According to a recent New York Times article, a study conducted on Oregon’s Medicaid program found that found that individuals who gained Medicaid coverage spent more on health care and made more visits to doctors and trips to the hospital.

According to the article

But the study suggests that Medicaid coverage did not make those adults much healthier, at least within the two-year time frame of the research, judging by their blood pressure, blood sugar and other measures. It did, however, substantially reduce the incidence of depression, and it made them vastly more financially secure.

“There was this view that Medicaid coverage would not do much for the low-income uninsured, either because they had access to charity care or because Medicaid is not good insurance,” said Amy Finkelstein of the Massachusetts Institute of Technology. “This rejects that notion entirely.”

Where Medicaid seemed to have the strongest measured impact was on depression. Getting Medicaid coverage reduced the probability of a positive screening by more than 30 percent.

“The authors are almost tilting the spin on the story to be a little more pessimistic than I would have been,” said John Holahan of the Urban Institute, responding to the new findings.

“There are some positive effects on health,” he said, calling the effect on depression “especially strong.”

Confirming previous findings released by the researchers, the new round of results found that adults covered by Medicaid increased their use of a broad number of health services, like mammograms and cholesterol tests. That increased their medical spending by about 35 percent, compared to adults who did not win Medicaid coverage in the lottery.

Depression is closely linked to anxiety, so if you step back and think about it, it should not come as a surprise that individuals who suddenly found themselves with health coverage achieved lower rates of depression.

With troubles mounting for  the administration’s administration of the Affordable Care Act,  the line is one HHS Secretary Kathleen Sibelius might well be saying to the congressional authors of the law. So far, the ACA is running low on both care and affordability.

Last week, six Republican senators released a 28-page white paper, “REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT” which enumerated their concerns about the ACA and other aspects of federal health IT policy.

In their report, the lawmakers acknowledged that the meaningful use program aims to improve health care quality and reduce costs.

According to the report

“Nearly four years after the enactment … we see evidence that the program is at risk of not achieving its goals and that $35 billion in taxpayer money is being spent ineffectively in the process.”

The report went on to list these specific concerns:

The use of health IT systems “may have actually accelerated the ordering of unnecessary care, as well as increased billing for the same procedures”;

The federal government has not required different EHR systems to be able to exchange medical information;

There are few protections in place to prevent fraud and abuse in the meaningful use program;

Processes to protect patient privacy are “lax and may jeopardize sensitive patient data”; and

It is unclear whether health care providers who have received meaningful use incentive payments will be able to maintain their EHR systems without continued federal funding.

If that wasn’t bad enough, Sibelius took heat from Democratic Senator Max Baucus. He gave the “a failing grade” for its efforts to educate the public and small employers about sweeping changes due to take effect in eight months.

According to Insurance Journal,

“I just see a huge train wreck,” Senator Max Baucus of Montana told Secretary Sibelius at a hearing of the Senate Finance Committee.

“I’m very concerned that not enough is being done so far. Very concerned,” said Baucus, citing examples of perplexed small business owners and polling data showing that most Americans either do not know much about the coming changes or have false information about what to expect.

“The administration’s public information campaign on the benefits of the Affordable Care Act, I think, deserves a failing grade. You need to fix it,” he said.

A main concern is the creation of state online marketplaces where consumers will be able to buy private health insurance at subsidized rates intended to make the coverage affordable for those with family incomes of up to $90,000 a year.

Those exchanges are due to start enrolling beneficiaries on Oct. 1 and are open to individuals and businesses with fewer than 100 employees. Full operations are scheduled for Jan. 1.

Another classic movie punch line, one used in many thrillers is “When this is all over, we’re going to look back on this moment and laugh.”

Laurel & Hardy

Let’s hope when the ACA is completely implemented in three, four or five years from now, we will be able to look back on this challenging time and laugh – or at least not grit our teeth.

Sharing information about cancer patients that has been de-identified is apparently OK.

According to a story in the iHealthbeat newsletter, the American Society of Clinical Oncology (ASCO), has completed a prototype of a cancer care database that leverages health IT to improve care.

