactly looking for ways to spend money these days. I'd like to see the time limits on the executive order extended so that hospitals have a chance to rebound and fund some physician EHR infrastructure. The MIPPA-type or RHQDAPU-type incentives will move docs, as other similar incentives have moved docs and hospitals to report on a million measures.
I'd like to see the federales make some bold moves -- which the Obama administration may be prepared to do -- and fund EHR infrastructure in the private sector. Directly. By writing some checks. There's at least $700 million of public and private funds on the table, but more is needed. The benefits to be realized are great enough, both in terms of public health and in terms of cost savings to government and other payors (and by payors I mean ultimate payors -- those who pay health insurance premiums) that the short-term cost (which is not inconsequential) should be underwritten in the same sort of deficit spending kind of way that FDR used to fund the New Deal.
The campaign trail was littered with candidates' plans to bring fiscal discipline to the Medicare Advantage and Medicare fee-for-service plans, due to the spotlight shone in recent times on these excess payments, and also on the "slamming" or "cramming" hard-sell tactics of some brokers who pushed elders into Medicare fee-for-service plans that may not have been right for them. Descriptions of these tactics have led to stricter marketing regulations.
It seems that what's lacking in the discussion is an emphasis on how we came to this pass: It is important to remember that Medicare Advantage started life as "good" capitation, with Medicare laying off risk to HMOs at 95% of average Medicare fee-for-service costs. The Medicare Advantage plans and, to an even greater extent, the Medicare fee-for-service plans, exploded in volume after Congress managed to turn the program inside out by authorizing payment at higher rates.
Congress and the new administration have a ton on their plates, but rolling back Medicare payments to private plans to the 95% of cost levels would be an easy win, would maintain appropriate levels of care and care coordination -- one of the good things about "good" capitation -- and Obama and Daschle have indicated their interest in moving in the right direction.
Update 11/24/08: The invisible hand sees the writing on the wall too.
