Health Care Legislation: Possible Macro Trends

It is very difficult to gauge the ultimate outcome of proposed health care legislation, but several common themes do allow one to make educated guesses on trends.

The trends:

1. A shift from plan exclusion of pre-existing illness to controlling expenditures of covered members
   
2. Rising health care costs
3. More dialogue between payer intermediaries and decisions at the point of care
4. More capitation and risk relationships with providers
5. More dynamic provider networks based on a variant of social networks and preferences
6. A shift in the delivery of health care services from physician-based practices to networks of clinicians with varying skills practicing in a wider range of accessible settings
   
7. A shift in "ROI" from short-term return to long-term value
8. A shifting responsibility from intermediaries to individuals
9. Administrative simplification
10. Pricing and quality transparency

Trend: A shift from plan exclusion of pre-existing illness to controlling expenditures of covered members

• It appears that in far fewer cases will health plans be allowed to exclude from participation those with pre-existing conditions. This is heartening to those of us who have family members with such conditions. What will be the consequences of this? In a September 22, 2006 NY Times Op-Ed article (subscription required), Paul Krugman cites a September 17 Lisa Girion article in Los Angeles Times article entitled "Sick but Insured? Think Again" and, carrying that theme, argues that the current incentive structures pit parties against the best medical interests of the individual. He states "cruelty and injustice are the inevitable result of the current rules of the game."

• Krugman makes the following claims without reference:

Between 2000 and 2005, the number of Americans with private health insurance coverage fell by 1 percent. But over the same period, employment at health insurance companies rose a remarkable 32 percent.

• These positions will be eliminated or transformed into efforts that apply actuarial skills to care management. Health plans and providers will both be forced by cost pressures to exert more influence within a specific care episode and across providers and episodes of care.
  
• Debate will grow over "minimal benefits package." What are the "basic" health care services that will be required from all payers? Publications from the Cato Institute are but one example of the dilemma faced by those who seek to define a "minimal benefits package." Glen Whitman summarizes the challenge:

If you're going to mandate something, you have to define it. Under an individual mandate, legislators and bureaucrats will need to specify a minimum benefits package that a policy must cover in order to qualify. It's not plausible to believe this package can be defined in an apolitical way. Each medical specialty, from oncology to acupuncture, will pressure the legislature to include their services in the package. And as the benefits package grows, so will the premiums.

Limiting the mandate's scope with vacuous phrases like "basic health care products and services" will not solve the problem, because what is basic to some is crucial to others. Does contraception constitute basic health care? How about psychotherapy? Dental care? Chiropractic? The phrase "medically necessary" is just as problematic, because there is no objective definition of necessity. And even if there were, it wouldn't matter, because the content of the law will be determined by the legislative process. The "basic" package might initially be minimal, but over time it will succumb to the same special-interest lobbying that affects every other area of public policy. If psychotherapy is not initially included in the package, eventually it will be, once the psychotherapists' lobby has its way. And likewise for contraception, dental care, chiropractic, acupuncture, in vitro fertilization, hair transplants, ad infinitum.

Trend: Rising health care costs

• Health care costs in general are expected to increase. One could elaborate at length on this, but it seems redundant.
  

Trend: More dialogue between payer intermediaries and decisions at the point of care

• Since intermediaries cannot exclude the sick and costs will continue to rise, an increasing emphasis on cost controls through real-time dialogue seems inevitable. EMR technology "clinical decision support" will include dialogue with intermediaries on test ordering behavior. Much as formulary requirements and prior-authorization are drivers for prescription writing, similar metrics will be applied to the use of diagnostic testing and procedures. (Think of "prior authorization" on steroids). Technology makes this possible. Those who don't adopt will see claims denied post hoc for lack of authorization or assertions that a test was unnecessary or redundant.
• Consider the following example: a practitioner encounters a new patient with anemia and chronic abdominal pain. A CT scan is ordered. The practitioner does not know that the patient received an abdominal MRI scan from a neighboring institution only a week before. Those responsible for payment have a justifiable claim in asking "wasn't that abdominal MRI scan informative enough?" and "shouldn't you have made greater efforts to obtain a report or review the study (through a health information exchange or by other means) before ordering the CT scan? Payers will have one of two broad approaches: they can either encourage the use of health information exchanges so that the provider is aware of the other test and argues for the new test, or they can post hoc deny payment for the second test. Both will happen. Certainly this pressure should promote health information exchange in one form or another.
  

