tag:blogger.com,1999:blog-34995178993928954302024-03-12T23:17:28.275-04:00Brian KlepperOn Health Care And Other MysteriesAnonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.comBlogger93125tag:blogger.com,1999:blog-3499517899392895430.post-3544309471778707772011-03-04T02:09:00.000-05:002011-03-04T02:09:50.542-05:00Fixing America's Health Care Reimbursement System<div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><i>First published 3/3/11 on <b>Kaiser Health News</b></i></div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">A tempest is brewing in physician circles over how doctors are paid. But calming it will require more than just the action of physicians. It will demand the attention and influence of businesses and patient advocates who, outside the health industrial complex, bear the brunt of the nation's skyrocketing health care costs.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><a href="http://www.publicintegrity.org/articles/entry/2571/" style="color: #175682; text-decoration: none;">Much responsibility</a> for America's inequitable health care payment system and its cost crisis is embedded in the informal but symbiotic relationship between the Centers for Medicare and Medicaid Services and the American Medical Association's Relative Value System Update Committee -- also known as the RUC. For two decades, the RUC, a specialist-dominated panel, has encouraged national health care reimbursement policy that <a href="http://www.graham-center.org/online/graham/home/publications/onepagers/2010/op67-income-disparities.html" style="color: #175682; text-decoration: none;">financially undervalues</a> the challenges associated with primary care's management of complicated patients, while <a href="http://economix.blogs.nytimes.com/2010/12/10/the-little-known-decision-makers-for-medicare-physicans-fees/?scp=1&sq=economix%20REinhardt&st=cse" style="color: #175682; text-decoration: none;">favoring often unnecessarily complex, costly and excessive medical services</a>. For its part, CMS has provided mostly <a href="http://online.wsj.com/article/SB10001424052748704657304575540440173772102.html" style="color: #175682; text-decoration: none;">rubber-stamp acceptance</a> of the RUC's recommendations. If America's primary care societies noisily left the RUC, they would de-legitimize the panel's role in driving the American health system's immense waste and pave the way for a more fair and enlightened approach to reimbursement.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"></div><a name='more'></a>As it is, though, unnecessary health care costs are sucking the life out of the American economy. Over the past 11 years, health care premium inflation has risen nearly <a href="http://facts.kff.org/chart.aspx?ch=1189" style="color: #175682; text-decoration: none;">four times as fast</a> as the rest of the economy. Health care costs nearly <a href="http://www.commonwealthfund.org/Content/Publications/Chartbooks/2010/Apr/Multinational-Comparisonsof-Health-Systems-Data-2008.aspx" style="color: #175682; text-decoration: none;">double</a> those in other developed nations have put U.S. corporations at a severe competitive disadvantage in the global marketplace.<br />
<div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Many health care experts believe that half or more of all health care expenditures -- the costs of bloated transactional processes as well as inappropriate procedures, service sites and prescription drug levels -- <a href="http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml" style="color: #175682; text-decoration: none;">provide no value</a>. For perspective, this year we'll unnecessarily spend nearly $1.5 trillion on health care, an amount equivalent to the national debt. Though we continually have given physicians and the health care industry a pass on this issue, its impact can be understood as the difference between our national prosperity and decline.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">The current system's under-valuing of primary care is one of three structural flaws -- the other two are fee-for-service reimbursement and a lack of cost, quality and safety transparency -- that produce excess spending and block the health care sector from working as a true market. <a href="http://healthaffairs.org/blog/2010/05/04/new-health-affairs-issue-reinventing-primary-care/" style="color: #175682; text-decoration: none;">Overwhelming evidence</a> shows that allowing physicians to serve as patient advocates and guides throughout the entirety of care results in better outcomes at significantly lower cost. Recently, patient-centered medical homes, super-charged primary care practices, have demonstrated <a href="http://www.pcpcc.net/files/pcmh_evidence_outcomes_2009.pdf" style="color: #175682; text-decoration: none;">measurable cost and quality successes</a>, also proofs of the approach. These facts are indisputable and are, by the way, the reason why America's corporations are stepping up the use of on-site primary care clinics.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Meanwhile, <a href="http://www.replacetheruc.org/" style="color: #175682; text-decoration: none;">a spate of recent articles</a> about the RUC have produced swift, strong responses within key circles. They have been passed virally among primary care physicians. Discussions have begun with people who might have influence over the process. And sensible changes in this advisory system seem possible.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Seizing that opportunity would first require mobilizing primary care doctors to demand that their professional societies, such as the American Academy of Family Physicians and the American College of Physicians, abandon the RUC. Then these physicians also would call on CMS to replace it with a more independent advisory panel. That effort would also launch a national discussion about how to more fairly value and pay for America's health care.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">But one man's waste is another's income. The current reimbursement system handsomely serves most of the health care industry: health plans; hospitals; specialists; and drug, device and technology firms. Threaten that revenue stream, and those organizations would direct their considerable resources to its protection. In 2009, records show that some members of <a href="http://www.publicintegrity.org/articles/entry/1953/" style="color: #175682; text-decoration: none;">Congress collected $1.2 billion in health care lobbying contributions</a> - more than it had ever received from an industry on an issue - from health care interests. America's 250,000 primary care physicians are simply no match for the combined power and influence of the rest of the health care industry.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">In an influence-driven government like ours, it is the non-health care business sector that has the organization and leverage necessary to drive the health care changes America so desperately needs. The health care industry represents one dollar of every six dollars in the U.S. economy, but industries outside health care represent the other five. If American businesses, led by groups like the National Business Group on Health, the Pacific Business Group on Health, the Business Roundtable, the National Retail Federation, the U.S. Chamber of Commerce and the National Federation of Independent Business were to advocate for the same policies in national health care reimbursement policy that their members are often implementing in their own on-site clinics, it would have a dramatically positive impact on the nation's physical and economic health.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Ironically, health care reform specifically avoided addressing the carnage that has been wrought by the RUC. If America's primary care physicians, backed by the nation's corporations, all working out of enlightened self-interest, were to focus on addressing this one structural defect, the corrective impact on our health system would be greater than all the reform bill's cost-reduction provisions combined.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><i>Brian Klepper is an independent health care analyst, Chief Development Officer for<a href="http://www.wecaretlc.com/" style="color: #175682; text-decoration: none;">WeCare TLC Onsite Clinics</a> and the editor of <a href="http://www.careandcost.com/" style="color: #175682; text-decoration: none;">Care & Cost</a>. His new site, <a href="http://www.replacetheruc.org/" style="color: #175682; text-decoration: none;">Replace the RUC</a>, provides extensive background on the issue.</i></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com1tag:blogger.com,1999:blog-3499517899392895430.post-89349066014638900902011-02-15T11:29:00.002-05:002011-02-22T11:32:38.380-05:00Replace the RUC<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">A few weeks ago, my writing partner David C. Kibbe and I ran an article on Kaiser Health News called “<a href="http://careandcost.com/2011/02/15/replace-the-ruc/www.kaiserhealthnews.org/Columns/2011/January/012111kepplerkibbe.aspx" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;" target="_blank">Quit the RUC!</a>“ that has caused some turmoil within the physician community, particularly in DC.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">First, it noted that the RUC, the informal specialist-dominated AMA panel, has made recommendations for 20 years about the value of medical procedures within the highly arcane and jiggered Resource-Based Relative Value Scale (RBRVS). As the Wall Street Journal recently reported, CMS (and its predecessor, HCFA) has accepted some 90 percent of its recommendations, apparently almost without question. It shouldn’t surprise anyone that the vast majority of recommendations involve payment increases to specialists that have come at the expense of primary care.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span id="more-3089" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></span><img alt="" src="http://replacetheruc.wordpress.com/wp-includes/js/tinymce/plugins/wordpress/img/trans.gif" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;" title="More..." /></div><a name='more'></a>This combination – a highly conflicted advisory panel making methodologically questionable recommendations about payment to a blithely accepting regulatory agency – is at the heart of the American health care cost crisis and the greatest reason why the American economy is literally being bankrupted by its health care costs. This year alone, we’ll spend about $1.3 trillion on health care products and services that provide no value. This is two-thirds again more than we’ll spend over the next decade on the economic stimulus package.<br />
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">David and I argued that the RUC’s outrageous behavior has been “enabled” by the ongoing participation of the primary care medical societies – the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the American Academy of Pediatricians (AAP) and the American Osteopathic Association (AOA) – whose members and whose members’ patients have been increasingly compromised – by poor primary care reimbursement, by poor quality of care systemically and by a system that favors complexity and expense – by the RUC’s actions. We called on the primary care societies to “loudly and visibly” abandon the RUC, and by doing so de-legitimize and shine a bright light on the process. We urge the RUC’s replacement by a new panel that is more independent and balanced, and less conflicted. And we advocate for the development of an alternative payment system to RBRVS that appreciates complexity but also measurable value.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">I have been working on this project with Paul Fischer, MD, a family physician in Augusta, GA who became nationally prominent for his early work against tobacco companies. I’ve known Paul for several years, and was immediately impressed by his passion about “the death of primary care.” Paul and I have developed a modest Web site, <a href="http://www.replacetheruc.org/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;" target="_blank">Replace The RUC</a>, that provides credible content about the RUC and RBRVS, as well as prepared letters that primary care physicians who agree with our position can send to their societies.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">We hope you’ll visit the site and, if you believe this is useful and important, pass it along to all colleagues who might be in our camp. This is the wonderful power of the Web, and we should use it to advantage.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">One last thought. There will be charges that this is about getting more money for primary care. It is, but that is the least of the goals. The real goal is to wring a hefty portion of the immense waste out of America’s health care system by re-empowering primary care.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; font-family: Georgia, 'Bitstream Charter', serif; font-size: 16px; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">It is impossible to overstate how important this is for the future of our country. To our minds, it should be something that all Americans, Republicans, Democrats and Independents, can agree on.</div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-9719129014195222932011-02-15T06:52:00.000-05:002011-02-15T06:52:32.096-05:00The Politics of Scarcity<div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">Larry Arrington and Brian Klepper</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">First <a href="http://www.kaiserhealthnews.org/Columns/2011/February/021111klepperarrington.aspx">published </a>2/11/11 on Kaiser Health News</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">Medicaid, along with debt and shortfalls in public pension funds, is driving state and local governments toward budgetary disasters. The ways we cope with this fiscal crisis will test our political system and our national character. Political expediencies could further compromise the lives of the sick and the disadvantaged, and risk unnecessary human suffering and social turmoil.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;"><br />
<a name='more'></a>The politics of scarcity demand leaders with a long term vision of a sustainable society who are able to sort through complex issues, competing interests and ideologies. In a poorly managed economic crisis, the vulnerable, with no strong political voice that can influence funding or public policy, are hit hardest. By contrast, successful solutions will shore up the safety net, protecting the weak while maintaining as much political and social stability as possible.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">A $360 billion annual federal and state Medicaid expenditure pays for the health care of more than 60 million low-income Americans. But the recession has generated millions of new enrollees, placing Medicaid under enormous fiscal and political pressure. Unlike their federal counterpart, state and local governments must balance budgets. They are in a full-blown fiscal crisis that will worsen when federal stimulus package subsidies end in June.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">It is easy to imagine terrible scenarios. As competition for scarce public funding intensifies, fewer vulnerable citizens qualify for Medicaid, and services available within Medicaid shrink. Stressed safety net hospitals are overwhelmed and financially collapse, transferring the care burden to community hospitals. To contain the damage, policies shift so that health care systems' care for the poor becomes purely voluntary.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">The problem is acute in our home state of Florida. Since 2007, the Sunshine State's unemployment rate rose from <a href="http://www.fcfep.org/attachments/022_FINAL%20WELL-BEING%20REPORT.pdf" style="color: #175682; text-decoration: none;">4.1 percent</a> to <a href="http://www.bls.gov/news.release/laus.nr0.htm" style="color: #175682; text-decoration: none;" target="_blank">12 percent</a> and Medicaid enrollment grew by 40 percent, exacerbating an already dire state budget shortfall. Medicaid spending consumes more than $20 billion dollars of the state's approximately $70 billion budget, and is climbing. Each of the past two years, Florida's Medicaid expenditures<a href="http://www.kaiserhealthnews.org/Stories/2010/September/08/FT-states-budget-crisis-medicaid.aspx" style="color: #175682; text-decoration: none;" target="_blank">increased</a> about 25 percent, or double the national average.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">Absent a robust economic recovery or more federal assistance, complying with reform's requirements will force state and local governments to cut eligibility and services to the extent regulations allow. Raising taxes and fees is highly improbable in Republican-controlled states. Some states have talked about getting out of Medicaid altogether.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">The new health law will further <a href="http://www.nytimes.com/2011/01/29/us/politics/29medicaid.html?_r=1&hp=&adxnnl=1&adxnnlx=1296303874-eYPXbHmrvW2sIkDEAgpMiQ" style="color: #175682; text-decoration: none;" target="_blank">increase the burden</a>, adding 16 million more Medicaid beneficiaries nationally by 2019. The feds will cover expansion costs through 2016, but then gradually transfer a 10 percent share to the states. Reform's impact on state Medicaid budgets partly explains Republican governors' fierce lobbying for congressional repeal of the health law. </div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">The various lawsuits brought by states and other stakeholders challenging parts of the sweeping overhaul, including its Medicaid expansion, also are evidence of state-level uncertainty. </div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">When it comes to Medicaid, politicians avoid characterizing the issue as "class warfare." But efforts to diminish or eliminate the program, combined with other trends bearing down on the disadvantaged, can be understood as that. Unemployment, the decreasing availability of health care, and a <a href="http://www.fcfep.org/attachments/022_FINAL%20WELL-BEING%20REPORT.pdf" style="color: #175682; text-decoration: none;" target="_blank">rising income gap between rich and poor</a> create a "perfect storm" for social unrest and political instability.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">If history repeats itself, state governments will likely shift as much cost as possible to local governments through unfunded state mandates. Coupled with continuing pressures to lower property taxes, that approach will merely push the crisis closer to home.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">All these social and fiscal trends are "counter-cyclical." As tax revenues fall, demand for services rises. These circumstances are complex and difficult to resolve. Their solutions demand strong political will combined with innovations that ensure the needy continue to have access to health and human services while holding programs such as Medicaid accountable for value.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: justify;">Of course, approaches that reflect the politics of sustainability seem like an elusive ideal. But as we're seeing elsewhere around the world, the politics of scarcity, combined with the new openness in communications, make transformative change possible. This is the opportunity in the present crisis: To use sustainable governance to transcend the politics of scarcity and to avoid the upheaval that so often accompanies it.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><a href="mailto:arrington.larry@gmail.com" style="color: #175682; text-decoration: none;" target="_blank"><i>Larry Arrington</i> </a><i> </i> <i>is a public management consultant and author. His new book </i><a href="http://www.larryarrington.com/americancovenant.html" style="color: #175682; text-decoration: none;" target="_blank"><i>Covenant in Crisis: Lessons in Democracy, Sustainability and Commonsense</i> </a><i>, is due out in 2011. </i> <a href="mailto:bklepper@gmail.com" style="color: #175682; text-decoration: none;" target="_blank"><i>Brian Klepper</i> </a><i> </i> <i>is a health care analyst.</i></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-46865696770119551382011-02-15T06:48:00.002-05:002011-02-15T21:16:57.997-05:00Quit the RUC<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">BRIAN KLEPPER and DAVID C. KIBBE</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">First <a href="http://www.kaiserhealthnews.org/Columns/2011/January/012111kepplerkibbe.aspx">published </a>1/20/11 on <b>Kaiser Health News</b></span><br />
<b><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br />
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<div class="column" style="clear: both;"><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Recently, a <a href="http://online.wsj.com/article/SB10001424052748704657304575540440173772102.html" style="color: #175682; text-decoration: none;">Wall Street Journal expose</a> and a New York Times column <a href="http://economix.blogs.nytimes.com/2010/12/10/the-little-known-decision-makers-for-medicare-physicans-fees/?scp=1&sq=economix%20REinhardt&st=cse" style="color: #175682; text-decoration: none;">by Princeton economist Uwe Reinhardt</a> detailed how vast health care resources are steered by the American Medical Association’s Relative Value Scale Update Committee -- or RUC, a secretive, 29 person, specialist-dominated panel. Since 1991, the RUC has been the main, if unofficial, adviser on Medicare physician reimbursement – how specific procedures should be valued - to what is now called the Centers for Medicare & Medicaid Services. Many Medicaid and commercial health plans follow Medicare’s lead on payment, so the RUC’s influence is sweeping.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span><br />