The new system is designed to be able to collect patient data such as laboratory tests, genomic profiles and physician notes in any standard directly from any electronic health record system.

The prototype, named “CancerLinQ,” has four core functions:

• Real-time data collection;
• Clinical decision support;
• Data mining and visualization; and
• Quality feedback.

According to the article

Sandra Swain — medical director of the Washington Cancer Institute at Medstar Washington Hospital Center, a professor at Georgetown University and ASCO president — noted that only 3% of cancer patients participate in clinical trials and that older patients in particular are left out of such research.

Swain said that CancerLinQ will “help us unlock that 97% of data that’s beyond our reach,” adding that the “result will be higher quality, higher value care and better outcomes for patients.”

John Sharp,  manager of Research Informatics at the Cleveland Clinic, called CancerLinQ “an ambitious attempt to achieve a piece of the learning health care system,” adding, “Rather than developing treatment guidelines over years of clinical trials, the learning health care system proposes a more rapid cycle of analyzing real-time data and incorporating this into evidence-based guidelines.”

The article notes that the new system is based upon open-source software, but does not mention how it will be paid for. Presumably, physicians or hospitals will have to pay a fee to access the information. Nor does the article address the difficult topic of using private health information of individuals for research purposes. For example, would this data base be made available to pharmaceutical companies that could use the information to develop drugs which they might eventually patent and sell for profit?

data base

In the bestselling book The Immortal Life of Henrietta Lacks, author Rebecca Skloot documents how cancer cells, later turned into a cell line used for hundreds of medical experiments, were taken without the knowledge or permission of a poor black woman. Her family never gave permission, nor were they compensated.

The ASCO data base project will not use human tissue, of course, but it does raise the issue of health care organizations benefitting from the illness of individuals and the use of private health information without permission.

Employers are blowing hot and cold on Obamacare’s coming requirement to provide health insurance for all workers.

Beginning in January 2014, the law requires businesses with more than 50 employees to offer health insurance to employees who work an average of at least 30 hours a week, or pay a fine. Many employers of 50-100 workers have been contemplating shrinking their full-time workforce to less than 50 to avoid the requirement.

I was in a meeting with a business owner last week who is already making plans to outsource a dozen janitorial and clerical jobs to reduce his workforce.

For those employers who will be impacted, just how great will the cost be? Keep in mind, the employer just has to offer a health insurance plan, he is not penalized if the worker decides not to join.

The Wall Street Journal reported today that one major restaurant chain has greatly reduced its cost estimate for compliance.

Wendy’s Co. initially estimated the health-care law would increase the cost of operating each of its 5,800 U.S. restaurants by $25,000 a year. But Chief Financial Officer Steve Hare told an investment conference on March 14 that executives have cut the estimate by 80%, to $5,000 a year, primarily because they expect many employees to decline the insurance offering.

AFC Enterprises, operator of the Popeye’s chain, is among the employers that has few takers for its current plan. Ralph Bower, Popeye’s president-U.S., said in an interview that fewer than 5% of employees have signed up for a plan that carries high deductibles and costs $2.50 a week. So he doesn’t expect many more employees to enroll next year, when employees likely will have to pay about $25 a week for a plan offering more coverage.

Instead of buying insurance, Mr. Bower expects many employees will choose to pay the $95-a-year fine for being uninsured. “Do you want to pay $100 a month for health care, or are you going to pay a $95 fine that comes out of your income-tax return at the end of the year?” he said.

Jack in the Box already offers health insurance to any employee who has worked at least three months, but only about 20% use it,  [a spokesman] said. He said he doesn’t expect that number to change next year.

So the good news is that the new health reform law won’t “break the bank” for small employers. The bad news is that it will still leave many workers without health insurance.

1. the latest strain of the flu virus
2. Health Information Exchange
3. Health Insurance Exchange
4. None of the above

You should know this, because you’re in the cotton-pickin business! It is 2. of course.

The fact is many people don’t know about the new health insurance exchanges, due to roll-out in less than a year. At this point 33 states have tossed the “hot potato” of HIX formation back to the federal government.

According to a recent article in Politico the Obama administration is struggling to get the exchanges up and running.