Trend: More capitation and risk relationships with providers

• An inability to control costs through exclusion of pre-existing conditions will lead to a growth in service agreements between plan intermediaries and providers or coalitions. Provider coalitions - whether capitated or not - will have to increase their investments in information technology that helps them understand the quality and cost of care across providers. The focus will be on the longitudinal care of an individual rather than the service delivered for any one discrete event.

Trend: More dynamic provider networks based on a variant of social networks and preferences

• Since care will be more patient-centered, collaboration technologies more available, and (I argue) administrative mechanisms more uniform, one can imagine an evolution from static provider networks to more dynamic relationships based on community preferences and patient needs. Technology in the form of some business-related "social network" allows more dynamic relationships between buyers and sellers. One may see an evolution of the notion of competition from competition among static provider networks to more dynamic and fluid competition aimed at increasing quality and cost metrics for populations.
• Consider a population of diabetics. Health plans and providers will not doubt continue managing many individuals through static care delivery networks contracted to deliver services at certain fees of capitation levels. At the same time, they (and consumers) may also begin exploring "bids" from coalitions that coordinate care for specific individuals or groups at a pre-arranged price. These coalitions may be more dynamic and individual than the more static relationships. Two diabetics under the same employer coverage may have different networks of care that deliver agreed-upon services at a given price. Both networks create contracts dynamically under a set of business rules set by the payer. I admit, this is not only speculative, but as some of my colleagues state: "I don't understand what you are talking about."
  

Trend: A shift in the delivery of health care services from physician-based practices to networks of clinicians with varying skills practicing in a wider range of accessible settings

• The experiences of states with expanded coverage has shown that the traditional primary care based physician model is insufficient to meet demand. Accordingly, pharmacists, nurse practitioners, and many other health care professionals and individuals will play an expanded role in care delivery delivered through networks sharing clinical and administrative data. Settings will also change. Retail services - including pharmacies and retail clinics delivering a limited set of services - will complement a broader range of clinical services offered in traditional settings. Care coordination services enabled by health care technology will be essential for effective and efficient care delivery.

Trend: A shift in "ROI" from short-term return to long-term value

• An elimination of pre-existing illness barriers will eliminate the current illogical tendency to withhold short-term expenses (e.g., medication expenses) at the expense of long term costs towards the realization that within communities, shifting of consumers from one plan intermediary to another is a zero-sum game. All benefit if health care issues are addressed immediately. But this notion is at risk because of lower adherence due to consumer price sensitivity and short term incentives to optimize local costs despite legislative change. If government is a safety net, one can imagine scenarios in which care is limited because long-term sequelae will be paid for by "the government." Hypertensives, for example, need control, but if their control is poor and they ultimately require dialysis, intermediaries are off the hook and Medicare (i.e. all of us) pays dearly for earlier inattention.
• The reaction of my colleagues to this point is summarized by the statement "I don't think so." I admit that the change will be gradual, but adherence programs and wellness programs suggest such a trend is occurring, albeit slowly.
  

Trend: A shifting responsibility from intermediaries to individuals

• Health care costs will not be reined in until the individual has a better sense of what they are getting for what portion they pay. Until "everyone pays something," the moral dilemma argument is sound. Individual payment of at least a fraction of a known total cost seems essential. Regina Herzlinger's views on consumer-focused health care seem very applicable.

Trend: Administrative simplification

• Plans have "differentiated" on the basis of minor differences in procedures and plans. For example, this writer believes the number of formularies in the United States is in excess of 3,500 and the number of prior authorization variants for some drugs and procedures range in the hundereds. (Any better data would be greatly appreciated!). The unnecessary complexity of this number of formularies or prior authorization rules has been passed on to the larger "system." As margins in plan intermediaries are squeezed and greater cost-related administrative dialogues engage providers, a more simple, uniform approach will be a technical and business necessity.
• This claim is also met with skepticism, but I believe the simplification and ad hoc standardization we've seen evolve in other industries is inevitable to maintain margins. Time will tell.
  