<a name='more'></a><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Not surprisingly, the Committee’s payment recommendations have consistently favored specialists at the expense of primary care physicians. More striking, however, is CMS’ rubber stamping of about 90 percent of their suggestions, even though, in their last three service reviews, the RUC urged payment increases six times more often than decreases.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">This arrangement has played out well for specialists, but the health system consequences have been catastrophic. One significant result has been a primary care shortage. Specialists now earn, on average, <a href="http://www.graham-center.org/online/graham/home/publications/onepagers/2010/op67-income-disparities.html" style="color: #175682; text-decoration: none;" target="_blank">$135,000 a year and $3.5 million over the course of their careers</a> more than their primary care colleagues. The income disparity has driven all but the most idealistic medical students <a href="http://www.seattlepi.com/local/378492_fewerdocs10.html" style="color: #175682; text-decoration: none;">away</a> from primary care.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"></div><div class="custominlineImage" style="clear: left; float: left; margin-right: 12px; width: 408px;"><a href="http://www.graham-center.org/online/graham/home/publications/onepagers/2010/op67-income-disparities.html" style="color: #175682; text-decoration: none;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><img alt="" src="http://www.kaiserhealthnews.org/Columns/2011/January/~/media/Images/KHN%20Features/2011/January/17%2021/kleppe400.jpg?w=400&h=250&as=1" style="border-bottom-color: rgb(214, 212, 210); border-bottom-style: solid; border-bottom-width: 1px; border-color: initial; border-left-color: rgb(214, 212, 210); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(214, 212, 210); border-right-style: solid; border-right-width: 1px; border-top-color: rgb(214, 212, 210); border-top-style: solid; border-top-width: 1px; border-width: initial; display: block; height: 250px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 2px; padding-left: 2px; padding-right: 2px; padding-top: 2px; width: 400px;" /></span></a><br />
<div class="customcaption" style="color: #666666; font-size: 10px; line-height: 13px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 5px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Figure 1. Comparison of annual income (median compensation) by physician subspecialty. Source: Phillips RL Jr, et al.; Robert Graham Center. <a href="http://www.graham-center.org/online/graham/home/publications/monographs-books/2009/rgcmo-specialty-geographic.html" style="color: #175682; text-decoration: none;" target="_blank">Specialty and geographic distribution of the physician workforce</a>: what influences medical student and resident choices? March 2009. Accessed January 4, 2010.</span></div></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Most health care professionals acknowledge the compelling<a href="http://content.healthaffairs.org/content/29/5/766.abstract" style="color: #175682; text-decoration: none;">evidence that primary care reduces cost while improving quality</a> and are chagrined by its devaluation. Susan Dentzer, editor-in-chief of Health Affairs, calls American primary care "<a href="http://content.healthaffairs.org/content/29/5/757.full.pdf+html" style="color: #175682; text-decoration: none;">horribly broken</a>." A <a href="http://www.physiciansfoundations.org/FoundationReportDetails.aspx?id=78" style="color: #175682; text-decoration: none;">2008 Physicians Foundation survey</a> found an overwhelming 78 percent of doctors in all specialties believe the U.S. has a primary care shortage. During the reform debate, advocates and critics alike <a href="http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1826" style="color: #175682; text-decoration: none;">wondered</a> whether universal coverage was practical in a system in which most primary care doctors' capacity was already saturated.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">But there is a more insidious and destructive issue at hand. The perverse incentives that are embedded in fee-for-service physician payments influence care decisions and are a principal driver of the health system's immense excesses. Encouraged by the RUC, sometimes unnecessary specialty procedures may appear more valuable and appropriate than primary care services. The system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life. The resulting waste, <a href="http://pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml" style="color: #175682; text-decoration: none;">half or more of all health care dollars</a>, has fueled a cost explosion that has led the industry and the larger economy to the <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/06/the-health-industrys-achilles-heel.html" style="color: #175682; text-decoration: none;" target="_blank">brink of instability</a>.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Even so, although the health law began a transition away from fee-for-service reimbursement, it gave short shrift to remedying the shortcomings in primary care reimbursement, offering a mere 10 percent boost, and only if office visits account for at least 60 percent of overall Medicare charges. One can speculate why primary care was mostly ignored. But the wealthier specialists, and the drug and device firms that support them, apparently had more influence over policy.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In the absence of meaningful policy-based payment reforms, the RUC's specialty bias continues to hold sway over payment policy. Dr. Reinhardt calls for a broader, more balanced, independent panel. We agree.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Given the recent attention to the issue, it is possible -- but unlikely -- that CMS will move toward that approach. The professionals and organizations that benefit from the current structure will fight to maintain the status quo.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So we propose a radical action. Quit the RUC.<br />
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America's primary care medical societies should loudly and visibly leave, while presenting evidence that the process has been unfair to their physicians and, worse, to American patients and purchasers. Primary care physicians have tried to change the process, but to no avail. Leaving would de-legitimize the RUC, paving the way for a new, more balanced process to supplant it.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">There are times when hopeful discussions and appeasement simply enable the continuation of an unhealthy situation. Abandoning and replacing the RUC would be an important first step toward re-stabilizing primary care, health care and the larger economy.</span></div><div style="font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Brian Klepper, PhD and David C Kibbe, MD MBA write together on health care issues. The views stated are their own. Although David Kibbe is a senior adviser to the American Academy of Family Physicians, this commentary is not associated with the AAFP.</i> </span></div><div><b><br />
</b></div></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-15913008261164372582011-01-13T12:04:00.003-05:002011-02-09T18:02:48.954-05:00The Year of Reform<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: 10px; line-height: 10px;"></span><br />
<h3 style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; font-weight: normal; margin-bottom: -5px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-size: small;">BRIAN KLEPPER</span></h3><div><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div><i>Originally <a href="http://www.ipractice.com/wps/portal/ipractice/industrycareer/!ut/p/c5/rc1LdoIwAADAs3AATBBCyhIIP23Q8BU2PKBWQUCxNiCnr131An1zgAE5eBlK3pzKR3Mdyg4cQK4W6x02keFiPUqYBD3GcKTjBEJzDVJwgEoRts-bt1yWoF2CLV2yySf1RIkl0TagNG4gtdR1ZKH3sLKgH0PpKzJnSDUpsZml27DbV0wAvnvtjyADOf4bEdv-jr7n7HfGWsIyiP5x3IC8qfrVVPcruML4DcqSqiIZa1h5TWlSw5l80ROxSDAiYpQFqS9LlB9cvbw5JqvjVPksv68hLvlDfhaiE8vjpOmTj_FgI0SamAy8Z0bXSAE1vKDNRl3JmrnfiPzowWIKaBJ2mTnM-ybX-t153nx4Tpwy20_TLQ7dy10883zplWkMeSUXyzyMGX9MqVgyQQC3np_v6CT8AO4CGfA!/dl3/d3/L2dBISEvZ0FBIS9nQSEh/?pcid=2f30170045211d0a83c9cfdd955e4848">published </a>12/23/10 on <b>iPractice.</b></i></div><h4 style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; display: inline; font-weight: normal; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></h4><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">“The search for static security — in the law and elsewhere — is misguided. The fact is security can only be achieved through constant change, adapting old ideas that have outlived their usefulness to current facts.”</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-align: right; vertical-align: baseline;">William Osler, MD, 1849-1919</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Even as the healthcare reform process hit snags, it had a sense of inevitability. For decades, anyone with even a modest understanding of how the current system worked could only conclude that it was too costly, delivered too little value, was fragmented in ways that often thwart quality and safety, and was an inordinate burden on the rest of the economy. It was, in a word, unsustainable.<br />
<br />
So the question was not whether change would come or not, but what forms it would take. And, of course, against this backdrop was the nagging worry, at least for doctors, that it would mean a further erosion of position: more intrusion and less say.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Perhaps it isn’t the practice of medicine, per se, that has become so challenging, but the environment of practice. The system can be complex, adversarial, and bureaucratic, wringing away the pleasure of caring well for patients.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><br />
<a name='more'></a>At the same time, it hasn’t been any less stressful for the patients and their employers. Healthcare cost, in the form of premiums, grew <a href="http://facts.kff.org/chart.aspx?ch=1189" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">four times as fast</a> as the Consumer Price Index over the last decade, according to the Kaiser Family Foundation. In the four <a href="http://facts.kff.org/chart.aspx?ch=878" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">years leading</a> up to this year’s reform, about 1 in 10 commercial health plan enrollees may have been priced out of the market and lost coverage.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Now, both policy and the market will change how the system works, hopefully for the better. Change of this magnitude, though, tends to be bumpy.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">The stated intention of the Patient Protection and Affordable Care Act (PPACT) is to lower healthcare costs while extending coverage. To get there, the legislation focused most closely on health insurance reform. This stems from the theory that premiums are the engine of the healthcare economy — health plans collect money to pay for care products and services throughout the system — and changes in the ways healthcare is funded could impact the supply and delivery of care downstream.<br />
<br />
Three provisions in the new legislation, staged over the next eight years, have promise for driving down costs. But even if those provisions are less successful in reshaping medicine, powerful new tools emerging in the marketplace should support clinical decision making, streamline and simplify administration, and reduce healthcare waste. Together, these transformational healthcare trends could significantly shrink healthcare cost while improving the quality, safety, and continuity of care.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">These innovative dynamics are almost certainly not fads. They are new paradigms taking hold because they create compelling value for those involved in healthcare. Because they have the potential to make care easier, better, and cheaper, they are gaining wide acceptance throughout the industry.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Here’s a quick overview of five changes, with some thoughts on how you may want to position your own practice.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">You can like or dislike them, but because they are designed to sweep and change the environment, you probably shouldn’t ignore them.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Healthcare Transparency</strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Increasingly, the quality, safety, and cost performance of individual physicians is being monitored by purchasers.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Commercial health plans, large employers, and employer collaboratives profile physicians to identify high and low performers. The data are often difficult, though not impossible, to come by. At present, <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/02/the-ama-wins-a-round-against-patient-information.html" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">Medicare physician data, the simplest and most logical place to look, is locked and unavailable</a>, but there are hints this could change. Self-insured employers have good data. A number of commercial interests provide quantitative physician profiling services for individuals, employers, and health plans.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Revelations from the analyzed data can be startling. <a href="http://www.google.com/url?q=http%3A%2F%2Fwww.thehealthcareblog.com%2Fthe_health_care_blog%2F2009%2F06%2Fdatadriven-health-care-an-interview-with-jerry-reeves-md.html&sa=D&sntz=1&usg=AFQjCNE2yItR6kRuirEQ7arnfbA5i0fFlA" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">Jerry Reeves, MD</a>, a prominent former health plan manager, points to as much as an eight-fold cost difference between the least and most expensive physicians to obtain the identical outcome for an episode of a specific condition in Nevada, Illinois, New York, and Pennsylvania. Documentation of this tremendous variation is a powerful wake-up call for employers who have always assumed that each physician approaches a specific problem in much the same way, and it impacts how they view selecting a physician. It should also challenge physicians to reconsider whether their practice patterns are optimal.<br />
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In some ways, the data are becoming much more available and easier to analyze. The explosion in electronic health information technologies has spawned projects that are integrating healthcare data of all types — including physician performance profiling/rating — into market and clinical decision making.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Consider these separate initiatives, all part of the same trend.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></div><ul><li>The Department of Health and Human Services, in collaboration with the Institute of Medicine, recently <a href="http://www.google.com/url?q=http%3A%2F%2Fwww.nextgov.com%2Fnextgov%2Fng_20100602_2094.php&sa=D&sntz=1&usg=AFQjCNF58tRhIr0M_Y-79nlxFFzJOgG6Rw" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">launched</a> the <a href="http://www.google.com/url?q=http%3A%2F%2Fwww.hhs.gov%2Fopen%2Fplan%2Fopengovernmentplan%2Finitiatives%2Finitiative.html&sa=D&sntz=1&usg=AFQjCNGixIvqUWtXvXluKaEKV3U20V-AVw" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">Community Health Data Initiative</a>, which will release data on a variety of topics, including smoking and obesity rates, access to healthy food, utilization of medical services, and quality of hospital treatments. The purposes are to “raise awareness of community health performance, increase pressure on decision makers to improve performance, and help facilitate and inform action to improve performance.”</li>
<li><a href="http://www.google.com/url?q=http%3A%2F%2Fhealthit.hhs.gov%2Fportal%2Fserver.pt%3Fopen%3D512%26objID%3D1325%26mode%3D2&sa=D&sntz=1&usg=AFQjCNEwZoi1lBWbe8c1K04CqUROxT6h_A" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">The Meaningful Use Rules for Electronic Health Record technologies</a> will incorporate quality measures developed by the <a href="http://www.google.com/url?q=http%3A%2F%2Fwww.qualityforum.org%2FMeasures_List.aspx&sa=D&sntz=1&usg=AFQjCNGkGACFbSarLUWtPdrYB5j3lgXODQ" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">National Quality Forum</a>, and so physician data would be far more detailed. Even if these data are devoid of patient identifiers, physicians could easily be distinguished based on unique metrics if they were to become public.</li>
<li>After a hiatus of more than a decade, medical management infrastructure is being aggressively rebuilt by virtually every major health plan to cope with the requirements of healthcare reform. Despite the plans’ continued gain using the old paradigm of fee-for-service without much oversight, more aggressive medical management approaches based on performance and value data will almost certainly become far more prominent going forward.</li>
<li>Many commercial health plans now provide an up-to-date online resource for primary care physicians who rank specialist performance.</li>
</ul><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">It may be useful to remember the economist Adam Smith’s observation that markets need information to work. The sudden availability of large amounts of comparative physician data will make healthcare into a market, which could profoundly change the ways physicians practice.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Physician Perspective:</em></strong> <em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Seek profile data through your local health systems or health plans that compare your performance to those of specialty peers. How do you rank? Think through what you might do to become a “higher performing” physician. Patients and purchasers are intent on finding objective quality, safety, and cost measures that can guide choices.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">While you may be skeptical of ranking methodologies, it may be counterproductive to assume all approaches are worthless. Still, if you have been profiled, you have a right to know the methodology used. The mechanisms for achieving transparency must be transparent as well.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Clinical Decision Support</strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">In 2003, Elizabeth McGlynn and colleagues at RAND, a research and analytics firm, published a <a href="http://www.google.com/url?q=http%3A%2F%2Fcontent.nejm.org%2Fcgi%2Fcontent%2Fshort%2F348%2F26%2F2635&sa=D&sntz=1&usg=AFQjCNGvl2QVmQyYq9QhriWvNEqklSGtEQ" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">seminal article in<em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"> The New England Journal of Medicine</em></a> showing that American adults get only about 55 percent of recommended care.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">With 40,000 new medical articles released every month, it is all but impossible for physicians to stay current. A new and gradually improving crop of decision support tools leverage data (e.g., claims, EHR, drug/PBM, lab) to provide clinicians with reminders, care gap guidelines, and best practice guidelines at the point of care. These tools are intended to support rather than supplant a clinician’s efforts, offering information for consideration. The professional caregiver retains the necessary latitude to exercise judgment that fits each circumstance.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">In a more transparent environment, as reimbursement is increasingly tied to performance, these aids will be expected to help most physicians hit targets and optimize their value in the marketplace.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Physician Perspective:</strong> Investigate and consider investing in tools — for example, those from <a href="http://www.docsite.com/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">DocSite</a>, <a href="http://www.wellcentive.com/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">WellCentive</a>, <a href="http://www.anvitahealth.com/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">Anvita Health</a>, and <a href="http://www.medai.com/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">MEDai</a> — that are built to facilitate care management with the most current knowledge and help physicians with reminders and actionable care items. Could prompts like these help improve your practice and help you achieve desired quality targets?</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Healthcare Reform’s Revival of Medical Management</strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">In November 1999, at the height of anti-managed care fervor, <a href="http://www.nytimes.com/1999/12/23/business/doctors-complain-about-promise-by-hmo.html?scp=4&sq=unitedhealth+group&st=nyt" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">UnitedHealth Group announced that their health plans would no longer do medical management</a>. Many physicians at the time complained that health plans were second-guessing their decisions. But flawed as they were, the medical management processes were bent on containing real excesses. After United’s announcement, oversight of care delivery significantly diminished. Most health plans followed suit, dismantling their medical management functions. Healthcare utilization and cost exploded. In the succeeding six years, healthcare <a href="https://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">costs rose 57 percent</a>, compared to 39 percent in the preceding six years, a 46 percent increase. As recently as 2008, <a href="http://www.google.com/url?q=http%3A%2F%2Fwww.pwc.com%2Fus%2Fen%2Fhealthcare%2Fpublications%2Fthe-price-of-excess.jhtml&sa=D&sntz=1&usg=AFQjCNFgG7793yt1ny-JzZX930YMec-Qow" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">estimates of waste</a> in American healthcare were as high as 55 percent of all healthcare expenditures.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Recognizing that a great deal of healthcare behavior is driven by health plan arrangements, the healthcare reform bill tries to incentivize health plans to reconstitute their medical management functions, reduce unnecessary and inappropriate care, and slow healthcare cost growth. The provisions call for:</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></div><ul><li>A reduction in medical loss ratios (effective 2010). That is, the percentage of premiums spent on medical claims should be no lower than 85 percent for large groups and 80 percent for small groups. Functionally, this requires insurance companies to limit the portion of premium dedicated to administration.</li>
