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April 6, 2012
Supreme Court: A Blow to HIT?
Will the coming June U.S. Supreme Court decision on the Patient Protection and Affordable Care Act (aka Obamacare), impact healthcare IT?
According to Janet Marchibroda, chair of the Bipartisan Policy Center Health IT Initiative, health IT funding will not be reduced if the individual mandate is thrown out. If the Court rules the entire law unconstitutional, some HIT funds would be lost, but not the meaningful use incentives.
Marchibroda was formerly CEO of the eHealth Initiative and prior to that COO of the NCQA. She has been at the Bipartisan Policy Center since April 2011.
Speaking to the HIMSS Southern California Chapter on April 4, Marchibroda noted that it is impossible to predict exactly what the Court will do. However, many analysts believe the individual mandate will be ruled ineligible.
That would have little, if any, effect upon healthcare IT. The meaningful use incentive funds are part of the $36 billion HITECH Act, passed in 2009. If the Court tosses out the entire PPACA, some $10 billion in funding for pilot programs (e.g. pay for quality) to be allocated by CMS would be eliminated.
Marchibroda said that currently spending for healthcare IT enjoys bipartisan support, as most legislators continue to believe it will lead to lower costs and better quality.
She expressed concern about interoperability and said that healthcare vendors need to do a better job in that area. She warned that “Congress did not allocate $36 million to invest in building more silo” and predicted the issue would come up later this year if more oversight hearings are held.
Obamacare vs. Romneycare
An article published yesterday on the Associated Press noted that aside from constitutional issues, a major threat to Obamacare is funding.
“If the Obama plan hits all of its spending targets and realizes all of its projected revenues and savings, it would have minimal impact on the federal budget deficit through 2018. But in following years, the plan would begin running a deficit that would grow to nearly $50 billion annually, according to CBO projections revised last month. In addition, there are good reasons to believe that the Obama plan will run much larger deficits starting well before 2018.”
“The health-care plan Mitt Romney signed into law in Massachusetts is the closest parallel to the Obama plan. Since 2006, costs in Massachusetts have outpaced the original projections by more than 8%. If the Obama plan experiences similar overruns, the shortfall would be greater than $110 billion a year. Add in the deficit projected after 2018, and the Obama plan could eventually increase the annual budget deficit by as much as $150 billion in today’s dollars. Just as a benchmark, that’s about twice the amount that would be raised by ending the Bush tax cuts for people earning over $250,000 a year.”
Whatever the Court’s decision, health reform will be a major issue in the Presidential race. Each side will claim the other’s plan will be too expensive and will lead to poor quality care. We are bound to see all sorts of cost projections. One good thing about our current healthcare system: it is a major engine of job growth.
April 1, 2012
“Best” Practices?
Everyone want to follow “best practices,” right?
This term has been used for so long in the health care debate that I didn’t think twice about it. Now Dr. Jerome Groopman and Pamela Hartzband have questioned the whole concept in a very interesting commentary in the March 30 issue of the Wall Street Journal.
The authors note that both Democrats and Republicans are trying to convince the public that they have experts to answer questions about improving care and reducing costs.
“President Barack Obama and the Democrats propose panels of government experts to evaluate treatments and, in the president’s words, ‘Figure out what works and what doesn’t.’ Republicans claim that the free market (that is, insurance companies with their own experts) will pay for value and empower consumers. Both sides insist that no one will come between us and our doctors.”
According to the authors, both Democrats and Republicans share a fundamental misconception about medical care. Both parties are assuming there is a single right answer for every health problem.
“These ‘best practices,’ they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.”
“Yet in medicine, there are many contrary opinions about ‘best practices.’ You cannot pick up a newspaper, turn on the TV or surf the Internet without encountering conflicting reports about various tests and treatments. Medical experts disagree about many issues, often dramatically.”
Groopman and Hartzband point to the current controversy surrounding screening for breast cancer. They note that the U.S. Preventive Services Task Force issued new recommendations in 2009 stating that women under 50 should no longer undergo routine mammograms. This was due to the consideration that the potential benefit (e.g. lives saved) was “not sufficient to balance the pain and suffering related to false positive diagnoses, unnecessary biopsies, the unknown risks of exposure to radiation and toxic treatment of cancers that might ultimately prove indolent.”
This is not a “consensus position,” according to the authors.
“The American Cancer Society’s own experts took a very different view of the trade-offs between risks and benefits. They still recommend mammograms for women under 50.”
They conclude by stating
“Policy makers need to abandon the idea that experts know what is best. In medical care, the ‘right’ clinical decisions turn out to be those that are based on a patient’s goals and values.”
That is a laudable concept but hardly cost-effective. If you present a patient with a choice of two cancer drugs, one that costs $80,000 and another one that is “almost as effective” and costs only $8,000, he is going to choose the high-cost one every time. After all, in most cases, the patient is not bearing the cost, it is the taxpayers or (in a commercial HMO) his fellow employees.
March 21, 2012
Online Banking vs. Online Healthcare
How long have you been banking online? Two years? Ten years?
A recent survey from the Deloitte Center for Health Solutions found that patients are still twice as likely to use the Internet for online banking than for health tasks, even simple ones such as researching treatment options. In addition, the research found that patient engagement through personal health record services remains difficult with only one patient in nine is interested in using PHR services, let alone actually doing it.