The federal role in building the health insurance exchanges is bigger than expected — and money wasn’t set aside. The Obama administration di

dn’t expect 33 states to refuse to build their own health insurance exchanges. When it asked Congress for another $1 billion.  Without IT infrastructure to process enrollments and payments, verify eligibility and establish call centers, health insurance for millions of Americans could be further delayed.

In addition, the article adds

Obamacare won’t work if people don’t sign up for coverage. But they won’t sign up if they don’t know how to enroll, how it may help them or precisely what — after three years of fuss — they are signing up for.

The hardest piece is the cyber architecture connecting a slew of federal agencies to one another, the states and consumers…The idea is sort of like Travelocity — but health insurance, of course, is more complicated than plane tickets. The consumer provides basic information about age, location, family size and tobacco use, and the “hub” kicks in data about the applicant’s citizenship, income and employment. All of that is supposed to generate information about eligibility, subsidies and net costs for various health plan options.

The State of California embraced the concept early on and is farther along than the other states.  According to an article in  KQED’s The California Report

“We know buying insurance is really complicated. We want to make it as easy as buying a book on Amazon,” said Peter Lee, executive director of the California Health Benefit Exchange.

But as the state has worked to create the actual application for health insurance, the idea of a one-click purchase is far from the reality. …The contract for California’s application was awarded to Accenture last summer. While a draft of the federal application was just released, stakeholders have yet to see a version of California’s application, which, like the federal model is being based on the UX2014 work.

The new federal draft application is 15 pages long for a 3-person family. A single applicant is only required to fill out 6 pages. Meanwhile a YouTube video shows what to expect from the online federal version:

Karp (of the California Healthcare Foundation) says after early promises that this would be like buying an airline ticket online, it’s important to set the right expectations.

“The law says we should have a consumer friendly process … it should be better than what people are experiencing today and we should go to lots of lengths to make it easier for people,” Karp says.

The California Report article shows a screen shot of the first page of the form. Have you ever filled out a six-page form online?

It does not require a six-page form to buying an item from Amazon or book a flight at Travelocity. Perhaps companies like TurboTax will emerge that can capture an individual’s information and help them through the process.

Health Insurance exchange

You would be justifiably angry, no doubt. You might rage against private health insurers. Now, what if the insurer said it would submit the decision to IBM’s Watson supercomputer and accept the option it determined was best?

If IBM’s Watson then agreed with the health insurer (e.g. go with safer, lower-cost procedure), would you accept that decision because it came from an “objective” machine not motivated by financial considerations?

These questions came to mind when I read an article in the current Health Data Management titled

“What’s the Deal with Watson and Cloud Computing?” by David Linthicum.

According to the article

After about a year of training its Watson system on more than 600,000 pieces of medical evidence and 2 million pages of medical research, IBM is now offering a cloud-based Watson service to help oncologists develop the best-possible treatments for cancer patients.

Watson is designed as a question-answering system that emerged victorious on Jeopardy! in 2011. It’s just artificial intelligence (AI) technology at its core, using natural-language processing, machine learning and other data-analysis techniques. It’s able to understand written questions, and then analyze them against the source material to find the best possible response.

Computer medicine

Keep in mind that over the past two decades, insurers have been vilified for refusing to pay for a number of experimental treatments.

I was working as Director of Public Affairs for CIGNA Healthcare of California in 1995 when a jury awarded $20 million dollars to the family of a California woman who had died of breast cancer. Health Net, the family’s insurer, had declined to pay for a treatment involving high-dose chemotherapy with autologous bone marrow transplant. The Health Net medical director said it was unproven and risky. A civil litigation jury disagreed.

Six years later an extensive study, reported in the New England Journal of Medicine, reported that the ABMT treatment was “not effective” and should be abandoned. The medical director at Health Net had been correct in the first place.

EHRs

Now that most hospitals and many physicians have EHRs, the EHR software market is stagnating but companies that provide services to health IT customers are booming.  Once a small hospital or medium-size physician group buys a new, advanced EHR system, it will then likely need a raft of new services: servers, routers, encryption, wireless, payment processing, credit checks and HIPAA compliance.