<li>The establishment of cooperative (i.e., member-owned) health plans (effective July 1, 2013). These new structures — under the Consumer Operated and Oriented Plan (CO-OP) program — would be “owned” by their enrollees, which would give them ample reason to root out unnecessary costs. Even more important, existing insurance companies are prohibited from being involved with these health plans, which means that the legacy plans will suddenly have new market competitors.</li>
<li>A slowing of system-wide cost growth (effective January 1, 2018). By 2018, an excise tax of 40 percent will be levied on the portion of a health plan premium greater than $10,200 for an individual and $27,500 for a family. While most discussions during reform focused on taxing excessively “rich” (or expensive) health plans, as a practical matter it now appears that these rules could apply to nearly all health plans. <a href="http://facts.kff.org/chart.aspx?ch=1545" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">New data</a> from the Kaiser Family Foundation/HRET 2010 Employer Health Benefits Annual Survey show that 2010 premium growth for family health plans slowed dramatically, rising only about 3 percent this year. If annual health plan cost increases remain at 8.2 percent until 2018, as they have for most of the past decade, then they'll avoid the Cadillac tax. But if they rise much at all beyond this, to 9.1 percent, they’ll trip the threshold and the tax penalties will be significant.</li>
</ul><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">This provision is designed to encourage health plans to reestablish and aggressively pursue medical management that can reduce healthcare cost growth. On the other hand, the provision also states that, if healthcare costs have risen more than expected, Congress can relent.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">All three of these initiatives should result in a renewed interest in clinical appropriateness and medical management. The belief that much of current healthcare activity and cost is unnecessary will drive efforts by purchasers and payers to clamp down on what they perceive as excess, when compared to evidence-based benchmarks.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Many physicians will see these initiatives as onerous and intrusive, and there will undoubtedly be pushback. But the reality is that healthcare’s historical cost growth is destabilizing both the industry and the larger economy. When push comes to shove, it will be the industry that is forced to moderate its behaviors.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Physician Perspective:</strong> The legislation prompts several questions:</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></div><ul><li><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">“Am I practicing as efficiently and effectively as I could?”</em></li>
<li><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">“Are some elements of my care — e.g., laboratory tests, advanced images — simply there to boost my income? Are others based on preferences rather than hard data?”</em></li>
<li><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">“If my success was tied to ‘value’ targets, how would I fare?”</em></li>
<li><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">“If my patients’ costs (e.g., severity-adjusted episodic costs) and outcomes (e.g., postsurgical readmission rates) were compared to those of other physicians within my specialty, locally and nationally, how would I rank?”</em></li>
</ul><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">As healthcare becomes managed more like a market, driven by both policy and economic forces, these questions will become increasingly compelling.<br />
<br />
<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Value-Based Benefit Design</strong></em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">The idea that health plans should reward proven approaches and discourage unproven ones is spreading like wildfire, especially among large employers. Spearheaded by organizations like <a href="http://www.google.com/url?q=http%3A%2F%2Fwww.vbhealth.org&sa=D&sntz=1&usg=AFQjCNFEn87qDwgkd_DdT2SssmOI3fOYEg" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">the Center for Value Health Innovation</a>, health plans will increasingly design benefits that tightly link reimbursement to medical evidence, and that reward both positive outcomes and efficiency. This paradigm is diametrically opposed to fee-for-service reimbursement, which financially rewards the delivery of more products and services, independent of appropriateness. Getting it right may require retooling many aspects of practice.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Examples of how this might play out?</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></div><ul><li>Install a stent into a stable heart patient and the plan might reimburse you a fraction of what you’re used to.</li>
<li>Get rewarded for addressing and eliminating patient care gaps — e.g., HbA1c’s for diabetics; Pap smears for women; PSAs for men. Leave gaps unaddressed, and you may be penalized.</li>
<li>Self-referred advanced images are more likely to be scrutinized and severely discounted. (In June 2009, a <a href="http://www.medpac.gov/chapters/Jun09_Ch04.pdf" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">Medicare Payment Advisory Commission (MedPAC) report</a> to Congress found that, in 2005, “episodes with a self-referring physician are associated with greater imaging spending than episodes with no self-referring physician, controlling for differences in patient severity level, geographic market, and physician specialty.”)</li>
</ul><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Physician Perspective:</strong> Investigate and contact any local health plans that claim to have value-based designs. Think through how you might practice differently if fee-for-service reimbursement went away, and your practice’s success became more significantly bound to your ability to deliver measurably high-quality and efficient care. Determine how your specialty and practice might change positively and negatively if you were to adhere strictly to guideline-driven practice.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Medical Homes</strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Medical homes are more than just places where patients can turn for information and concerns. Primary care physicians in medical homes are patient advocates and guides, rather than the gatekeepers for managed care. Some, like on-site employer clinics, have moved outside fee-for-service reimbursement, which allows them to escape volume-based visit schedules. <a href="http://content.healthaffairs.org/cgi/content/full/29/5/779?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=primary+care&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT#SEC2" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">Reduced patient loads let primary care physicians explore and manage more complex problems without referring</a>. </div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Medical homes make use of a variety of tools, programs, and incentives to optimize care. They use analytics to identify which patients have risks or potential care gaps. Patients with chronic diseases —<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497638/pdf/15158105.pdf" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;"> who account for as much as 75 percent of healthcare expenditures nationally</a> — are paired with an on-site disease management nurse, who works with the physician to provide regular face-to-face counseling. At least one study has shown this approach to <a href="http://www.idph.state.ia.us/hcr_committees/common/pdf/clinicians/savings_report.pdf" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">be one of the most effective methods</a> for producing lifestyle behavioral change.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Medical homes may provide free access to primary care, drugs, and labs, so that patients have no financial reason to resist going to the doctor or taking their medicines. They take advantage of clinical decision support tools to help ensure clinicians deliver the most appropriate care at the right time no matter how obscure the medical condition presented or how new the appropriate data-driven guidelines may be.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Perhaps most important, good medical homes reestablish a collaborative working relationship between the primary care physician and the specialist. This means open communication and sharing of information. This approach also establishes a line of accountability from the specialist back to the primary care physician.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Physician Perspective:</strong> If you’re a primary care physician, check the <a href="http://www.ncqa.org/Portals/0/PCMH%20brochure-web.pdf" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #333333; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">National Committee for Quality Assurance (NCQA) criteria</a> to see whether your practice could qualify as a medical home. If you’re a specialist, think through how you might best collaborate with a PCP to help optimize care through a medical home.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Consider what new tools, programs, incentive structures, or skill sets might enhance your ability to manage patients, and think how you might practice differently if, for example, patients could come to you for free, or receive their labs for free.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Imagine what opportunities could arise if you knew, using analytics, which patients had chronic disease or were likely to have a major acute event over the course of the next year. Look into gaining access to new technologies, and then imagine how they might alter the workflow of your practice.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Consider the impact if you were to add a nurse whose job was to manage patients with chronic disease.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Finally, investigate whether local health plans or employers are willing to reimburse you to manage patients in this way, so you can make this shift toward delivering better care to your sickest patients.</em></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Working with Change</strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">The healthcare marketplace is being transformed by the simple fact that cost has exceeded the ability of individuals, employers, and governments to pay for it, leaving too many patients with inadequate care. The recent reform bills are likely to have sweeping consequences. It’s not easy to adapt, but embracing change may be easier if you seek out solutions in the emerging market to seize on the opportunities for positive change by creating improvements in quality, safety, and cost. New technologies are being developed for analysis, communications and decision support, data collaboratives, mechanisms that re-empower primary care, clinical decision support — all with tremendous promise for helping you deliver better, more efficient care.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">But at the same time, these new approaches, combined with a powerful, if gradual, transition away from fee-for-service reimbursement and toward an emphasis on results, will almost certainly change the fundamental nature of most practices, as well as the ways patients interact with physicians. Not all these changes will be welcome, but there is no question that many are direly necessary and overdue.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">If you agree with the aphorism that “the only constant is change,” then the only path is to adapt. I believe the most successful professionals will be those who embrace the coming changes and learn to be distinguished within them.</div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; color: #515151; line-height: 1.3; margin-bottom: 10px; margin-left: 0px; margin-right: 0px; margin-top: 10px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">What do you think of the changes produced by reform? Click “Comment or ask a question” to add your thoughts.</div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-41775054040968753122011-01-13T11:54:00.001-05:002011-01-13T12:05:36.073-05:00Unfreezing the Health IT Market<span class="Apple-style-span" style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 20px;"></span><br />
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-family: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">DAVID C. KIBBE AND BRIAN KLEPPER</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><i><span class="Apple-style-span" style="font-family: inherit;">Originally <a href="http://healthaffairs.org/blog/2011/01/12/unfreezing-the-health-it-market/">published </a>1/12/11 on Health Affairs Blog</span></i></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;"><em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Washington Post </em>columnist Ezra Klein recently <a href="http://www.washingtonpost.com/wp-dyn/content/article/2010/12/30/AR2010123004626.html" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;" target="_self">described</a> the Obama administration’s consistent efforts to improve troubled private markets:</span></div><blockquote style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-color: rgb(221, 221, 221); border-left-width: 5px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #777777; margin-bottom: 0px; margin-left: 10px; margin-right: 30px; margin-top: 15px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 20px; padding-right: 0px; padding-top: 0px; quotes: none; vertical-align: baseline;"><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">Isolate the eight key economic decisions of the Obama presidency: The intervention in the financial sector, the intervention in the auto sector, the intervention in the housing sector, the stimulus package, the health-care bill, financial regulation, and the tax deal…Where there was a market that they considered functional-but-frozen, they worked to unfreeze it.</span></div></blockquote><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></div><a name='more'></a><span class="Apple-style-span" style="font-family: inherit;">Intervention into health IT should be added to this list. Nowhere has this administration’s activities to unfreeze private markets been more dramatic than in the health IT products and services sector, especially for electronic health records (EHRs). </span><br />
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">When the President was elected, <a href="http://www.zdnet.com/blog/healthcare/to-cchit-or-not-to-cchit-is-the-question/1559" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">this market was dominated </a>by the vendor-controlled Certification Commission for Health IT (CCHIT). The entry rules were intentionally complex and expensive, safeguarded by an interlocking system of standards organizations and both open and clandestine industry alliances that defended against innovation and new entrants.<span id="more-8620" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></span></span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">By 2008 it had become so obvious that the EHR market was functional-but- frozen that a website arose for a fictitious EHR brand, <a href="http://www.extormity.com/index.html" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">Extormity</a>, and gained a widespread following. With a byline of “<em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Expensive, Exasperating, Exhausting</em>,” the site lampooned legacy EHR vendors with heavy satire. In a fake press release, Extormity’s management promised to mirror and at the same time out-do CCHIT. They would create</span></div><blockquote style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-color: rgb(221, 221, 221); border-left-width: 5px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #777777; margin-bottom: 0px; margin-left: 10px; margin-right: 30px; margin-top: 15px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 20px; padding-right: 0px; padding-top: 0px; quotes: none; vertical-align: baseline;"><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">a new, completely independent association known as <a href="http://www.extormity.com/index.php?option=com_content&view=article&id=65" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">SEEDIE</a> – the Society for Exorbitantly Expensive and Difficult to Implement EHR’s. We created standards that we knew we could promote and adhere to, and we are now fully SEEDIE certified. Several other colossal, slow and unresponsive EHR companies have joined SEEDIE, giving medical practices, hospitals and clinics a number of costly and combative EHR vendors to choose from.</span></div></blockquote><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">And it was indeed a small number. In 2009, at the height of CCHIT’s certification dominance, it had “certified” fewer than 40 EHR products, a handful of which had cornered the small but lucrative market — about 20 percent of physicians and fewer than 10 percent of hospitals. Pricing for these vendors’ ambulatory products could be as high as $50,000 per physician the first year, with 15-20 percent annual maintenance fees subsequently. Hospital EHR contracts routinely ran into the tens of millions of dollars during the first years of implementation.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">Breaking The Ice</span></strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">Contrast this with early 2011, after administration of certification rules had been transferred to the Office of the National Coordinator for Health IT (ONC) inside the Department of Health and Human Services (HHS). Now more than 200 EHR technology products have passed ONC certification, and can be used by physicians and hospitals participating in the incentive programs that reward “meaningful use” of EHR technology. Three-quarters of these are complete EHRs and/or EHR “modules” for the ambulatory care space, nearly<em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"> four times</em> the number of EHRs certified under the old regime.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">Many newly-certified ambulatory EHRs are web-based and sold by subscription, with minimal up-front costs. Industry pricing is now nearly an order of magnitude less than before, with fees in the $150-$400 per physician per month range. A couple of these products are ad-supported, and free of <span style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline; vertical-align: baseline;">any</span> fees. A handful have been designed to run on mobile devices, such as the iPad, and iPhone and Android smart phones. And, almost overnight, <a href="http://en.wikipedia.org/wiki/Cloud_computing" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">cloud-based computing</a> has come to dominate the emerging EHR technology market.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">None of this could have happened without the Obama administration’s intervention, which included coordinated actions by the staffs at ONC, the Centers for Medicare and Medicaid Services (CMS), the National Institute of Standards and Technology (NIST), and the White House IT team. The 2008-09 health IT market environment – low penetration and sales, expensive products, predominance of older client-server architectures, extensive barriers to entry – was at odds with the administration’s goal of rapid EHR adoption, considered necessary to both improve quality and lower costs of care. Nor was it consistent with Congress’ intentions, expressed through the Health Information Technology for Economic and Clinical Health (HITECH) portion of the American Recovery and Reinvestment Act (ARRA) of 2009. That bill included more than $20 billion in incentive payments for doctors and hospitals as part of an ambitious national effort to modernize health care’s IT infrastructure.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">When Obama’s health IT team took office, the market was unable to satisfy these policy objectives, So they set about to change the market with a series of deft moves that almost no one expected.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">How They Did It</span></strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">First, they overturned the industry ‘voluntary’ EHR certification process, replacing it with one based on internationally accepted procedures. This established a competitive landscape where private companies – transparently credentialed by the government – would compete on price and service.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">They increased the number of ONC accredited certifying and testing bodies (ACTB), creating competition where once there was a bottleneck. There are now six – count ‘em – organizations doing certification and testing.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">They endorsed a modular approach to EHR technology design, specifically permitting EHR modules to be certified under the new certification and testing regime. Modularity, among other things, makes it easier for developers to focus on a particular set of functions – e.g. e-prescription or quality reporting – and bring those products to market more quickly.