Physicians are scoring a somewhat higher but still have a ways to go. The Deloitte survey found 46% of physicians do not use Internet tools to enhance patient care, and only one in five provide patients with the ability to view lab results or schedule appointments online.
While this lack of online patient access to medical information is hardly news, the problem has become a much more significant barrier to cross in the wake of the recent Meaningful Use Stage 2 rules.
A recent story in SearchHealtIT (http://searchhealthit.techtarget.com/news) notes that the new MU2 rules require that more than half of an eligible provider’s (EP) patients receive online access to their medical records within four days of the records becoming available to the physician.
“The kicker, though, is 10% of patients must view, download or transmit their health information. This objective moves from its current place in the stage 1 menu set to a core requirement in stage 2.”
“This requirement also presents a quandary for meaningful use compliance. Essentially, caregivers would have no control over whether patients will view, download or transmit their medical information. If compliance hinges completely on actions outside the caregiver’s hands, there could be backlash among providers who see the core requirement as unfair.”
“Additionally, how will hospitals and physicians be able to prove that 10% of patients were active with their medical information?”
This proposed requirement (the new rules aren’t final yet) is bound to draw a lot of negative comments from physicians who see it as a “bridge too far.” I predict that it will be eased considerably when the final rules are issued later this summer.
March 16, 2012
Bigger Not Always Better
Two separate surveys from KLAS point out that in the EHR world, biggest isn’t always best.
The first survey by KLAS, the Orem, Utah-based healthcare technology research organization, was reported last week in Health Imaging. KLAS surveyed 104 providers about their attestation experience. The publication reported that
“Some large vendors-like Allscripts, McKesson and Siemens-had successful attesters, but it was a small number compared to the size of their client base. KLAS reported that Meditech is both a success and a struggle for providers. While they have the highest number of successful attesters at 203, the bulk of their attesters came from one large integrated delivery network (IDN).”
While this hardly a secret, it is a fact played down by the big companies and often ignored by the press, which tends to look at simple, gross numbers rather than percentages. The fact is there are a number of smaller EHR vendors with a smaller client base that can boast of having a very significant percentage of their customers achieve attestation.
According to Health Imaging, the survey found the top three investments needed to meet meaningful use Stage 1 attestation were hardware, interfaces and EMR upgrades.
In addition, most providers surveyed reported problems with adopting CPOE and problems lists, reporting quality measures and interfacing.
KLAS, which makes money selling customer survey information, issued another report last week, this one about EHRs serving surgical specialists. As reported in Information Week, the survey found that specialists are less satisfied with their EHRs than primary care doctors.
The survey assessed physician satisfaction with the ambulatory-care products of 18 vendors. Information Week reports that
“Mark Anderson, a health IT consultant in Montgomery, Tex., (said) that specialists like their EHRs less than primary care doctors do because most systems were developed for primary care and lack many of the features and templates that the specialists’ work requires.”
“’Ophthalmologists, for instance, have to take pictures of the eye and do all these eye tests, so they need totally different things in an EHR,’ he said. ‘Oncology is really hard because of the way oncologists do their chemotherapy and the supplies that they have to track.’ As for surgical specialists, he noted that few EHRs have templates designed to document procedures in the ways that surgeons require.”
In fact, several smaller EHR vendors do a very good business selling to specialists who are affiliated with hospitals using Epic, Cerner and GE. Their products are designed for particular specialists, such as orthopedists or oncologists, who find them much easier to use.
March 9, 2012
Patients Not in Sight at HIMSS
Many of us are still sorting out the deluge of information, business cards and swag that poured forth at the HIMSS 12 show.
One interesting analysis comes from Andrew R. Watson, MD, Medical Director, Center for Connected Medicine, Pittsburgh, writing in the mHIMSS newsletter.
Dr. Watson notes
“As I reviewed the schedule of educational sessions and toured the exhibit hall, however, two concerns arose.
“The first was how rarely the word ‘patient’ appeared in prominent signage on the booths. I took notes during one of my tours on the floor and was disappointed to see that ‘patient’ and ‘outcomes’ were not among the primary messages vendors were projecting. Concepts that held marquee status, on the other hand, included data, scalability, cost, HIE and meaningful use.”
I agree with Dr. Watson on this point, the concept of “benefits to patients” in terms of better health, lower costs and convenience was notably lacking.
There are two reasons for that.
1. The patient rarely pays for the full cost of his health care. If you went to a car show, all of the displays would be centered on car buyers. No so at HIMSS. Patients are not the direct buyers of the technology on display. They will, however, bear the costs indirectly. Which brings me to the next point.
2. Relatively few of the technologies on display at HIMSS will lead to decreased costs for the consumer in the short-term. Most of them are sold as “improvements to workflow” or “enhancing productivity.” This basically means the physician will see more patients each day. This will lead to busier physicians, but will it reduce the number of unnecessary tests, or decrease length-of-stay? The jury is still out.
What is Dr. Watson’s second concern?
“The second consideration I found myself wondering about revolves around how all of these remarkable companies, drawn together through HIMSS and its annual event, could work together.”
I do not share this concern. For the few who went downstairs to the “basement,” the HealthStory booth in the Interoperability Showcase displayed some excellent examples of collaboration by vendors.
Fortunately, Dr. Farzad Mostashari went down and was pleased with what he saw. His challenge to send a new clinical document electronically across the country in less than an hour was quickly met by two different teams of vendors.