At the just concluded HIMSS 13 conference, I saw a number of new entrants to healthcare IT (including companies in all of the above categories).

To cite just one example, Ciphertex, a company known for making portable, high-speed encryption devices for the oil and gas and film industries was at HIMSS for the first time (disclosure: they are a client of Westside). To cite another example, Fiserv, a software provider to banks and credit unions, also was another first-time exhibitor.

In addition to new entrants, entirely new service sectors (you can’t call them industries yet) are rapidly being created; for example, HIPAA auditing consultants. These companies (some of them just one or two people) will come to your hospital and report on your readiness for a government audit on HIPAA compliance.

Not worried about an audit from the HHS? You should be if you qualified for meaningful use dollars. Once you have cashed your MU check, you are eligible to be audited. The auditors will be looking to see if you’re using your EHR and if you are in compliance with the new HIPAA regulations on data security and patient privacy.

I talked to a dozen first-time exhibitors at HIMSS and one common complaint was poor treatment by HIMSS organizers. Many exhibitors complained of extra charges (for chairs, carpeting) and poor booth location. One Austin-based company found itself boxed-in between a large exhibitor with an eight-foot high “Berlin Wall,” a massive building column and an empty food court.

The young marketing director, close to exasperation, told me “On the map this looked like a great location, next to (giant exhibitor).  It’s been a disaster. I’ve complained, but they don’t care. We don’t matter because we have a small booth and are first-time exhibitors.”

Welcome to the rough and tumble world of healthcare IT.

Speaking to the Los Angeles Venture Capital Association earlier this month, Dr.  Coye remembered the days when the attitude at many hospitals was “let a hundred flowers bloom.” (Note: this was a phrase first used by Mao in the Chinese Cultural Revolution).

Today, Dr. Coye said she refers to a popular quotation from economist Joseph Schumpeter:

“Innovation turns cash into ideas.”

Her job at UCLA, she said, is to flip that concept, “We need take innovation and turn it into cash.”

Dr. Coye said one of her mandates for leading innovation at the giant UCLA Health care system, which includes four hospitals and more than 2,000 physicians,  is to find innovations in hardware and software that will “move the needle,” by reducing total costs 5-10 percent in one or more areas.

In today’s environment, hospital CIOs must move to a “more refined approach. What exactly are we trying to do? How do we get there?”

She said that when considering new technologies “incremental change” may be preferable to “disruptive” change because of the difficulty in getting buy-in from physicians.

She noted that she is personally very interested in “comparative effectiveness from the patient’s point of view” and cited the work of the Patient-Centered Outcomes Research Institute (PCORI), founded by the 2010 Patient Protection and Affordable Care Act.

Dr. Coye that whether or not a “fiscal cliff” situation develops, hospital leaders believe Medicare will be reducing overall rates by up to 35 percent in coming years and private insurers will be following suit. In an effort to reduce costs, the UCLA system has recently formed an ACO and the UCLA campus is moving its employees into a self-insured system and away from commercial health insurance.

Increased transparency and “reference pricing” is another priority for UCLA she said. She noted that

“56 percent of baby boomers have less than $25,000 in assets” outside of their home. In coming years, when they develop a serious medical condition they are going to face the choice of “getting a second diagnosis or going broke.”

Dr. Coye said the UCLA system is right in the middle of adopting an Epic EHR system with go-live set for next month. The Epic installation has generated a lot of controversy, she said. “Some people have said it is a rigid enterprise with a lot of black boxes. But what choice does a large academic medical center have?  Epic or Cerner. You are caught between the devil the and deep blue sea.”

Portions of this article originally appeared in the Feb. 18. 2013 HISTalk Connect.

That finding comes from a report recently released by Deloitte Center for Health Solutions. The consultant group conducted in-depth interviews with 12 hospital CIOs in late 2012. The report can be accessed at the Deloitte site:

“Health System CIOs: Juggling Responsibilities, Managing Expectations.”

Although interviewing 12 CIOs does not produce a statistically significant survey, the interviews captured executive concerns.

The top priority, not unexpectedly, was “navigating the regulatory environment.”