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">They insisted on health data exchange standards that included the market-tested <a href="http://www.centerforhit.org/online/chit/home/project-ctr/astm.html" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">Continuity of Care Record (CCR) standard </a>that emphasizes XML and simplicity. This broke the near monopoly that the HL7 standards organization has enjoyed with respect to data formats used for transporting clinical content.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">They funded research that explicitly seeks to move the market towards innovative approaches developed outside health care, including the establishment of <a href="http://www.smartplatforms.org/2010/11/us-cto-aneesh-chopra-announces-the-smart-health-app-5000-challenge/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">a plug-and-play “medical app store</a>,” based on the Apple iPhone/iPad App Store.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">They collaborated in the writing of the PCAST (President’s Council of Advisors on Science and Technology) <a href="http://www.whitehouse.gov/sites/default/files/microsites/ostp/pcast-health-it-report.pdf" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">recommendations</a>, including a “universal health data exchange language” in XML that would accelerate the pace of interoperability among EHR technologies.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">And they initiated <a href="http://directproject.org/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3333cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">the Direct Project </a>to create the protocols and specifications necessary for simple, secure, and affordable e-mail exchange between doctors, and between doctors and patients. This approach will dramatically advance the number of physicians capable of meeting MU requirements for health data exchange.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">A Fast And Sustainable Intervention</span></strong></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">The administration’s intervention in the health IT market has been lightning fast, in large part because it’s policy imperative came from Congress and the ARRA/HITECH timeline. It also owes much of its speed to the liberal amounts of money that Congress approved, some of which ONC/CMS has been able to spend right away. That these trends are likely to be sustained is due to the fact that much more money has been committed over the next 5 years on EHR incentives to physicians and hospitals.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">It’s important to note that the administration did not choose to take over the health IT market, for example, by requiring all doctors to use a particular brand of EHR owned by the government. This was proposed by more than a few observers who had grown frustrated with the lack of adoption, but it would not have worked well. Instead, the Obama team chose to unfreeze the health IT market, to improve its dynamics and its offerings. </span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 16px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: inherit;">And the result, so far, are impressive. The new wave of EHR technologies, by themselves, won’t fix American health care. But they provide a common foundation for information capture, exchange, storage and analysis that will be transformative, enabling a new era of care quality and cost that would be unachievable without it. The scope and importance of this approach are breathtaking, and could not have occurred if not for the leadership and guidance of the Obama administration and its health IT team.</span></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-228865586031992492011-01-07T06:59:00.003-05:002011-02-22T11:34:09.201-05:00Why Everyone Should Experience the Holocaust Exhibition<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">January 07, 11</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">First <a href="http://careandcost.com/2011/01/11/why-the-holocaust-exhibition-should-be-part-of-everyones-experience/">published</a> in the <b>Florida Times Union</b></span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">An extraordinary traveling exhibition and lecture series from the US Holocaust Museum, <em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><a href="http://careandcost.com/2011/01/11/why-the-holocaust-exhibition-should-be-part-of-everyones-experience/www.ushmm.org/museum/exhibit/online/deadlymedicine/" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;" target="_blank">Deadly Medicine: Creating the Master Race</a>, </em>is in my community now. The presentations describes the events leading up to the arrest of Jews and other minorities in Nazi Europe in the 1930s and 1940s, and then the depraved acts – medical experiments and genocide – that were carried out in the name of “cleansing.” There can be a tendency among Jews, like me, to focus on our own victimization, but there is a larger message and opportunity here.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span id="more-2160" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></span>It would be a mistake to think that this exhibition is only about Jews or Germans. Rather, it is about a deep sickness that all societies – even the most enlightened – can fall prey to. In recent years alone, we’ve seen horrific mass murders in Nigeria, Bosnia, Cambodia, Uganda, Armenia, Rwanda, Sudan, Congo and throughout South America, always as more stable nations stood by and watched.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">There are patterns that typically occur before and after these disasters. The persecuting groups organize in ways that make them more powerful and effective. They portray the people they hate as threats, inferior, less worthy, unfeeling and sub-human. As atrocities become known, they orchestrate messages that deny any wrongdoing and deflect blame back onto their victims.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><br />
<a name='more'></a><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">As the campaigns get stronger, the assumptions about the victims become more mainstream and the boundaries of behavior change. Acts of violence that, in normal times, would have been considered outrageous, even criminal, grow organically and become acceptable. The societal rules that limit our actions are perverted or go by the wayside. All bets are off on the ways people behave toward one another.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Until the late 19th and early 20th centuries, Germany was among the most advanced, open, enlightened societies in Europe. Jews thrived there for hundreds of years. Hard work allowed many to attain positions of comfort and respect. But as difficult economic times emerged, they became easy to blame. Restrictions began, minor at first, but then grew, eventually becoming catastrophic.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">It is hard to not worry about this kind of process here at home. We have a passionately bitter political environment, leveraged 24/7 by politicians and pundits. Many groups – minorities, gays, immigrants, Muslims, the poor – are stereotyped and portrayed in threatening terms. It becomes easy to lump them together. And sometimes the discussions edge dangerously to excess. It may be that <a href="http://www.nytimes.com/2011/01/10/us/politics/10giffords.html?hp" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;" target="_blank">Saturday’s Tucson attack </a>was related to just this kind of sentiment.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The Holocaust Exhibition will not be pleasant. For most of us, its images and ideas will directly conflict with our deeply held sense of fairness and justice.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">But it carries a profoundly important message that we all should hear. All nations, ours included, are capable of the kinds of acts carried out by the Germans. All people can lose their moral balance, and do things that their great-grandchildren will be tainted by and ashamed of for life.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The perpetrators will always believe that they’re right, that their actions are justified.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So, informed by the overwhelming evidence in history, it falls to the rest of us to resist.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #333333; line-height: 24px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The mission, then, is safeguarding our society, its values and all those within it. The Holocaust Exhibition provides a very focused window into what happens when that mission fails.</span></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-75239943701605035832010-12-07T03:37:00.002-05:002010-12-07T03:41:00.205-05:00Book Review - The Emperor of All Maladies: A Biography of Cancer<span class="Apple-style-span" style="font-family: inherit;">BRIAN KLEPPER<br />
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<i>Originally published on Care & Cost <a href="http://careandcost.com/2010/12/05/book-review-the-emperor-of-all-maladies-a-biography-of-cancer-by-siddhartha-mukherjee/">here</a>.</i><br />
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The opening page of Siddhartha Mukherjee’s The Emperor of All Maladiesbegins with a quote by Susan Sontag that is so on-point, yet so rare and fresh, that one can’t help being excited by the prospect of what’s to come.<br />
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<i>Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship in the kingdom of the well and in the kingdom of the sick.<br />
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Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.</i><br />
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You open the book with great expectations. It is weighty, yes – 570 pages, 100 of which are end notes – but beginning, you immediately find its expansive scholarship wrapped in a writing style so fluid and lyrically engaging that it instantly dispels any hesitancy, and you are captured.<br />
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</span><br />
<a name='more'></a><span class="Apple-style-span" style="font-family: inherit;">The scope of Mukherjee’s effort is breathtaking. A marvel of organization and narrative flow, Emperor is literary drama, history, mystery, science, with literally hundreds of anecdotes reaching back through the breadth of recorded world history and across an astonishing array of disciplines, each element of content so precisely and vividly drawn that it is accessible to any intelligent lay person. There is Atossa (550-475 BC), the Persian daughter of Cyrus the Great, wife of Darius and mother of Xerxes, whose cancerous breast finally brings her to turn away from court physicians and command her Greek slave to cut it off. She survives.<br />
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There is the endless stream of seekers, filled with heroism or hubris, who, step-by-step, uncover truths about the disease and its mechanisms. Some, like Marie and Pierre Curie, pay a steep price along the way, discovering, in their case, that the radiation that can curb cancer can also bring it on. Others, like the Scottish surgeon Joseph Lister, would, in trying to cope with the infections that accompanied so many of his operations to remove cancer, find that carbolic acid can transform all surgeries. Or Sidney Farber and Mary Lasker, who unite in a decades-long campaign to find a universal cancer cure.<br />
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Perhaps most awe-inspiring is Mukherjee’s careful descriptions of the unfolding science of cancer, the constant search for silver bullets. In recounting the history of chemo-therapy, he muses:<br />
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<i>Every drug, the 16th century physician Paracelsus once opined, is a poison in disguise. Cancer chemotherapy, consumed by its fiery obsession to obliterate the cancer cell, found its roots in the obverse logic: every poison might be a drug in disguise.</i><br />
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The stakes are so great, and this realization so promising, vast and potentially lucrative, that it seeded a strategic shift in the way we attack the disease. Even so, the cancer cell’s remarkable ability to thwart by adaptation has continued to provide transformational revelations, precipitating advance upon advance in both our knowledge and our treatment tactics.<br />
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Still, it is cancer’s resilience, its ability to evade, adjust and grow, that causes Mukherjee to observe that cancer cells seem “a more perfect version of ourselves.” But this is always with an awareness that cancer is ultimately about the destruction of life, not its continuance.<br />
<br />
And this, his humanity, is one of Mukherjee’s greatest strengths. He never forgets that, at base, cancer is a catastrophic affliction that descends capriciously and violently on unsuspecting patients and families, laying waste to everything. Six hundred thousand Americans and 7 million people worldwide will perish from it this year. It is the attempt to do something, anything, to relieve that suffering, that has motivated efforts for centuries, and that has mushroomed into a mammoth 21st century commercial enterprise that dominates much of the American health care landscape.<br />
<br />
Emperor is a great, once-in-a-decade book of unimaginable mission-driven ambition. It succeeds first by painting a kaleidoscope of the dimensions that cancer resides in, including the science that everyone touched by the disease pins their hopes on.<br />
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But it succeeds most deeply by rendering an entire universe, located around a pervasive, cruel and brilliant adversary, in which we find the commonalities – strengths, failures, desires, fears, foibles, and very occasional successes – that render us all human.</span>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com1tag:blogger.com,1999:blog-3499517899392895430.post-14638086398713031812010-12-03T15:30:00.003-05:002010-12-07T03:38:25.716-05:00Toward A Healthier America<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">BRIAN KLEPPER and DAVID KIBBE</span><br />
<i><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
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<i><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Originally Published 12/1/10 on <a href="http://careandcost.com/2010/12/01/609/">Care & Cost</a></span></i><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span><br />
<i><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Note: This article was published to frame the approach that David Kibbe and I have in developing our new national health care professional forum, <a href="http://www.careandcost.com/">Care & Cost</a>. </span></i><br />
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<i><span class="Apple-style-span" style="color: #333333; font-style: normal; line-height: 24px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"></span></span></i><br />
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">It’s not that we don’t know what’s wrong with health care or how to fix it</strong><span style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #4789cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">.</span> The problem, instead, is how to change a system rigged to protect industry excess over care and cost.</span><br />
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</span><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"></span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">As we begin this forum, we see American health care edging closer to a cliff and dragging the larger American economy with it. The health care cost bubble, inflated by duplication and waste, is poised to pop. At the same time, the industry’s bloat has encouraged innovation, driving improvements in quality, safety and cost throughout health care.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span id="more-609" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"></span></span><br />
<a name='more'></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Consider this: <a href="http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Credible sources</a> now estimate that half or more of all health care expenditures are unnecessary or provide no benefit to care. (This amounts to at least $1.3 trillion in 2010. Or, annually, it’s just short of double the stimulus package cost over the next ten years.) For a decade, health care – which represents one dollar in six and one job in eleven in the US economy – has <a href="http://www.businessweek.com/magazine/content/06_39/b4002001.htm" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">absorbed</a> most of the nation’s economic growth. During that period, health care premium inflation grew <a href="http://facts.kff.org/chart.aspx?ch=1189" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">four</a> times faster than the US economy, and per capita costs were <a href="http://facts.kff.org/chart.aspx?ch=359" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">double</a> those of every other developed nation. It is an industry wildly out-of-control.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Against the backdrop of these skyrocketing costs, both public and private purchasers may finally be reaching the limits of their capacity or willingness to pay. In 2010, employers, whose health plan sponsorships pay for nearly half of all care, appeared to draw a line in the sand, <a href="http://online.wsj.com/article/SB10001424052748703431604575467902840224786.html" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">passing along</a>, as a group, all health plan cost increases to employees. Nearly a third <a href="http://articles.latimes.com/2010/sep/02/business/la-fi-healthcare-costs-20100903" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">reduced benefits or increased employee out-of-pocket expenses</a>, and, compared to recent years, the erosion in health plan enrollment <a href="http://www.epi.org/publications/entry/decline_in_employer-sponsored_health_coverage_accelerated" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">tripled</a>.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Similarly, Medicare and Medicaid have become our national budget’s fastest growing cost component, with <a href="http://www.cbo.gov/doc.cfm?index=11579" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">the potential to stifle expenditures</a> for other mission-critical national needs, like education and infrastructure.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Meanwhile, the vast health care industry and it’s allied interests have become our largest and most influential lobbying group, with campaign contributions of $1.2 billion during the 2009 reform proceedings. Worried that the Affordable Care Act’s (ACA) provisions – e.g., Cadillac tax, Accountable Care Organizations, reimbursement pilots – would <a href="http://www.kaiserhealthnews.org/Columns/2010/September/092010klepperkibbe.aspx" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">reduce reimbursement </a>from payment for every product and service to payment only for what’s appropriate, they have continued to <a href="http://www.bloomberg.com/news/2010-11-17/insurers-gave-u-s-chamber-86-million-used-to-oppose-obama-s-health-law.html" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #0066cc; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">campaign</a> against it’s survival.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The politicized firestorm surrounding ACA’s provisions – Medicare cuts, the impending Sustainable Growth Rate (SGR) physician payment reductions, comparative effectiveness research and other efforts to control costs – vilifies the reform law’s intent but does not acknowledge the most obvious and straightforward fact behind the need for reform: we simply can’t afford health care in the future the way we’ve bought it in the past.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The result is a clash between an irresistible force, overwhelming cost, and an immovable object, an entrenched industry making historically high profits. At stake is the stability and sustainability of both the current health system and our national common economic interest.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">It isn’t all bad news, though. Even as the system strains, every part of health care is experiencing an explosion in innovation. Supercharged by tremendous advances in health IT, bio-tech, analytics, clinical decision support, surgical procedures, and many other areas, new ventures are promising to significantly drive down cost while improving quality. There can be no vibrant market for this innovation until our payment system changes, however.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">America cannot be great again until we get health care costs under control. That will not happen until we have national policy, combined with individual, business, and community action, that focuses on restoring the health of our people, rather than on the excessive enrichment of an industry. Unless, of course, that industry, greedy and blind to the public good, brings about its own crash.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Care and Cost (C&C) will be a forum that unblinkingly asks the questions: How, specifically, can we make health care stable and sustainable again? How can we lower costs, but avoid bankrupting the industry? How can we broaden access to medical care, so we get a healthier populace? How can we improve the quality and safety of that care? And how can we take back our lawmakers from lobbyists, and return to policy that is, first and foremost, in the common, rather than the special interest.</span></div><div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; margin-bottom: 24px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">We believe America is capable of understanding that there ARE answers that make sense, that we can work our way out of the health care crisis. Recovering will require leadership, commitment and hard choices, yes, but inaction, the alternative, can only lead to the status quo.</span></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-17924709333134697202010-12-03T15:26:00.001-05:002010-12-03T16:15:23.187-05:00Clinics As Health Care's Transformational Engines<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">BRIAN KLEPPER</span><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Originally Published 12/1/10 in Medical Home News</span><br />