Trend: Pricing and quality transparency

• Pricing and quality transparency - cornerstones on the last Administration, will become central as a by-product of health care reform because of the pricing pressures and care decisions that individuals and the public will be forced to make. "Rationing" will take place at the level of individual consumer decisions as well as at the level of plan intermediaries, states, and the federal government. Such "rationing" takes place now and can only be more dominant as price pressures grow. It might be "invisible" to the public rhetoric, but it will be there. The only way out of this is to make prices and value more transparent to all. Administrative simplification and greater consumer involvement will accelerate this trend (at present, it is very difficult to know exactly what the full cost of a retail prescription is, for example).

Budget Deficits

If one accepts the findings of David Leonhardt's June 9, 2009 New York Times analysis, the stimulus package and the proposed Obama initiatives in energy, health care, and education, at face value contribute only 10% to our future sea of red ink. But 10% is a huge number. In business, smaller percentages make the difference between prosperity and failure.

adapted from: David Leonhardt. Economic Scene: America’s Sea of Red Ink Was Years in the Making. New York Times. June 9, 2009.

• Follow this link to Leonhardt's article
• Follow this link for an different view from Weems and Sasse
  

The central issue may be the extent to which policies contribute to the "business cycle." This is the overall economy - jobs, productivity, markets, and the other factors that lead to social prosperity.

Perhaps its not the proposals per se. It's hard to argue against better education, health care, and energy policy. Perhaps instead its just the very real argument about how current policies will influence not only the well-being of Americans but our collective future economic prosperity.

e-Patient Dave

"....I didn't highlight a lot of administrative data. Administrative data, it is true, what we have today, but one caveat for you. You read the Boston Globe, and you will see that I have had some fun over the last two weeks investigating the nature of administrative data."

John Halmka, NCHVS, April 28, 2009

A remarkable series of public postings and articles demonstrates how people are getting the bugs out of systems. It all surrounds a self-identified cancer survivor named Dave deBronkart who is fairly unique:

• He is cared for by Danny Sands, an informatics leader practicing at Beth Israel and also employed by Cisco
• His care is provided at Beth Israel Deaconess; the inaccuracies were in transferring claims data from B.I. to Google Health. The CIO of Beth Israel is John Halamka, a national authority on health IT and an advisor to Google Health.

One would think: "If there is anyplace where things should not go wrong, this would be it." Not so. (But this writer points out that there were no adverse medical events and that the system responded very quickly to the issues).

The series begins with an April 1 posting on ePatients.net. Mr deBronkart found numerous innacuracies in his Google personal health record, primarily because the record contained a wide array of medical claims. (Read this long posting and ask again what the risks are of using medical claims as a medical record "proxy.")

• Follow this link to the posting

This in turn was picked up by the Boston Globe.

• Follow this link to the Globe article

John Halamka gave a very thoughtful answer to the concerns in his blog.

• Follow this link to Halamka's posting on April 17

On April 18, e-patient Dave was able say that the Boston Globe published an article saying Beth Israel had discontinued transferring claims data to Google Health.

• Follow this link to the Boston Globe article
• Follow this link to Dave's posting

• Follow this link to David Kibbe's comments (May 1)
• Follow this link to Roni Zeiger's (Google) response
  

Bottom line:

• Claims data do not correspond to clinical situations; one should view claims-based clincial systems with suspicion
• The Internet seems to be a great way to raise awareness and bring about positive quality control.

Joe Bugajski: The Data Model That Nearly Killed Me - what does this mean for "meaningful use"?

Danny Sands posted to Facebook a link to a blog posting (March 17) at Syleum.com written by Joe Bugasjski and entitled "The Data Model That Nearly Killed Me."

• Follow this link to the blog posting

The posting provides a very human and disturbing set of circumstances depicting one view of how things can go wrong when an information technology professional becomes ill. Although the posting addresses the "data model," within the story are examples of flawed processes, internal communication, inadequate hand-offs, and, arguably, poor communication among the patient, and the many providers who tried to help. One could argue that the right term here is "system model" where the system routinely has access to medications, allergies, laboratory tests, and other core information.