According to the Deloitte report

They are preparing for “accountable care” driven more by competitive forces in their markets than legislative efforts vis-à-vis the ACA and others. They envision it the most significant near-term “pressure point” on their organization’s preparedness since it requires core competencies, systems, and controls heretofore not part of their organizations.

Another top priority is the need for “real-time data – clinical and administrative – that informs decisions across the enterprise.”

The report found

CIOs are realistic: they understand the risk associated with “big bets” on IT and the chorus of naysayers prone to criticize these investments. They see innovations in personalized medicine, distance telemetry, retail clinics, alternative therapies, implantable bio-monitoring devices, “smart” medical homes, and mobile health – they are keen to realize their potential as competitive advantages and conscious they will require a new set of skills and processes under their oversight. Many are apprehensive about there being enough companies and sufficient lead-in-time to build a product base across the large spectrum of need.

In looking at the future, hospital CIOs are very aware that the acute care sector is increasingly dependent on ambulatory and off-site services to manage its patients.

The inpatient business, in some markets, is already a loss leader. As a result, CIOs understand that the scope of their enterprise should embrace non-traditional settings – retail clinics, teleradiology, wellness and healthy living, hospice and skilled nursing facilities, activities in the workplace and in-home bio-monitoring, self-care devices, and so on.

A hospital’s inpatient business may be a loss leader, but it provides the largest set of measurable data for regulators and payers – and it is the “benchmark” by which the public makes decisions. Consumers don’t choose to go to UCLA rather than Cedars Sinai because of the SNFs or hospice care, they look at the US News rankings and the miracle organ transplants reported in the media.

Hospital CIOs

A brief recap:

A Dec. 1, 2010 article in the Huffington Post Huffington Post.com noted:

In 2005 the United Kingdom embarked on the largest investment ($18 billion) in health information technology in the world. Yet despite expectations that the system would increase efficiency and reduce medical errors, their efforts neither improved health nor saved money — in fact in some cases, they may have led to patient harm

Rather than create one system and beta-test it, the U.K. government depended on four companies to build the system, two of which quit or were fired for missing deadlines. So the health records were never developed in the south of England. The computer software was secret and proprietary. There was no accountability to the public, and the vendors did not provide enough technical support to clinicians having trouble using the records.

Fast forward to January 2013 and a new Conservative-led government in the UK. According to an article in Information Week

A central IT executive in the U.K.’s National Health Service (NHS), Tim Kelsey, who holds the formal title of the NHS Commissioning Board’s director of patients and information, has gone on record that English hospitals must have operational EHRs working in just over two years

We’re not in a position to put a massive investment into EPRs,” he says. “I haven’t got hundreds of millions of pounds.”

..He believes IT leaders in the NHS should take their lead from the U.S.’s network of 60 regional extension centers in accelerating the adoption of EPRs in American medical culture.

It’s a model of clinical IT adoption Kelsey sees as highly successful, and one he is going to copy. “The biggest change in adoption in the U.S. came not from the Meaningful Use billions, but when [President Barack] Obama set up regional extension centers to train doctors and managers and develop and spread sustainable business models,” Kelsey said. He seems convinced the spread of knowledge achieved by the centers was a more important factor in accelerating U.S. EPR adoption than the $9 billion so far channeled through the Meaningful Use initiative.

This is a very interesting perspective, one I think most healthcare IT executives in the U.S. would disagree with. While some RECs have trained hundreds of MDs, others have achieved little. In comparison to the $10 billion in meaningful use incentives, the REC program’s impact has been minimal.

Ironically, the same 2010 Huffington Post article that described the UK debacle (and written by two public health professors) contained a warning for US policy makers:

How do we avoid the U.K.’s failure? ..We should conduct rigorous studies of the cost-effectiveness of electronic health records systems before mandating their use. Rather than force doctors to choose from dozens of commercial software products developed in secret, we should take a hint from the non-commercial sector, such as the Veterans Administration, which uses “open-source” coding so people can work collaboratively to continuously improve the system.

The U.S. did not take that route, of course, and the U.K. is unlikely to either.