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<div align="center" style="margin-bottom: 0.0001pt; margin-left: 0in; margin-right: 0in; margin-top: 0in; text-align: -webkit-auto;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;">The recent explosion of interest in onsite clinics - not just by employers, but by health plans, hospital systems, public health programs, and others - is anything but just another health care fad. At once, clinics’ growing popularity signals purchasers’ weariness with an intransigent, self-interested health system, as well as their guarded optimism about a better way.</span><span style="color: black;"><br />
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</span><span style="color: black;"></span></span><br />
<a name='more'></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span style="color: black;">Today’s best clinics are single-mindedly focused on what works best for the patient and purchaser within a competitive health care marketplace. They are a return to the hard-learned care management lessons of the last several decades. They look like what experienced health care professionals would develop if they could start fresh, without the perverse incentives that drive so much of health care today. But by leveraging new tools, programs and incentives, they also create a uniquely powerful, contemporary design for managing care and cost.</span><span style="color: black;"><br />
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</span><span style="color: black;">It would be a mistake to confuse the onsite clinics of the past 25 years with those incubated over the past five. For most of their history, onsite clinics were favored only by large companies with money to burn. Palatial and convenient but without much in the way of modern management tools, the care typically was modeled on an old-fashioned doctor’s office. Many of these clinics were friendly and employees loved them, but often they were more designed to handle walk-in care than life management issues. In most cases, though, it was impossible to demonstrate that the quality of care was better than out on the network. It was also rare for a clinic to produce a quantifiable return on the investment.</span><span style="color: black;"><br />
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</span><span style="color: black;">Not so anymore. A new generation of on-site clinics firms has streamlined physical plants but expansive capabilities. In addition to providing comprehensive primary care, they are fully-realized medical homes and integrated medical management engines. They produce documented quality improvements and savings using a variety of techniques: Rx step therapies, empowered primary care that reduces specialty visits, data-driven decision-support, chronic disease management, influence over downstream care, referral into high performance networks, occupational health management. There are many variations on the theme, but most modern clinics incorporate medical management located at the front end of the care delivery system, where it can get the most traction over the rest of the continuum.</span><span style="color: black;"><br />
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</span><span style="color: black;">The results, nearly (but not quite) unilaterally, range from promising to astounding. In a </span><span style="color: black;"><a href="http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml"><span style="color: #000099;">system rampant with waste</span></a></span><span style="color: black;">, most clinic firms claim to improve quality while saving money. Some show very significant, verifiable savings immediately upon implementation, as much as 30 percent in group health, and equally significant (though harder to measure) impacts in occupational health. They undeniably encompass a better way to organize and manage care delivery.</span><span style="color: black;"><br />
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</span><span style="color: black;">Two great leaps forward are the foundation of this new approach. </span><span style="color: black;"><br />
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</span><b><span style="color: black;">Start by Realigning the Incentives</span></b><span style="color: black;"><br />
</span><span style="color: black;">Clinics gain the high ground, first, by rejecting fee-for-service reimbursement, the heroin of the health care industry, which insidiously promotes excessive care in the service of revenue generation. Many clinic firms now divide their ongoing pricing structure into two components: reimbursement, without markup, for the costs associated with daily operations - staffing, drugs, labs, office supplies - and a management fee that covers enterprise costs - medical direction, clinic oversight, marketing, accounting, IT - and profit.</span><span style="color: black;"><br />
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</span><span style="color: black;">Unlike virtually everyone else in health care, this model contains no financial incentive to provide unnecessary services or, more importantly, to deny necessary ones. The clinic vendor is paid only to manage care processes, and is judged on how effectively it does that.</span><span style="color: black;"><br />
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</span><span style="color: black;">This is a welcome revelation to employers who have endured a decade of health care costs skyrocketing at </span><span style="color: black;"><a href="http://facts.kff.org/chart.aspx?ch=1189"><span style="color: #000099;">four times general inflation</span></a></span><span style="color: black;">. One of modern clinics’ genius innovations is obtaining risk-bearing sponsors - mostly employers so far - to invest in the process. That sponsorship allows the clinic to manage as an independent fiduciary, outside fee-for-service, creating impacts that are realized in savings to the far larger group health plan and occupational health programs.</span><span style="color: black;"><br />
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</span><b><span style="color: black;">Elevate Primary Care To A Medical Management Platform</span></b><span style="color: black;"><br />
</span><span style="color: black;">Second, clinics embody a renewed appreciation of the primary care physician’s power as a patient advocate and guide. And they leverage the primary care practice, making it a platform that can integrate and coordinate a wide range of care coordination tools, programs and incentives, all aimed at tracking and orchestrating the patient’s needs for primary care and throughout the continuum.</span><span style="color: black;"><br />
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</span><span style="color: black;">It is impossible to overstate the value of liberating primary care, especially given </span><span style="color: black;"><a href="http://www.thehealthcareblog.com/the_health_care_blog/2007/12/bad-medicine-ho.html"><span style="color: #000099;">it’s reduced standing in recent years</span></a></span><span style="color: black;">. It’s worth noting that, while America’s primary/specialty physicians percentage split is 30/70, in all other developed nation’s health systems, the ratio is reversed and their costs are approximately half ours. </span><span style="color: black;"><br />
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</span><span style="color: black;">In a specialist-dominated health system that primarily pays primary care doctors to do office visits, dis-empowering primary care has been corrosive in two ways. It has pushed patients, often unnecessarily, to specialists, who cost far more. At the same time, primary care physicians have too often been disengaged by overwhelming case loads to maintain accountable relationships with the specialists they refer to, neutralizing the collaborative oversight that is critical to assuring medical appropriateness.</span><span style="color: black;"><br />
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</span><span style="color: black;">Relieving primary care physicians’ worries that they’re spending too much time with a patient pays big dividends. With the breathing room of a 20 minute office visit, they can more readily explore the issues of their patients, address those that are within their capabilities, and refer far less often, generally with better results.</span><span style="color: black;"><br />
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</span><span style="color: black;">The litmus test for the effectiveness of a particular clinic’s (or physician practice’s) approach is whether the data show a significant improvement in population health status, and in cost savings that outweigh the investment. Different models produce different results, so medical management impact is the key differentiator among vendors. As purchasers become more discriminating, demonstrated performance will become both a requirement and the all-consuming focus of clinic vendors.</span><span style="color: black;"><br />
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</span><span style="color: black;">But the infrastructure associated with excellent medical management is not only costly, but complex to develop and put into place. We may find that, as a rule, it is highly unlikely for individual doctors or small physician groups to build these capabilities, especially while grappling with the dominant fee-for-service system. Instead, the best clinics may be focused efforts solely dedicated to all facets of medical management, sponsored through corporations or, possibly, through more traditional health care entities, like health plans or health systems.</span><span style="color: black;"><br />
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</span><span style="color: black;">There is no question that the intensifying cost crisis has increased pressure on both purchasers and on the health industry. The recent Kaiser Family Foundation employer benefits survey found that, in 2010, </span><span style="color: black;"><a href="http://online.wsj.com/article/SB10001424052748703431604575467902840224786.html"><span style="color: #000099;">employers passed along ALL health care cost increases </span></a></span><span style="color: black;">to employees, an unprecedented trend suggesting that purchasers’ ability or willingness to absorb additional cost is saturated. This environment, with few alternatives, offers the best possible opportunity for mechanisms that can rationally reduce cost and risk.</span><span style="color: black;"><br />
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</span><span style="color: black;">Which is why the new generation of clinics are applicable to far more than employer environments. As their capacity to reliably improve quality and cost becomes more clearly demonstrated and accepted, the approaches they represent will be embraced by any organization that has assumed health care clinical and financial risk. Health plans are already beginning to focus on them. Accountable care organizations are likely next.</span><span style="color: black;"><br />
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</span><span style="color: black;">Clinics’ transformative power resides in medical management models that can be used by anyone focused on managing population-level health and financial risk. Against a backdrop of a health care bubble poised to burst, that is a simple, compellingly stable value proposition that can help stave off disaster or prove effective in a new environment with fewer resources.</span></span><span style="color: black;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span> <br style="mso-special-character: line-break;" /> </span>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com1tag:blogger.com,1999:blog-3499517899392895430.post-53603359043803034942010-12-03T15:24:00.001-05:002010-12-03T16:15:48.178-05:00If Employers Walked Away From Health Coverage<div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">BRIAN KLEPPER & DAVID C. KIBBE</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Originally Published on 11/24/10 on <a href="http://www.kaiserhealthnews.org/Columns/2010/November/112410klepperkibbe.aspx">Kaiser Health News</a></div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">What would happen if the rank and file of America's employers, financially overwhelmed by the burden associated with sponsoring health coverage, suddenly opted out?</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">It isn't so far-fetched. Enrollment by working age families in private health coverage<a href="https://docs.google.com/viewer?url=http://www.cdc.gov/nchs/data/nhis/earlyrelease/201006_01.pdf" style="color: #175682; text-decoration: none;">dropped</a> more than 10 percent over the last decade, as individuals and business were priced out of the coverage market. Others, victims of the downturned economy, have lost their jobs and access to subsidized coverage. Those who still have coverage have narrower benefits with higher out-of-pocket costs than before.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
<a name='more'></a>In 2010, <a href="http://prescriptions.blogs.nytimes.com/2010/09/02/survey-employers-pass-on-more-health-costs-to-workers/" style="color: #175682; text-decoration: none;">employers transferred ALL health plan premium cost increases to employees</a>. Employee health costs rose 14 percent. Over the last five years, their costs have risen 47 percent, while wages have increased only 18 percent.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">It may be reasonable to interpret this action as a line in the sand. Employers, who typically provide about a $10,000 subsidy for family coverage, are saying, "Enough. This is the limit of our financial commitment. More cost will have to be passed on to someone else."</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">That someone else, of course, would be employees and his/her families, who, on average, will make about $50,000 gross this year, and who are paying about $4,000, or 8% of that income, for health coverage.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Employer frustration with being held hostage by America's health system has been percolating for a long time. Various arguments -- both for and against -- recur in the debate over whether employers should sponsor health coverage. On one hand, healthier employees are more productive, and comprehensive health coverage is critical to recruiting and retaining better employers. But on the other, health care's relentless cost inflation renders American businesses that offer coverage less competitive than their domestic counterparts that don't. Similarly, they are less competitive than international firms whose employees' coverage costs significantly less.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">With such a large financial stake in the process, most employers are carefully watching the health reform battle and its potential implications. Those could be very different, depending on which side prevails. Now that the Republican Party has resurged in Congress, in large measure galvanized by a "Repeal Reform" platform, let's imagine two scenarios.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">In the first, Republicans, backed by <a href="http://www.kaiserhealthnews.org/columns/2010/september/092010klepperkibbe.aspx?referrer=search" style="color: #175682; text-decoration: none;">a health care industry daunted</a> by the prospect of lower revenues if the health law's cost control provisions remain intact, nullify those provisions. Freed from constraints once again, excessive practice patterns continue unabated and costs continue to soar.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">With the economy still weak, employers withdraw even faster to escape the higher costs. With government programs only capable of absorbing some new participants, the number of uninsured people mushrooms. Safety net programs are overwhelmed, and pressure on government to devise a new solution rapidly intensifies.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">In the second scenario, the Democrats hold fast. But in 2014, the health insurance exchange provision kicks in, allowing businesses to drop coverage sponsorship by paying a $2,000 per employee penalty, plus <a href="http://hhcf.blogspot.com/2010/07/before-employers-consider-dropping.html" style="color: #175682; text-decoration: none;">costs related to current benefits expenditures</a>. In a recent <a href="http://online.wsj.com/article/SB10001424052702304510704575562643804015252.html?mod=WSJ_Opinion_LEADTop" style="color: #175682; text-decoration: none;">Wall Street Journal op-ed</a>, Tennessee Governor Philip Bredesen detailed an analysis showing an immediate $146 million dollar yearly savings by transferring coverage of core state employees to the exchanges. It seems an attractive solution.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">How many businesses would likely maintain coverage at $10,000 per employee if they had, say, a $6,000 alternative? Many might, according to a recent <a href="http://www.mercer.com/press-releases/1399495" style="color: #175682; text-decoration: none;" target="_blank">survey</a> by Mercer, the benefits consulting firm. But some wouldn't. Those that make tremendous per employee profits, like financial services, technology and pharmaceutical firms, may not drop coverage. Those with occupational health exposures that give them reason to aggressively and directly manage employee health might not. But for <a href="http://www.kaiserhealthnews.org/stories/2010/november/09/businesses-health-insurance-mercer.aspx?referrer=search" style="color: #175682; text-decoration: none;" target="_blank">small businesses</a>, which are less likely to offer coverage anyway and typically struggle more with these costs, the health exchanges may be an appealing option. With so many variables, it's hard to know. But in the face of a weak economy and continued explosive health care cost growth, a mass employer exodus is not outside the realm of possibility.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">In round numbers, America now spends about $2.6 trillion annually on health care. Commercial coverage comprises half ($1.3 trillion), with $300 billion paid by individuals or families and $1 trillion by businesses. The question, then, is how the reduction in business' health coverage subsidy -- $400 billion a year in the example here -- would be replaced, and what might happen if it isn't.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">In the current anti-tax political environment, it is difficult to imagine Congress could compensate for the lost employer subsidy by raising taxes. Business is unlikely to acquiesce to paying higher taxes commensurate with whatever health care costs accrue.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">And consider that a new dedicated tax of $400 billion per year would be an astounding five times the bailout and economic stimulus that, earlier this year, rightly or wrongly, raised the fury of the American people. Will we also be willing to bail out the health care industry, because it is "too big to fail?" Finding the dollars to keep the current health system and the industry afloat would require a new national commitment of historic proportion, far greater than the recent Wall Street bailout.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Either of these scenarios could result in massive public conflict and, equally importantly, significantly diminished resources for the health care sector. An inability to continue funding the industry's excesses would surely burst the health care cost bubble, unleashing a cascade of harshly chaotic consequences. Only then might we see a reform process that more rank and file Americans might appreciate and embrace.</div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-85177117109608263732010-09-29T07:25:00.012-04:002010-10-29T09:25:26.169-04:00Healthy Eats For Data-Hungry DoctorsDAVID C. KIBBE and BRIAN KLEPPER<br />
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Imagine that an innovative health plan - aware that half or more of health care cost is waste and that physician costs to obtain the identical outcome can vary by as much as eight fold - hopes to sweep market share by producing better quality health care for a dramatically lower cost. So it begins to evaluate its vast data stores. It’s goal is to identify the specialists, outpatient services and hospitals within each market that, for episodes of specific high-frequency or high value conditions, consistently produce the best outcomes at the lowest cost. Imagine that, because higher quality is typically produced at lower costs - there are generally fewer complications and lower incidences of revisiting treatment - the health plan will pay high performers more than low performers. Just as importantly, it will limit the network, steering more patients to high performers and away from low performers.<br />
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Suddenly, it will become very important for physicians and other providers to understand, in detail, how they compare to their peers within specialty, and how to provide the best care possible. And if they find the results aren’t so positive, they may want to figure out where their deficiencies lie, and how they can improve.<br />
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Now imagine that clinicians could easily view data about their patients and themselves.<br />
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Basic demographics: e.g. age, gender, length of time since last visit.<br />
<ul><li>A problem list based on diagnoses within the past year. </li>