Echoing the spirit of the National Resource Center Report, Bugasjki states that "The root cause of these problems is the failure by information technology (IT) system architects to correctly capture business requirements. There also is evidence that no one ever produced a reliable conceptual data model."

He lists a number of observations - copied verbatim from his posting (but the graphics and the narrative are essential to understand his position; please read his full posting).

1. Incoherent database design isolates patient information from one department to the next and from one organization to the next. This wastes time and increases errors because medical personnel must enter patient information into a unique view of the system that corresponded to user identity and department - this prevents one medical professional from seeing patient information input by another medical professional.
2. Patient information is easily lost inside the electronic records system
3. Hard copy patient information becomes dissociated with the electronic record
4. A healthcare professional’s work pattern is not reflected in either the system design or data model - people spent considerable time searching and data reentry
5. No master data management (MDM) in evidence - Production of a consistent record of me as a patient required the ICU nurse to copy data from multiple database views into the in-patient record
6. Admitted in-patient records are treated differently by the system than out-patient or ER record only patients - no information about my medical history gathered during a prior visit to ER was available to my doctors or nurses.
7. Nurses and doctors do not have ready access to listings of pharmaceuticals which wasted much time while they searched for information about my daily medications - lists of medications in the system are limited to those at the hospital pharmacy.
8. No support existed for recording allergies differently than to ambient source and foods - Lists of allergies were not in drop down menus although these are well known by allergists and drug companies.

What Bugajski has experienced is the absence of a patient-focused care delivery system. He's shown yet another example of what happens when data are not "liquid" and available easily and securely across his many sites of care. A few elements - providers, medications, allergies, could - if made uniformly available ease the complexity and "data loss" he cites through complex system designs.

I would argue that his story is just a sampling of what needs to be done and that some simple priorities, "data utilities," and work flow patterns could ease the risk dramatically. Not everything has to be done to avoid errors and delays; if just some of the important tasks were routine and data were available, a significant majority of these concerns could be addressed because health care professionals would have far more time to think about care and less trying to understand what all has gone on.

From reading the story, it appears that he sought care at very solid institutions but that the system as a whole failed him.

Addressing simple things in a systematic way could do much to address the problem. Meeting the foundational data needs of this individual would, in my opinion, constitute "meaningful use."

Update on the MidSouth eHealth Alliance - Memphis Health Information Exchange

While national experts urge "implement now" and press releases announce early award of non-profit status, some established exchanges - Memphis included - are wondering what the big deal is about.

In May, the Memphis health information exchange funded through AHRQ and the State of Tennessee will have been in operation for three years. The Exchange is governed through data-sharing agreements based on Markle and, through the Vanderbilt Regional Informatics, have supported efforts by organizations in thirty states. The system includes all major hospitals, all consenting patients, and is used hundreds of times a day in 14 emergency departments and 14 ambulatory clinics. The major value has been in a demonstrable reduction in duplicate radiology tests and significant impact on transitions from hospitals to safety net clinics and value to hospitalists seeing newly hospitalized patients. The model is generalized and will be extended to other regions.

• Follow this link to some screen shots (demonstration data)

To us, "health information exchange" is a verb more than a noun. Our project and organizations are viewed as interim measures to build trust among providers and the public to create a secure, simple, inexpensive approach to patient-centered care. Our mantra is not "make our project sustainable" but instead "find a way to make sure that every consenting Tennessean has access to their care information whenver - and wherever - it is needed for clinical care."

To us, such a reality will be inevitable whether achieved through our approach, PHRs, or some nascent combination of policies and technologies. This writer remembers speaking of "hypertext" in 1986 and saying that in the future, people won't believe you had to go to libraries to read books and newspapers. Audiences were skeptical. Looking forward a few years, few will believe that personal health information wasn't "liquid" and available in a secure and trusted way where it is needed. Can one really envision a health care system without such data liquidity?

