Transparency for Consumers

June 23, 2012

Will EHRs improve the quality and decrease the cost of care for consumers?

The research done to date is mixed: some studies find improved care, others to not. As far as cost, EHRs should theoretically reduce waste, reducing overall healthcare costs. Since many physicians and hospitals still aren’t using advanced systems, it’s probably too early to many generalizations about cost reduction.

Here’s another more difficult question: could the widespread adoption of EHRs result in the ability to provide consumers with more information about prices for medical procedures?

The lack of transparency in medical billing today was carefully set-out in a story in today’s New York Times. The paper reports

Hospital care tends to be the most confounding, and experts say the charges you see on your bill are usually completely unrelated to the cost of providing the services (at hospitals, these list prices are called the “charge master file”). “The charges have no rhyme or reason at all,” Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health. “Why is 30 minutes in the operating room $2,000 and not $1,500? There is absolutely no basis for setting that charge. It is not based upon the cost, and it’s not based upon the market forces, other than the whim of the C.F.O. of the hospital.”

That is a little harsh. Hospital CFOs do not base prices on whims, but rather on very complex financial analyses. Then they must bargain with insurance companies. If they represent a “four star” hospital like Cedars-Sinai or The Mayo Clinic, they are going to be able to negotiate

higher rates than lesser known facilities.

Some help is on the way for consmers. The PPACA (Obamacare) law (if it is upheld by the Supreme Court) will bring new information to consumers through its new make improvements HealthCare.gov Web site, a one-stop shop that lists all of your insurance options in one place. The new site focuses on insurance plans and benefits and does not specifically address individual medical services like surgery or tests.

A four-year old California law states that uninsured patients (but not those with insurance) have the right to contact hospitals and receive a price estimate. The law also states that if a patient is low-income the price estimate cannot exceed what the hospital is paid for the procedure by Medicare or Medi-Cal (California’s version of Medicaid).

A recent  RAND study found the law is widely ignored. The study found that only 28% of the hospitals responded as required by state law and the responses varied widely in content and price. Most included a price quote for hospital services only, the remainder included both hospital and physician costs or did not specify what was covered.

The individual prices for procedures varied widely. For example, estimates for a hysterectomy ranged from $5,569 to $15,950, while the estimates for a colonoscopy varied from $216 to $1,748. Many hospitals also offered discounts for actions such as payment in full at the time of care.

Maybe EHRs, digitization of medical information and new demands by consumers will bring about the needed transparency.

Today when you buy a new car, you can compare prices online between different dealers, even negotiate a better price online. You can also get an estimate from dealers on the value of your trade-in vehicle.

Ten years ago, before the rise of car-pricing sites, you had to drive from dealer to dealer, getting price quotes.  Car dealers initially opposed the concept of posting prices online, but eventually they all gave in.

Medical care is more complex than a Toyota Camry. The skill of the surgeon, the hospital facilities can vary widely, however, that could be factored into the posted price. Most, but not all, consumers would pay more to have their heart surgery done by a veteran surgeon in a top-notch hospital.

It is possible to imagine a day when consumers can go online and compare prices for various procedures from local hospitals for CABG surgery, appendectomies and MRIs.

For the time being your best bet is to have a good health insurance plan. Even better is to work for a large employer who is willing to advocate for you and who will have clout with the insurance company.

Is the IT Bar Set too High?

June 16, 2012

Has the federal government set the bar too high for EHR adoption?

Both the meaningful use and PQRI programs have reported disappointing numbers recently. The  American Medical News reported last week that

A recent report from CMS shows that fewer than 200,000 physicians, out of the more than 600,000 who were eligible for the (PQRI) incentive program, reported PQRS measures in 2010. More than 125,000 physicians reporting as individuals met enough of the requirements to share a total of nearly $400 million in bonuses, but hundreds of thousands of eligible doctors did not attempt to meet the pay-for-reporting criteria. More than 50,000 tried for the bonuses but did not report enough quality measures to hit the minimum.

The article notes that this low participation rate means a “huge segment” of physicians caring for Medicare patients will soon be penalized. In essence, 2012 is the last year without penalties. In 2013 physicians must begin reporting quality measures, or they will face a 1.5% noncompliance penalty. The penalty is not scheduled to be assessed until 2015, but it will be based on 2013 reporting.

Physicians face yet more penalties, according to the article.