<li>A list of medications prescribed, including ordering physician, dates and fulfillment information. </li>
<li>A list of lab tests ordered, by physician and date. </li>
<li>A list of immunizations. </li>
</ul><br />
Suppose the clinician could review, revise or copy this information to create a lasting “patient profile,” saving it online and retrieving it for use at each subsequent visit as appropriate.<br />
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Now imagine that this same Internet-based application provides a report based on aggregated patient claims data as current as 8-10 days old, and not just a single health plan's patients, but from all payers. The kinds of reports or “dashboards” available would include, but not be limited to:</div><div><ul><li>A count of patients with particular diagnoses or conditions, by provider. </li>
<li>A count of medications ordered, by most to least common. </li>
<li>A count of lab tests ordered, by most to least common. </li>
<li>Average number of visits per day, week, month. </li>
<li>Percentages of patients meeting targets for key metrics (e.g., blood pressure control, diabetes screening testing, smoking cessation). </li>
<li>Days before payment broken down by insurance companies and health plans. </li>
</ul><br />
Then add some basic clinical decision support:</div><div><ul><li>Analytics to identify patients at risk for chronic diseases or major acute events during the next year. </li>
<li>Care gap analyses to create lists of actionable care items for each patient, based on the information in claims, drug, lab and electronic health records. </li>
<li>Artificial-intelligence (AI) driven diagnostic aids. </li>
<li>Best practice guidance. </li>
<li>Online, real-time access to all prescriptions previously filled by the patient, along with automatic drug interaction information. </li>
</ul><br />
Now suppose that each physician or clinician could:</div><div><ul><li>Invite other physicians to provide their (de-identified) data to be pooled and compared with others in the pool. </li>
<li>Select benchmarks from local, state, regional, and national data sets to compare each physician’s quality, safety and episodic cost performance. </li>
<li>Start conversations and discussion groups with other physicians based upon questions raised by the data and its analytical indications: e.g., performance, the data itself, its reliability, evidence for higher or lower utilization, etc. </li>
<li>Begin to assemble the components of a "meaningful use" EHR technology suite that will meet the requirements for EHR incentive payments starting in 2011. </li>
</ul><br />
We could pose lots of additional “what ifs,” but you get the picture. Information is available now from clinical records, claims, drug and lab orders, and could be provided to all clinicians in a manner that:<br />
<ul><li>When reported in the aggregate, is completely de-identified, </li>
<li>Is compliant with applicable privacy and security laws and regulations, and </li>
<li>Comes with an explicit invitation to make suggestions about how to improve the data’s quality, accuracy, currency and integrity. </li>
</ul><br />
We are very near to a 'tipping point' that will make physicians, medical practices, and provider organizations of all kinds very hungry for these kinds of data. There is growing pressure to control cost, both through reform and the marketplace, and moves afoot to significantly penalize physicians and organizations that have unnecessarily high costs.<br />
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In all businesses but health care, success is impossible without good information about customers and performance. By contrast, the combination of fee-for-service reimbursement and a lack of cost/quality transparency have let health care business achieve financial success, even when the business itself is oblivious to its performance. Physicians, hospitals and other health care organizations have made so much money, and have increased their incomes/revenues so easily by simply increasing demand, that rigorous monitoring of quality and financial status have been discouraged.<br />
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We believe that is all about to change. There is now evidence that health care purchasers (Medicare, health plans, employers, patients) have reached the limits of their capacity to pay and are “putting the money on the stump and running.” In most metropolitan markets, and to a lesser degree in rural markets, health care organizations’ efficiency and productivity will become increasingly critical to their survival.<br />
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As we run out of resources to spend on fee-for-service health care, the payment methodology will change to reflect selectivity in purchasing and contracting for services. Affordability and value will become more important than ever.<br />
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The government is leading the trend towards health care data collection and transparency of reporting. ARRA/HITECH and the Meaningful Use EHR incentive programs are notable for their emphasis on data collection for both performance and quality measurement.<br />
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When one of us (DCK) was in his early forties, he designed and taught courses on data and information management for Don Berwick's Institute for Healthcare Improvement (IHI). Dr. Berwick was never a big proponent for computerization, but he was a stickler on data and its uses for understanding process and outcomes, and for guiding improvement efforts on a continuous basis. He believed strongly in comparing people, teams, and organizations in a collaborative fashion, and using gaps in performance as a stimulus to change for the better. Now he's running the Center for Medicare and Medicaid Services, CMS. Chances are very good he'll likely to continue to push for improved data.<br />
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We think it should be possible to create a multi-level offering of data, information, and EHR technology services to physicians and practices at a very reasonable cost. Every element in this article’s lists is not only imagine-able, but do-able already.</div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com1tag:blogger.com,1999:blog-3499517899392895430.post-24910771168677067952010-09-20T13:44:00.011-04:002010-10-29T09:26:54.399-04:00Keeping An Eye On The Health Care Prize<div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><a href="http://4.bp.blogspot.com/_GxIbBXVl5Lk/TJed7IfCjeI/AAAAAAAAJI4/FVsJdOmh6S8/s1600/K2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><i></i></a><br />
<a href="http://www.kaiserhealthnews.org/Columns/2010/September/092010klepperkibbe.aspx"><i>Published on Kaiser Health News</i></a><i>, 9/20/10</i><br />
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<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/_GxIbBXVl5Lk/TJtIoLZFnoI/AAAAAAAAJJw/Q1k_XubHwMk/s1600/K2Casual.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="143" src="http://3.bp.blogspot.com/_GxIbBXVl5Lk/TJtIoLZFnoI/AAAAAAAAJJw/Q1k_XubHwMk/s200/K2Casual.jpg" width="200" /></a></div>Many reformers undoubtedly believe that passage of the health overhaul law laid the issue to rest. But policy's wheels continue to turn, and the process is anything but over.<br />
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Decades of fee-for-service reimbursement became the health industry's article of faith, encouraging virtually everyone in the system to do as much as possible to every patient, with <a href="http://www.kaiserhealthnews.org/Columns/2010/September/~/media/Files/2010/May%20to%20September/pwcreport.pdf" style="color: #175682; text-decoration: none;">half or more of all expenditures wasted or unnecessary</a>. But it was also a recipe for national disaster. Over the last decade, <a href="http://www.kaiserhealthnews.org/Columns/2010/September/Keeping%20An%20Eye%20on%20the%20Health%20Care%20Prize" style="color: #175682; text-decoration: none;" target="_blank">nearly all U.S. economic growth was absorbed by health care</a>.<br />
<a name='more'></a></div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Now, after reform, the industry faces the prospect that the payment equation will be reversed. The money will be tied, in still unclear ways, to doing only what's appropriate. The notion terrifies many health care professionals. Sustaining the industry's current prosperity levels will depend on an ongoing excess from reform's failure.<br />
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<a href="http://www.kaiserhealthnews.org/Stories/2010/March/18/Cadillac-Tax-Explainer-Update.aspx" style="color: #175682; text-decoration: none;" target="_blank">The Cadillac tax</a>, probably the law's strongest cost control provision, threatens health plans with a 40 percent tax on the portion of premium that's higher than $10,200 (individual) and $27,500 (family), starting in 2018. The logic is straightforward. Health plans, which aggregate lives and dollars, will be encouraged to reduce costs, and will in turn create incentives throughout the continuum for more efficient care delivery. Everyone will follow the money.<br />
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The 2018 premium targets may seem high, but they are a short distance from here to where the penalties begin. Just-released <a href="http://ehbs.kff.org/pdf/2010/8085.pdf" style="color: #175682; text-decoration: none;" target="_blank">data from the Kaiser Family Foundation/HRET 2010 Employer Health Benefits Annual Survey</a> show that the growth in premiums for family coverage slowed dramatically, rising an average of 3 percent this year. (KHN is a project of the Foundation). If premium growth rates don't exceed an average of 8.2 % until 2018, as they have for most of the past decade, then they'll come in under the threshold for the Cadillac tax. But if they rise at all beyond this, consequences will accrue. And, of course, for the many higher cost union and governmental health plans, the threshold is even closer. Many health care professionals will see this mechanism as a financial peril, and seek to neutralize it.</div><div style="font-family: arial, helvetica, sans-serif; font-size: 13px; line-height: 18px; margin-bottom: 14px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">The new law also hangs its hopes on <a href="http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=23" style="color: #175682; text-decoration: none;" target="_blank">Accountable Care Organizations</a>, still unproven structures that will demand dramatic changes in health systems operations. Integrated Delivery Networks, hospitals, physician group practices and Independent Practice Associations are anxiously awaiting the fall release of the government's proposed rules describing the short- and long-term financial incentives for hitting quality and cost targets. The key question will be whether the arrangement warrants transitioning to a system that actually strives for efficient, quality care. Some thoughtful, experienced market analysts like <a href="http://healthaffairs.org/blog/2009/08/17/the-accountable-care-organization-not-ready-for-prime-time/" style="color: #175682; text-decoration: none;" target="_blank">Jeff Goldsmith</a> and <a href="http://www.thehealthcareblog.com/the_health_care_blog/2010/06/pitfalls-of-ppaca-accountable-care-organizations.html" style="color: #175682; text-decoration: none;" target="_blank">Roger Collier</a> doubt most organizations' capacity to develop and maintain the collaborative trust required for ACO success.<br />
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Many physicians, particularly <a href="http://www.healthnewsflorida.org/index.cfm/go/public.articleView/article/19130" style="color: #175682; text-decoration: none;" target="_blank">specialists</a>, see moves away from fee-for-service and toward accountability as an assault on "the patient-physician relationship," code for revenue generation. Infuriated over the American Medical Association's support of the health care law, the <a href="http://www.healthnewsflorida.org/index.cfm/go/public.articleView/article/19195" style="color: #175682; text-decoration: none;" target="_blank">Florida Medical Association recently issued a "no confidence" vote</a>and <a href="http://www.modernhealthcare.com/article/20100823/MAGAZINE/100829991/1139" style="color: #175682; text-decoration: none;" target="_blank">joined with 13 other state medical societies</a> to advocate for unregulated health care.<br />
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In 2009, health care-related organizations contributed <a href="http://www.publicintegrity.org/articles/entry/1953" style="color: #175682; text-decoration: none;" target="_blank">$1.2 billion to Congress</a> to protect their financial interests. That resolve makes it seem unlikely that the nation's wealthiest and most influential economic sector will simply accept constraints on its historical profitability.<br />
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Now the health industry's goals are aligned with the GOP, which has vowed to dismantle health reform after November and fostered <a href="http://www.politico.com/news/stories/0810/40536.html" style="color: #175682; text-decoration: none;" target="_blank">high profile, state-level lawsuits</a>. With reform teams focused on rule clarification and implementation, opportunities will abound for special interest influence.<br />
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Nor is the business community likely to mobilize to ensure that appropriateness and efficiency remain at the core of the law. During the fevered battles surrounding health care reform, <a href="http://www.politico.com/livepulse/1009/Employers_group_opposes_House_bill_.html" style="color: #175682; text-decoration: none;" target="_blank">mainstream business groups wrote letters to Congress</a> expressing their frustration with the lack of cost controls in the bills. But their lobbying contributions failed to provide a meaningful counterweight to the health industry's influence. They acquiesced, despite a direct productivity interest in higher-value health care and the fact that non-health care business represents five-sixths of the U.S. economy (to health care's one-sixth).<br />
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Last week's news that <a href="http://abcnews.go.com/Health/HealthCare/healthcare-cost-burden-shifting-employers-employees/story?id=11555746" style="color: #175682; text-decoration: none;" target="_blank">America's employers transferred recent health care cost increases to employees</a> can be understood as a self-imposed limit on their health care financial commitments. If this is confirmed by employers' withdrawal from health plan sponsorship, then the health industry could be stymied. The new rules promoting universal coverage notwithstanding, declining employer subsidies, increasingly nervous international creditors, and a recession that makes it harder to raise and allocate tax dollars could converge to price the rank and file of America's families out of the health care market. American health care could implode.<br />
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Even if the forces against health care policy change triumph, though, a new market interest in value is growing rapidly. Innovative new services and tools – Web-based data exchange, analytics to identify patient risk and provider performance, clinical decision support, patient engagement, medical homes, value-based benefit design, new clinical technologies – are achieving cost and quality improvements unimaginable a decade ago.<br />
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But everyone in health care is aware that both policy- and market-based reforms' ultimate goals are better care for less money. The operative words, "less money," mean we should expect a fierce, sustained effort by health care groups, bolstered by the opposition political party, to preserve and increase the profitability it has come to feel entitled to.<br />
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From where we sit, with the withering campaign that must be in the works, the odds of the new law remaining intact, with teeth, are questionable. For reforms to succeed, then, steady vigilant hands, focused on the nation's larger interest, will be critical.<br />
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<em>Brian Klepper, PhD and David C. Kibbe, MD, MBA write together about health care policy, market dynamics, technology and economics</em>.</div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-82244077035391022142010-08-31T04:53:00.003-04:002010-08-31T05:03:54.674-04:00Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">DAVID C. KIBBE and BRIAN KLEPPER</span><br />
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<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Finally, we have a </span><a href="http://healthpolicyandreform.nejm.org/?p=3732&query=OF"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">Final Rule on the Medicare and Medicaid EHR incentive programs</span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment. Doctors who get three-quarters of the way there won’t receive a dime. And a lot of uncertainty remains about dependent processes that CMS and ONC must quickly put in place, like accreditation of “testing and certifying bodies,” and the testing schemas for certification. All in all, we expect most physicians in small practices to sit on the sidelines until the dust settles, likely in 2012 or 2013.<a name='more'></a></span><br />
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<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Nevertheless, while it is good to get Meaningful Use behind us, it may be better still seeing beyond it. After all, the incentive payments for becoming a “meaningful user of certified EHR technology” are merely a small down payment on the savings that could be realized if health care supply, delivery and payment are affected by the changing policy and market environments over the next 5 years. The EHR incentive programs are meant to prime the pump by putting approximately $25 billion, give or take a few billion, into the hands of physicians and hospitals who adopt EHR technology during the 5 years between 2011 and 2016. </span><br />
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<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">During that same time, by comparison, reductions in waste, duplication, and unnecessary procedures might mean savings of $100 billion to Medicare alone,# depending on whose estimate you believe and how effective you think the reforms will be in replacing payment for volume with payment for value. It might be a lot more. </span><a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/10/saving-health-care-saving-america.html"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">Conservative estimates are that 30% of our total national health care expenditure of $2.5 trillion, or over $800 million</span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, is unnecessary and could be eliminated through real reforms. </span><a href="http://healthpolicyandreform.nejm.org/?p=3732&query=OF"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">Some authoritative estimates </span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">argue that half or more of care costs are unnecessary, so the target jumps to $1.25 trillion a year. </span><br />
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<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Put another way, the REAL money in is savings from reform, not health IT, though IT is a core tool to identify savings opportunities and to manage care appropriately. Some of it will go to doctors and hospitals that figure out how to achieve cost savings and are given the opportunity to share in those savings, thereby earning amounts that could easily be 10-20 times the value of EHR incentive payments. There is economic opportunity in health care reform for providers who figure out how to address the fragmentation of care, offer care that is coordinated and continuous, deploy the information technology required to capture and analyze fugitive health data, and then serve it up as shared clinical intelligence at the point of care to guide decisions toward safety, quality, and cost-effectiveness. </span><br />
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<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">With these care management cost savings in mind, we consider patient care data and clinical IT systems and components over the next five years likely to be “beyond meaningful use.” Of course, aspects of the EHR Meaningful Use incentive are themselves part of the trends, most notably the standards and protocols which EHR technology vendors must adhere to to obtain ONC/HHS certification. Here are the most important trends to watch, roughly in order of importance:</span><br />
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<ol><li style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">The expanding uses of structured health data using XML. </span><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">EHR vendors, HIE companies, consultants, and other middlemen are used to making fortunes on one-off health data interfaces between an EHR and sites of care (e.g., hospital) or service (e.g., lab). The </span><a href="http://www.centerforhit.org/online/chit/home/project-ctr/astm.html"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">CCR standard</span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, and the </span><a href="http://en.wikipedia.org/wiki/Continuity_of_Care_Document"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">CDA CCD</span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, based on the CCR, are now federally approved health data summary standards in XML, the lingua franca for data on the Web and used in e-commerce. There will be other standards that employ XML to make the exchange of health data more standardized and cheaper to put in place. Removing the costs and hassles of fax machines will be the lowest hanging fruit on this vine. But eventually, health data will be Internet-accessible to services that will focus on new applications of the data, like helping doctors and patients identify the best “next steps” for prevention or treatment, or providing warnings that a patient at home is de-stabilizing.</span></li>