Returning to the Memphis Exchange, the coverage is extensive. As of April, 2009, salient metrics include:

• Total number of encounter records: 4,704,000
• Total # of patients: 1,284,000
• Total # of patients with clinical data: 1,018,000

• Estimates of monthly volume include:
• Monthly Encounter Data: 140,000
• Monthly ICD-9 admission codes (Chief complaints): 34,000
• Monthly labs: 2,400,000
• Monthly microbiology reports: 26,000
• Monthly chest x-ray reports: 35,000

Operational costs are under $3 million per year. That's less than $3 annually per person. Administrative claims data are available to some degree, but are considered by users largely irrelevant when they have access to labs, dictated reports, and other real clinical data.

But is this enough? It's not clear. The entire health care system has one primary sustainability strategy: get the health care dollars of the public first and hold on to as many of them as possible.

Is the not the absolute volume that counts, but instead the coverage for specific individuals and populations. Health care will be improved not so much by having 10% of the data of everyone as it will be when the Exchange supports care by making availble 90% of the important clinical information for specific individuals and groups. Hence a broad push into ambulatory arenas.

Governor Phil Bredesen spoke of "building version 1.0" when addressing HIMSS in 2007. That's what we are trying to do. Heavily influenced by Clayton Christensen and other innovation thought-leaders, we strive to build something simple that provides a low barrier to entry and incremental evolution as a "disruptive" approach to health care IT. We believe the standards are by and large sufficient, that value can be derived from semi-structured data, that systems can be inexpensive, and that, by and large, things are really pretty good if organizations would only focus on collaboration. Memphis isn't a final answer, but it has provided us with some insights into what it takes to improve care.

• Follow this link for a draft pdf document with additional historical details

States or Regions?

Current legislative language offers some choices between state and regional efforts. This is a sensible thing for the usual reasons:

• Change always has a strong local component
• Some regions span multiple state boundaries
• States, on the other hand, have financial and legislative frameworks regions do not.
• Medicaid is a primary driver for health care and is a state-level effort leveraged by federal FMAP funds
  

As financing models for health information exchange (the verb) evolve, it will be important to understand the tensions between regional and state effort and to learn from them. Every state (almost) has boundaries: rural vs. urban; east vs. west; up-state vs. down-state and within every state there is significant heterogeneity in cultural, policy, and technical readiness to accelerate efforts.

California - always a leader - is one state where such differences are playing out. Several blog postings and testimonies serve as a starting-point for understanding California efforts from afar.

• Follow this link to Dr. Molly Coye's March 13 testimony to the California Senate Committee on Health
• Follow this link to Will Ross' observations on the difference between local and state-wide perceptions
• Follow this link to Christine Thielst's observations and insights
• Follow this link to a newly formed California eHealth collaborative
• Follow this link to a posting about the April, 2009 HIE board
• Follow this link to the State HIE work plan
  

There are differences of opinions here, different models, different versions of success and failure, and different views on how technologies should be governed. The California eHealth Collaborative is new but represents the common collaboration among a number of accomplished efforts. CalRHIO is a more long-standing effort to coordinate these same efforts from a top-down perspective.

What is more important, perhaps, than favoring one view over another is to recognize that different views exist and that the right outcome is not clear. Clearly the balance is important.

Time to dust of your copy of the Federalist Papers. Because of the pace of economic stimulus and sense of urgency, these controversies are coming to your state soon. Hopefully, we will all learn from one another.

Physician EMR Adoption and Attitudes; and What Will Dr. Blumethal Do?

Several recent publications describe once again the large "practice variation" in EMR adoption at least as seen through the eyes of surveys. A brief overview of ARRA written by David Blumenthal provides some hints as to the direction of policy.

see:

• Weimar C. Electronic Health Care Advances, Physician Frustration Grows. PEJ. 2009 March / April, 2009;March / April:8-15.
• Jha AK, DesRoches CM, Campbell EG, Karen Donelan, Rao SR, Ferris TG, et al. Use of Electronic Health Records in U.S. Hospitals. New England Journal of Medicine. 2009 e-publication, March 25. To be published in the April 16 edition of the print journal
• Blumenthal D. Stimulating the Adoption of Health Information Technology. New England Journal of Medicine. 2009 March 25. To be published in the April 9 edition of the print journal
• See a summary from the March 25 New York Times by Steve Lohr.
  