In addition to the 2015 PQRS penalty, Medicare rates would be reduced by 1% that year for those who do not achieve meaningful use of an electronic health record system. CMS also plans to adjust pay with a value-based modifier for physicians starting in 2015. The modifier would increase pay for some doctors who are deemed to provide high-quality, efficient care, but it would decrease rates for an as-yet-unknown pool of other physicians.

The Medicare EHR meaningful use program, which jumped off to a strong start in 2011, has slowed considerably in recent months. Combined registrations by eligible professionals (physicians) for the Medicare and Medicaid EHR incentive programs dropped in April to 12,228, down 12% compared with March numbers. Through May some 155,000 physicians had registered for the Medicare program and 56,214 had qualified. Those qualifying earned $953 million in incentive payments.

The AMA and a number of other organizations want the deadlines for both the PQRI and meaningful use programs pushed back by a year or more.

Would a change of administration make a difference in the programs? Would President Romney take a more “hands off” approach

Probably. Remember that President Bush mentioned EHRs in seven out of eight state-of-the-union messages, but his administration did very little (with either incentives or penalties) to stimulate adoption.

AARP & Microsoft Launch PHR

June 8, 2012

Could PHRs be ready to really gain traction? Until now, only about 10% of the public has used a PHR. The concept took a major blow last year when Google announced that it was closing its PHR product, Google Health on 1/1/12.

PHRs may be poised for new growth. The AARP announced this week that it will be partnering with Microsoft to launch “AARP Health Record,” a PHR for people aged 50 and older. The marketing power of AARP, which has 12 million members, should not be underestimated. Its Medicare HMO products are the most popular in the country.

The press release from AARP said that in addition to story a patient’s health data, the new product will offer applications to monitor chronic conditions, share data with physicians and track progress in meeting health goals.

These last three interactive features may be the key to winning new users.

PHRs are “patient centric,” meaning that the patient controls the data. Patient portals are “practice centric” because HMOs and medical groups control the data. PHRs have the disadvantage of using the “pull” model, rather than the “push” model of patient portals.

Patient portals have not been very popular with the public either, with one major exception – Kaiser Permanente. Kaiser’s patient portal is used by 35% of the HMO’s members. The Kaiser portal offers patients the ability to get an online consult and schedule appointments. Kaiser, of course, is a vertically integrated system, controlling all aspects of patient care (e.g. physician visits, lab tests, hospitals).

The AARP PHR will not be able to match that. However, the announcement says it will be able to “share data with physicians.” In theory, a medical group’s patient portal should be able to export data to a PHR. This is rarely done in practice. Medicare beneficiaries are major consumers of medical care. If the AARP PHR were to become really popular, many medical groups might want to link their portal to it.

Patient Portals

June 2, 2012

One of the biggest complaints organized medicine (AMA, AAMC) had about the proposed Meaningful Use Stage 2 rules was the requirement to have…

A patient portal is a unique web site with its own URL and content, sort of like a file you might store on Dropbox. It contains medical information about the patient such as lab results and is only visible to the patient and the physician.

Patient portals are not new. in an article on MDPhysicianmag.com, a GE Healthcare spokesperson said his company has had them available to customers for 10 years.

The article notes

Patient portals help physicians meet two proposed core measures of Stage 2. The first measure requires providing a clinical visit summary to at least half of your patients within three business days. The second measure requires physicians to electronically provide lab results, medication lists and the like to patients upon request.

Many newer, advanced patient portals provide a variety of functions including prescription renewals, test results, clinical summaries, personal medical history, health reminders and appointment  requests

Many physicians are reluctant to get involved with a patient portal, fearing it will become one more chore for which they will not get paid.  Some have been pleasantly surprised that it can actually smooth out the workflow and lead to increased patient engagement.

The physician magazine cites the example of Andrew McGlone, M.D., a family practitioner in Annapolis MD.

“At first I was leary of yet another responsibility that I wouldn’t be reimbursed for. Now, my biggest complaint is that not enough of my patients are using the portal.” Noting that about 20-30% of his patients have signed on, he adds, “I was amazed by the amount of time the entire office could save while also providing more immediate and better patient care.”

The magazine lists four suggestions for physician offices:

1. First convert your records from paper to electronic.
2. Select a software vendor with a proven functional portal.
3. Before launching the portal, test it and make sure employees can handle patient questions.
4. Don’t delay; future pay-for-performance based plans will require them.

Most (but not all) EHR vendors offer patient portals at minimal cost. I think you can compare it to online banking. ATMs were a big breakthrough in self-service, but you still had to find a teller machine. Now you can do many banking transactions online. Patient portals can potentially reduce trips to the pharmacy and doctor’s office.