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<ol start="2"><li style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">Point-to-point sharing of health data, securely, over the Internet. </span><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Local</span><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">and regional health information exchanges are proliferating, but they still face the problem of communicating beyond their own boundaries. Private networks are a kind of prison. </span><a href="http://nhindirect.org/"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">The NHIN Direct Project </span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(soon to be renamed, perhaps as HealthNetwork Direct) is developing policies, standards, and specifications that could open the health data floodgates by using proven, trusted Internet protocols and methods, like SMTP and DNS, to create a secure channel for point-to-point transport of even the most sensitive health information. Anyone with a valid NHIN Direct address will be able to “push” information to anyone else with an NHIN Direct address, regardless of the security moats around private networks, just the same way that individuals using different client applications for email can today communicate. More secure than email in the clear? Certainly. Bound to an enterprise or a particular vendor? No. The country’s doctors and patients don’t have to wait for massive state or regional HIE infrastructures to be built and deployed in order to start making health data more liquid.</span></li>
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<ol start="3"><li style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">Platforms+modular apps+network services. </span><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Almost everyone is familiar with this model: it’s the iPhone app store and the Android Market. It’s the use of the Internet without as much dependence on the web browser, with multiple mobile devices for platforms, and with the emphasis on replaceable apps and re-useable technology that offers up data from many sources simultaneously. Why should health care professionals and patients be locked out of the kinds of beneficial experiences we’re all getting used to with Facebook, Twitter, Amazon and Google? In fact, we think a very good argument can be made that social networking software is a key ingredient to care coordination and better teamwork in health care. But first, the older technological gridlock of client-server and walled enterprise HIS -- in which the health care professional is too often a data enterer and too seldom a data user -- has to be cleared from the path. CIOs in hospitals and large groups will eventually see how important connectivity and communications are to reducing overhead and improving productivity, and come to value the </span><a href="http://www.clinicalgroupwarecollaborative.com/"><span style="background-color: transparent; color: #000099; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">clinical groupware</span></a><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> world view in which more apps, selectable apps, replaceable apps, are key to making the underlying data really useful. As this occurs, we’re likely to see some health care organizations leapfrog over legacy EHR technology and going straight to network-accessible - that is, cloud - computing solutions.</span></li>
</ol><span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">It will probably take another 5 years for these trends involving applications in personal health and clinical IT to become mainstream. There are possible accelerators and some potential decelerators to this process. Right now, for example, the federal government is clearing the way for innovation with its encouragement of modular EHR technology and incentives for meaningful use of IT rather than simply its purchase.</span><br />
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<span style="background-color: transparent; color: black; font-family: Arial; font-size: 11pt; font-style: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">However, this is a long term process and the relentless lobbying power of legacy vendors threatened by being displaced could still win. If that happens, a retreat from the progress we’ve described, as well as an increasingly bureaucratic apparatus within ONC/CMS, might eventually work against innovation.</span>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-42441435429659028022010-08-19T09:52:00.002-04:002010-08-28T10:23:31.357-04:00Why The FMA Is Off-Base On ReformBRIAN KLEPPER and DAVID C. KIBBE<br />
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First Published in <a href="http://jacksonville.com/opinion/letters-readers/2010-08-19/story/guest-column-florida-medical-association-base-fighting">the Florida Times-Union</a><br />
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At an Orlando meeting last week, Florida Medical Association (FMA) members fumed that their parent, the AMA, isn’t adequately representing Florida’s private practice doctors. After talk of secession and forming a new group, they settled for writing a stern letter urging the AMA to straighten up.<br />
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The FMA dustup began with a resolution written by Douglas Stevens MD, a Fort Myers cosmetic surgeon – you can’t make this stuff up – complaining that the AMA’s support for recent reforms was “a severe intrusion in the patient-physician relationship and allows government control over essentially all aspects of medical care.” He wrote that it will “relegate physicians to the role of government employees…and essentially end the profession of medicine as we know it.” A St. Petersburg neurological surgeon, David McKalip, added, “Without (AMA) support, the whole thing (i.e., reform) would have died."<br />
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Well, no. We aren’t sure which reform provisions Dr. Stevens is referring to, but he might have two in mind. One uses subsidies to encourage doctors to obtain Electronic Health Record technologies, so patient information can be easily exchanged and unnecessary or redundant services can be reduced. Some data would be submitted to a federal repository, so doctors can better understand how effectively they practice compared to their peers and how to improve if needed. Of course, physicians opposed to these rules could opt to avoid patients whose care is paid for with public dollars. But we think most doctors will welcome the opportunity to modernize their care.<br />
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The second bone of contention was a well-intentioned but flawed 1997 Medicare formula, the Sustainable Growth Rate, which tied physician payments to the growth of the US economy. If Medicare physician spending exceeded the target in one year, then payment the following year would be reduced. But every year, Congress has relented from this discipline, delaying the payment reductions. Now, in 2010, the accumulated cuts would be a whopping 21.2 percent. Despite promises made to the AMA in exchange for support, and with massive costs looming for health care, the financial bailouts, two wars and other needs, Congress is reluctant to spend the additional $200 billion to forgive the cuts. American specialists, who make triple the salaries of their primary care colleagues, are bound to see smaller Medicare checks in coming years.<br />
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In the past, we’ve had many differences with the AMA, which was often more focused on physicians and their economic prosperity than on patients and theirs, especially as health insurance costs relentlessly grew four times faster than the economy. The AMA lobbied hard against Medicare and Medicaid, famously recruiting Ronald Reagan to play the “socialized medicine” scare card. Through a secretive, specialist-dominated reimbursement advisory committee, they urged Congress to pay specialists more at the expense of primary care physicians. As a result, it is not far-fetched to lay much of the current health care cost crisis at the AMA’s feet.<br />
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But recently, as it strived to reinvigorate itself and appeal to younger physicians, the AMA became more progressive. It mounted a three year campaign for universal coverage. It supported government’s efforts to facilitate and reward the meaningful use of modern computerized tools and the best medical science in clinical practice.<br />
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To its credit, the AMA has also learned that it shares influence over health policy. In the intense, 2009 health reform lobbying environment, the AMA contributed $21 million to Congress, but the pharmaceutical/health products industry alone contributed $267 million, or 13 times as much, according to the watchdog group Open Secrets.<br />
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Many groups assumed that reforms would be achieved, and the AMA knew it was not in control. So it wisely pressed points it believed were in doctors’ interests and compromised when it needed to.<br />
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While they are incredibly important to us, American physicians over the last half century have been handsomely, even often excessively, rewarded. But now, the system that has been hugely wasteful must find ways to reduce costs while improving quality, and make sure that care is accessible to everyone. These imperatives are emerging just as data and information tools are becoming more available. Health care will become more like a market than before.<br />
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Medical practice is changing profoundly, mostly for the better. In the process, doctors will still be highly valued, but many may earn less.<br />
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The FMA’s challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need. It is coming, and the FMA should get on board or out of the way.<br />
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<i>Brian Klepper, PhD (Atlantic Beach, FL) and David C. Kibbe, MD, MBA (Chapel Hill, NC) write on health care policy, market dynamics and technology trends. Their collected essays are at www.kibbeandklepper.blogspot.com.</i>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-88112984038466379182010-04-26T05:27:00.000-04:002010-08-28T10:29:34.630-04:00An Open Letter (1) to the New National Coordinator for Health IT - Untying HITECH's Gordian Knot<span style="font: 14px Calibri;">DAVID C. KIBBE and BRIAN KLEPPER</span><br />
<i><span style="font: 14px Calibri;"> </span></i><br />
<span style="font: 14px Calibri;"><i>First Published on <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/04/an-open-letter-to-the-new-national-coordinator-for-health-it-untying-hitechs-gordian-knot-part-1.html">THCB</a>.</i></span><br />
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<span style="font: 14px Calibri;">Congratulations to </span><span style="font: 14px Calibri;"><a href="http://www.hhs.gov/news/press/2009pres/03/20090320b.html" rel="external" target="_blank">David Blumenthal on being named National Coordinator for Health Information Technology (ONCHIT).</a></span><span style="font: 14px Calibri;"> Dr. Blumenthal will be the person most responsible for the rules and distribution of the American Recovery and Reinvestment Act's (ARRA) nearly $20 billion allocation, referred to as HITECH, designated to support physician and hospital adoption of health information technologies that can improve care.<br />
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The job is fraught with difficulties, which Dr. Blumenthal has readily acknowledged. His recent New England Journal of Medicine (NEJM) Perspective, "</span><span style="font: 14px Calibri;"><a href="http://content.nejm.org/cgi/content/full/NEJMp0901592" rel="external" target="_blank">Stimulating the Adoption of Health Information Technology</a></span><span style="font: 14px Calibri;">," is a concise, clear and honest appraisal of two of these challenges, namely how to interpret and act upon the key terms used in the legislation, "meaningful use" and "certified EHR technology." Dr. Blumenthal gets to the heart of the matter by identifying the tasks on which the National Coordinator's success will most depend, and which will foster the greatest controversy.</span><br />
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<div class="blog-entry-body"><span style="font: 14px Calibri;">The country needs Dr. Blumenthal to succeed. The issues are complex and, with huge ideological and financial stakes involved, politically charged.</span><br />
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Even so, we believe there are straightforward ways to help physicians and hospitals take advantage of this opportunity to use health IT to improve care. This article is the first of a series in which we'll try to disentangle the Gordian knot of inter-related issues embedded in HITECH. Below we identify six issues. Then we address the first.<br />
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A defining paragraph in Dr. Blumenthal's NEJM article offers his vision of the problem:<br />
</span><span style="font: 14px Calibri-Italic;"><i>....[M]uch will depend on the federal government’s skill in defining two critical terms: “certified EHR” and “meaningful use.” ONCHIT currently contracts with a private organization, the Certification Commission for Health Information Technology [CCHIT], to certify EHRs as having the basic capabilities the federal government believes they need. But 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. Similarly, if EHRs are to catalyze quality improvement and cost control, physicians and hospitals will have to use them effectively. That means taking 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. Finally, realizing the full potential of HIT depends in no small measure on changing the health care system’s overall payment incentives so that providers benefit from improving the quality and efficiency of the services they provide. Only then will they be motivated to take full advantage of the power of EHRs.</i></span><span style="font: 14px Calibri;"><br />
Here are issues that, to develop rules that can make the most of emerging Health IT trends, deserve clarification:<br />
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1. The term "electronic health record" (EHR) is unclear and imprecise, especially given the wide-ranging tools that can be used to manage health information in electronic format. Before developing rules that will guide our use of these tools, a clearer definition is essential.</span></div><div class="blog-entry-body"><span style="font: 14px Calibri;"><br />
2. In thinking about health IT, it is useful to separate health data from the applications used to manage health data. Separating them is critical to better understanding the role of standards, certification and the criteria used to validate physicians' and hospitals' claims on HITECH's incentive funds.<br />
</span></div><div class="blog-entry-body"><span style="font: 14px Calibri;">3. In a certification process, the appropriate scope of "basic [EHR] capabilities" should be limited to the critical few. Given constraints on time and resources and the "meaningful uses" that Congress wishes to promote, does it make sense to require a large package of features or a more limited set of basic capabilities?<br />
</span></div><div class="blog-entry-body"><span style="font: 14px Calibri;">4. How should the certification process be structured to ensure fairness, flexibility and openness to innovation? Does the current certification process meet these criteria?<br />
</span></div><div class="blog-entry-body"><span style="font: 14px Calibri;">5. The roles patients and consumers might play in any determination of "meaningful use" are important, but are left on HITECH's sidelines. How can health IT policy enhance the patient's health care experience and participation?<br />
</span></div><div class="blog-entry-body"><span style="font: 14px Calibri;">6. Will the incentive payments envisioned by HITECH actually encourage implementation of EHR technologies, and result in improvements in patient care quality? Or are better mechanisms available that can systemically improve care?<br />
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1. Definitions<br />
First, let's admit that there is no precise, universally-accepted meaning for "EHR." <br />
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The term sometimes refers to medical records themselves, digital files containing a person's health data and information. We believe this is what both Presidents Bush and Obama intended for the meaning when they have stated that all Americans should have their own electronic medical records. Individuals should be able to access their health information in electronic formats (of which there are many), and not just in paper records. Patients with their own EHRs can access them, give viewing permission to others, download them to computers or cell phones, and use software applications to manage and transfer the records in digital formats.<br />
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However, EHR may also mean a software application - like Intuit's Quicken for financial management or Microsoft Office for business productivity - used by doctors, nurses, and staff in a medical practice, hospital or other clinical setting. (EMR, for "electronic medical record," was an earlier term for this same class of software, now less used.) EHR software is typically utilized for creating, storing and managing a patient's care-related and billing data. Dr. Blumenthal uses this meaning in the passage above; EHRs are certifiable software programs that have "capabilities." We might also point out that EHR software for ambulatory care is very different from EHR software used in hospitals.<br />
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Unfortunately, many people have come to believe that a specific class of EHR software is required to consume and utilize the EHRs that are digital health records. But this is completely inaccurate. Many types of technologies can be used to manage digital records. If, for example, your electronic health record is a discharge summary written by a physician in Microsoft Word or PDF - two very common digital file format standards for text documents - you could use any number of word processing software programs to view that EHR, including some that are open source and/or free. </span><span style="font: 14px Calibri;"><a href="http://www.google.com/health" rel="external" target="_blank">Google Health</a></span><span style="font: 14px Calibri;">, </span><span style="font: 14px Calibri;"><a href="http://www.healthvault.com/" rel="external" target="_blank">Microsoft HealthVault</a></span><span style="font: 14px Calibri;"> and </span><span style="font: 14px Calibri;"><a href="http://www.worlddoc.com/" rel="external" target="_blank">WorldDoc</a></span><span style="font: 14px Calibri;"> store health records electronically for retrieval or updating by patients and the professionals or institutions that care for them. Even data that are digitally formatted in less publicly familiar standards, such as DICOM for radiological images and XML for structured medication or lab data, do not require an EHR application. Many types of software - personal health record applications (PHRs), image viewing programs, e-Prescribing applications, and even web browsers - can be used to create, consume, store, manage, and then transmit these data successfully. Each of these software programs, alone or in combination, deserves to be considered an EHR technology, by virtue of the fact that its main purpose is to handle electronic health records.<br />
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Further, the Certification Commission for Health Information Technology (CCHIT), initiated by the Health Information Management Systems Society (HIMSS), later re-organized as a non-profit and contracted by ONC while David Brailer was the the National Coordinator, insists that EHR software products must: a) include hundreds of features and functions, based on a model of such software that many would term "comprehensive," and; b) be supplied by a single vendor. This EHR definition prohibits CCHIT certification for many simpler, less feature-rich, and less expensive EHR applications. It also prevents end-users from assembling EHR software from components from separate vendors and submitting this for CCHIT certification.<br />
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The upshot is that the term "EHR" is no longer very useful. It creates more confusion than it resolves. This is more than a quibble. One can never be certain what EHR refers to: health data in electronic format; a technology that is designed to handle electronic health records in some fashion; an EHR software program that has fewer or different features and functions than those required by CCHIT, or one that has been assembled from compatible modules; or a CCHIT-certified, comprehensive software application from a single vendor whose product has been accepted by CCHIT.<br />
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It is not necessary to accept this confusion. Ever-expanding technological options, more than anything else, have made the term EHR obsolete. However, we think clarity is especially important now, as we face the challenge of setting rules to determine who will and will not qualify for ARRA/HITECH funding. If the language we use to define key terms is arbitrary, capricious, biased or simply out-of-date, the guidance we follow will fail to be fair or, more importantly, in our national best interest.<br />