Jha surveyed all acute care hospitals as part of an American Hospital Association annual survey. They received responses from approximately 3,000 (63%) of hospitals surveyed. The found very low rates of comprehensive use.

Carol Weimar of American College of Physician Executives has a piece that provides data on approximately 1000 respondents suggesting the "love/hate" relationship with the EMR. Quotations from the report include:

• “I feel like I hit a cliff head on and have been dragging myself to the top.” “But after 10 months, I can see the promised land.”
• “It’s expensive, difficult and essential. We would never go back. The trick is using the technology to improve the process. We’re still and will always be working on that.”
• “It was painful to implement, but I wouldn't go back to the way it was. Access to information is much faster and better, communication with patients has improved, but there has been some degradation of the office visit documentation.”
• [Adopting electronic medical records has been “the worst aspect of my 25 years in medicine. It has ruined doctor productivity, produced lower quality care and encouraged notes that are false to the point of fraud.”
• “The biggest issue is not necessarily the physician resistance—it is the administrative resistance to admitting that these are not just IT projects. They are clinical projects, just as any other process change in clinical care would be viewed.”
• “There has been little attempt to train physicians so they can use the system well. The interface between the physician and software program is cumbersome. Rather than interface the main system with a documentation system that has a proven record in emergency departments, they are using a system that the docs don’t like. Pound foolish!”
• “Don’t underestimate your partners’ anxiety in changing their comfortable ways of getting through the day. Promises of efficiency only come after hours of suffering. ‘It ain’t easy, but who said it should be simple?’”

In the same March 25 web publication issue, David Blumenthal, newly appointed National Coordinator, has a review of ARRA. Some comments in his piece (he also provided oversight for the Jha survey) are perhaps indicative of future trends.

First, he recognizes the "tight schedule" the requires the infrastructure to support HIT adoption to be in place "well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses." He rightfully states that "it takes time to develop and implement innovative federal programs, and it will take even more time to create the local institutions needed to support HIT implementation." This writer is concerned that the tight timeline may actually lead to the implementation of products in some settings that either do not meet needs or, in simplifying the complex fragmented health care payment system, actually make substantive health care reform more difficult.

Second, Blumenthal focuses on the two critical terms that will define so much: "certified EHR" and "meaningful use." With respect to CCHIT, he states that "many certified EHRs are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT." He further states that effective use will require physicians to take "advantage of embedded clinical decision supports that help physicians take better care of their patients. By tying Medicare and Medicaid financial incentives to 'meaningful use,"'Congress has given the administration an important tool for motivating providers to take full advantage of EHRs, but if the requirements are set too high, many physicians and hospitals may rebel — petitioning Congress to change the law or just resigning themselves to forgoing incentives and accepting penalties.

Third, he realizes that the full potential of EHRs will be realized only through a dramatic change in "the health care system's overall payment incentives so that providers benefit from improving the quality and efficiency of the services they provide."

These are formidable challenges. At present the carriage seems before the horse. Incentives are provided to automate a health care system whose characteristics are not well defined. Given the tight frame, this suggests only incremental changes with an increased reliance on our current means of measuring quality and receiving compensation through administrative claims. The most likely outcome of this process will not be the "disruptive innovation" Clayton Christensen and others believe is necessary but rather a refinement of the status quo. But with the rise of alternative vehicles for care like on-site clinics, alternative care providers, inexpensive generic drugs, and self-pay programs, disruptive change may happen despite the federal government rather than because of it.

ONC and the federal government face a formidable challenge and the true nature of this challenge is recognized. But the focus of past work has been primarily focused on physicians and hospitals and the emphasis has been on CPOE and clinical decision support. Little mention is made of the pressing need to create an infrastructure of laboratory, pharmacy, and other information required to enable person-centered care. Indeed, many from Harvard have published or stated publicly a great skepticism about the health information field. A closer examination of what has - and has not - taken place in Massachussetts is in order.

The skills of the individuals involved (including publications that John Glaser may join ONC as a consultant for some period), give great reason for optimism, but the outcome is far from assured. This challange and time frame is critical. Without success, we have simply automated a health care delivery system that we know needs improvement.