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So, in an effort to reach the appropriate level of clarity, we suggest that "EHR technology" replace the terms EMR or EHR in ONCHIT's lexicon. The term would be defined as:<br />
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"An information technology tool, such as a software program or application, that is used to create, consume, manage or transport health data in electronic or digital form."<br />
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This definition is very broad, allowing many different kinds of technologies to qualify as meaningfully useful -- required by HHS and ONC -- and without requiring features and functions that are not useful. For the market to work and to encourage optimal innovation that can benefit all Americans, it is important to allow recognition and certification of single function applications that can mix-and-match with others, as well as more comprehensive packages, according to the needs, the budget, and customers' capacity to adopt. A first step is to create clarity in the language used to describe these tools.</span></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-56732678364823966692010-04-24T11:16:00.000-04:002010-08-28T10:26:10.211-04:00Clinical Groupware: Platforms, Not Software<h2><span style="font-size: small; font-weight: normal;">DAVID C. KIBBE and BRIAN KLEPPER</span></h2><h2><span style="font-size: small; font-weight: normal;"><i>First Published on <a href="http://www.thehealthcareblog.com/the_health_care_blog/2010/04/clinical-groupware-platforms-not-software.html">THCB</a></i> </span></h2><a href="http://www.thehealthcareblog.com/.a/6a00d8341c909d53ef0134801a234c970c-pi" style="float: right;"><img alt="Kibbe" class="asset asset-image at-xid-6a00d8341c909d53ef0134801a234c970c " src="http://www.thehealthcareblog.com/.a/6a00d8341c909d53ef0134801a234c970c-320wi" style="height: 165px; margin: 10px; width: 136px;" title="Kibbe" /></a> Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools.<br />
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Since David first articulated Clinical Groupware's conceptual framework on this blog early last year -- see <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/02/why-clinical-groupware-may-be-the-next-big-thing-in-health-it.html">here</a> and <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/06/clinical-groupware-when-notasgood-is-actually-better.html">here </a>-- we've been discussing Clinical Groupware with a growing number of people and organizations who want to know what it is, where it's going, and what problems it may solve, particularly for small and medium size medical practices, their patients and their institutional/corporate sponsors and networks. <br />
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Clinical Groupware heralds a shift away from medical applications that are primarily based in local hardware and software. It creates a more fluid functionality in those applications, and empowers communications as well, by leveraging Internet connectivity, Web-based data resources, and new services (i.e., capabilities) performed upon these data by agents or applications.<br />
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In other words, Clinical Groupware is about platforms that can integrate modular applications, which in turn are supported by subsystems of data services. Although it is still in its infancy, Clinical Groupware is an end-to-end digital revolution in health IT.<br />
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It is still too early for a single best example of Clinical Groupware to have emerged. The creation of platforms, modules, and data services in health care has begun only recently, fueled by and borrowing from developments in popular computing that include search, social networking, geo-location, identity management, photo and music-sharing protocols, and remote storage.<br />
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Clinical Groupware is sometimes understood in terms of "remote hosting" or an "application service model" (ASP) of software. It is true that this might be a starting point for some users. But as a phenomenon, it is far more powerful than simply running a software program over the Internet instead of on your computer or local area network.<br />
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<a href="http://radar.oreilly.com/2010/03/state-of-internet-operating-system.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+oreilly/radar/atom+%28O%27Reilly+Radar%29&utm_content=Google+Reader">Tim O'Reilly</a> uses "Internet as operating system" as a short-hand way of describing the robust complexity of features and functions available to users of today's browser-based and mobile computing platforms. This approach contrasts markedly with the older client-server computing model. In client-server arrangements, a computer-resident operating system coordinates access to applications and machine resources on a single or, at most, a few computers on a network. In the "Internet as OS" model, the Internet itself coordinates that access across large numbers of computers and users. <br />
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The browser or the smart phone may be the means of gaining access to this new and rich "compu-cology," to coin a term. But what really matters most of the time is what is happening between your interfacing device and the many applications on the net that it can reach.<br />
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Consider the difference between the mere delivery of an application, such as an ePrescribing software program, over the Internet, versus the richness and complexity of two very popular, although very different computing platforms, Google apps and the iPhone with its app store.<br />
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Google's core competency is, of course, its search technology, which almost instantaneously takes the search string from your browser or mobile phone and serves it up to Google's proprietary software at one or more of its massive server farms. But Google also offers free (or very inexpensive) applications such as calendaring, email, photo organizing and sharing, word processing and presentations, mapping, etc. most of which are capable of sharing, indexing, and processing several different types of information in the background in a connected manner. Thus, at the push of a button while in Picasa Web Album, Google's online photo storing/organizing application, one can publish individual photos, or whole albums, to groups of people in one's Gmail account, while also allowing those people to upload new photos to some albums, but not others. It is also easy to place photos on a map location, view both photos and maps in Google Earth, and then share these with others. In each case there are complex data look-ups and indexing occurring, mediated by Internet protocols for identity management and access permissions, in the background.<br />
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The iPhone is a more proprietary platform - a "walled garden" in the jargon of the day - that integrates multiple data processing activities, some of which are hardware resident and others that occur online. Its wireless capability supports access to the Web, which can integrate with the built-in GPS location services that are in communication with satellites circling the earth. This arrangement can tap into a world-wide technical infrastructure that can help you find the nearest Chinese food restaurant or get to a nearby hospital trauma center. It can allow you to search for a doctor, map the location of the doctor's office, and get performance ratings on that physician's or organization's quality and service. Many different applications "run on" the iPhone device, but they depend on what O'Reilly calls "network available services" for value creation that far exceeds the features of the phone itself.<br />
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In other words, these new Web-based platforms allow distinct functions to interact with and leverage one another, creating a robustness of capability and productivity that was unthinkable in earlier, more limited hosted arrangements. Thinking of these platforms as merely running remotely-hosted applications is to miss their possibilities. Clinical Groupware, a very powerful and practical medical application of this model, is the revolution ahead that will foster intense competition among vendors vying for platform real estate.<br />
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Still skeptical? In fact, the leadership at ONC/HHS have already realized that the future of Health IT lies in a whole that is greater than the sum of its parts.<br />
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In early April, ONC awarded $60 million to four institutions - Mayo Clinic, Harvard University, University of Texas Health Science Center at Houston and University of Illinois at Urbana-Champaign - through the Strategic Health IT Advanced Research Projects (SHARP) program. Each institution's research projects will identify short- and long-term solutions to address key challenges associated with health IT and meaningful use. John Halamka recently blogged about the Harvard research, which will "investigate, evaluate, and prototype approaches to achieving an “iPhone-like” health information technology platform model, as was first described by Mandl and Kohane in a March 2009 Perspectives article in The New England Journal of Medicine." Further, Halamka writes:<br />
The platform architecture, described as a “SMArt” (Substitutable Medical Applications, reusable technologies) architecture, will provide core services and support extensively networked data from across the health system, as well as facilitate substitutable applications – enabling the equivalent of the iTunes App Store for health.<br />
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This new approach to a health information infrastructure was the focus of a June 2009 working group meeting at the Harvard Medical School Center for Biomedical Informatics and an October HIT meeting which brought together more than 100 key stakeholders across academia, government and industry in an exploration of innovative ways to transform the national health IT system.<br />
One of the challenges facing the Clinical Groupware, modular application approach, is that of data exchange between apps and data integration among several different apps. It is clear that the Harvard SHARP research grant will have these problems as high priorities for solutions during 2010 and 2011.Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-20126562761761174662010-04-09T05:33:00.001-04:002010-08-28T05:42:20.084-04:00A Self-Fulfilling Prophesy: The Continuity of Care Record Gains Ground As A Standard<span style="font: 14px Calibri;">BRIAN KLEPPER</span><br />
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<span style="font: 14px Calibri;">We live in a time of such great progress in so many arenas that, too often and without a second thought, we take significant advances for granted. But, now and then, we should catalog the steps forward, and then look backward to appreciate how these steps were made possible. They sprung from grand conceptions of possibilities and, then, the persistent focused toil that is required to bring ideas to useful fruition.</span><br />
<div class="blog-entry-body"><span style="font: 14px Calibri;">We could see this in </span><span style="font: 14px Calibri;"><a href="http://wistechnology.com/articles/5859/" rel="external" target="_blank">a relatively quiet announcement</a></span><span style="font: 14px Calibri;"> this week at </span><span style="font: 14px Calibri;"><a href="http://www.himssconference.org/" rel="external" target="_blank">HIMSS 09</a></span><span style="font: 14px Calibri;">. Microsoft unveiled this:<a name='more'></a></span><span style="font: 14px Calibri-Italic;"><em>"</em></span><span style="font: 14px Calibri-Italic;"><em><a href="http://www.microsoft.com/amalga/products/microsoftamalgauis/default.mspx" rel="external" target="_blank">Amalga Unified Intelligence System (UIS) 2009</a></em></span><span style="font: 14px Calibri-Italic;"><em>, the next generation release of the enterprise data aggregation platform that enables hospitals to unlock patient data stored in a wide range of systems and make it easily accessible to every authorized member of the team inside and beyond the hospital - including the patient - to help them drive real-time improvements in the quality, safety and efficiency of care delivery."</em></span><span style="font: 14px Calibri;"><br />
The announcement was amplified by </span><span style="font: 14px Calibri;"><a href="http://www.nytimes.com/2009/04/06/technology/companies/06health.html?_r=2" rel="external" target="_blank">a New York Times article</a></span><span style="font: 14px Calibri;">, earlier this week by Steve Lohr about New York Presbyterian's collaboration with Microsoft, now beyond the pilot stage, to transfer patient data into consumer-controlled personal health records (PHRs). The article acknowledges that Google, as well as Microsoft, are now actively engaged as well with major health care institutions - Mayo Clinic, Cleveland Clinic, Kaiser Permanente - to automatically move patient data into PHRs.<br />
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The facilitating technology in all these efforts is </span><span style="font: 14px Calibri;"><a href="http://www.ccrstandard.com/" rel="external" target="_blank">the Continuity of Care Record (CCR) Standard</a></span><span style="font: 14px Calibri;">. Here is </span><span style="font: 14px Calibri;"><a href="http://en.wikipedia.org/wiki/Continuity_of_Care_Record" rel="external" target="_blank">the Wikipedia entry</a></span><span style="font: 14px Calibri;">, cited in the Microsoft announcement, describing the CCR. It is<br />
</span><span style="font: 14px Calibri-Italic;"><em>"a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one care giver to another.<br />
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Because it is expressed in the standard data interchange language known as XML, a CCR can potentially be created, read and interpreted by any EHR or EMR software application. A CCR can also be exported in other formats, such as PDF and Office Open XML (Microsoft Word 2007 format)."</em></span><span style="font: 14px Calibri;"><br />
The creation of a new industry standard is an immense undertaking of breathtaking audacity, vision, skill and hope. It starts from scratch to craft a highly useful, flexible tool that can be easily adopted by developers, who are focused on wide-ranging aspects of common problems.<br />
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The CCR Standard was developed by a collaborative - the Massachusetts Medical Society[1] (MMS), the HIMSS (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors - under the auspices of </span><span style="font: 14px Calibri;"><a href="http://en.wikipedia.org/wiki/ASTM_International" rel="external" target="_blank">ASTM International</a></span><span style="font: 14px Calibri;">, a not-for-profit organization that develops standards for many industries, including avionics, petroleum, and air and water quality. David Kibbe MD, my friend, colleague and often co-author on the Health Care Blog, was a co-developer of the CCR, and serves as the 2008-2010 chair of </span><span style="font: 14px Calibri;"><a href="http://www.astm.org/COMMIT/COMMITTEE/E31.htm" rel="external" target="_blank">the E31 Technical Committee on Healthcare Informatics</a></span><span style="font: 14px Calibri;">, the leadership group within ASTM that works with individuals and organizations on the implementation and use of the CCR standard in the US and abroad,<br />
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The CCR's increasing adoption by major players is testament to the soundness of its vision and its utility. It's advance will allow patient health data to be easily transported from one platform to another, intact and with integrity, so that better decisions can positively impact care, health, and the costs of achieving them.<br />
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This is something we can all acknowledge and admire, because it fulfills the common mission - better, more affordable care for better health - that brings us together on this site.</span></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-1774194156502154592010-04-05T11:20:00.006-04:002010-08-27T11:40:00.548-04:00Are We Adequately Securing Health Care Information?<span style="color: #535353;">By BRIAN KLEPPER AND DAVID KIBBE</span><br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/_GxIbBXVl5Lk/THfYXTzmKQI/AAAAAAAAJFE/ws5jLgalQMg/s1600/recoveryplan.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="176" src="http://1.bp.blogspot.com/_GxIbBXVl5Lk/THfYXTzmKQI/AAAAAAAAJFE/ws5jLgalQMg/s200/recoveryplan.jpg" width="200" /></a></div>In a discussion about electronic health records (EHRs) a couple weeks ago, one of the Human Resource team members at a prospective client said, "I don't believe it's possible to secure electronic health data. It's always an accident waiting to happen."<br />
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There is some truth to that. More and more, our Personal Health Information (PHI) is in electronic formats that allow it to be exchanged with professionals and organizations throughout the health care continuum. It is highly unlikely that each contact point has the protections to wrap that data up tightly, away from those who would exploit it.<br />
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Of course, PHI is among the richest examples of personal data, often with all the key ingredients prized by identify thieves: social security number, birthday, phone numbers, address, and even credit card information. This should give health care organizations considerable pause.<br />
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Then consider that, while paper charts contain the same information, electronic files often aggregate hundreds of thousands or even millions of records, information treasures troves for someone really focused on acquiring, mining and making use of the data.<br />
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Which is what makes a <span style="color: #335583;"><a href="http://krollfraudsolutions.com/about-kroll/HIMSS-Security-Patient-Data.aspx">new health data security survey</a></span> commissioned by <span style="color: #335583;"><a href="http://www.krollfraudsolutions.com/">Kroll Fraud Solutions</a></span> and conducted by <span style="color: #335583;"><a href="http://www.himssanalytics.com/">HIMSS Analytics</a></span>, so provocative. As they had in 2008, HIMSS Analytics found that most provider organizations meticulously comply with data security rules and standards. But they're overly confident about the security that compliance actually conveys. Worse, many remain unaware, until confronted by an event, of the devastating implications of even a minor breach.<br />
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And the threat is intensifying as the market and technology evolve. In 2010, 19 percent of organizations reported a breach, half-again higher than the 13 percent in 2008. Apparently, both the complexity of the environment and the interest in the data are growing. Security may be diminishing as a result.<br />
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And breaches can be hugely costly. A <span style="color: #335583;"><a href="http://www.ponemon.org/local/upload/fckjail/generalcontent/18/file/2008-2009%20US%20Cost%20of%20Data%20Breach%20Report%20Final.pdf">Poneman Institute study</a></span> found an average cost of $6.75 million for organizational data breaches. This figure is not limited to incidents with malicious origins or even harmful consequences. In January 2009, the <span style="color: #335583;"><a href="http://www.boston.com/news/nation/washington/articles/2009/01/28/va_agrees_to_pay_20_million_to_veterans_in_2006_data_breach/">Department of Veterans Affairs</a></span> agreed to pay $20 million to veterans who could show they were hurt when, in 2006, a VA data analyst lost a laptop containing information on 26.5 million patients, nearly every living veteran. The laptop was eventually recovered without apparent data compromise. The VA is now struggling with a<span style="color: #335583;"><a href="http://www.nextgov.com/nextgov/ng_20100309_9888.php?oref=mostread"> new, serious health data breach</a></span>.<br />
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Nor is the impact likely to be financial alone. The larger cost may simply be in the loss of patient confidence. After all, if an organization can't competently manage my data, do I want to hand over management of my family's health?<br />
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Perhaps the HIMSS Analytics' study's most important and penetrating finding is that "health care organizations continue to think of data security in specific silos (IT, employees, etc.) and not as an organization-wide responsibility, which creates unwanted gaps in policies and procedures." Nearly 9 in 10 survey respondents said they have policies in place to monitor access to and sharing of health care information. But more than four-fifths of breaches occur in more mundane ways: e.g., lost/stolen laptops, improper document disposal, stolen tapes. In other words, the holes can't be addressed by isolated approaches.<br />
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Security is a process, not a product. This means that certification of PHI security must be larger than merely plugging the security gaps in information technology, and must extend to the ways that people access and use information and the information technology.<br />
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It is clear that the answers here involve making heath data security an enterprise-wide responsibility, creating highly aware environments resistant to breach in even the most seemingly insignificant interactions. That will demand a significant cultural shift, critically necessary but, as this survey shows, difficult for many organizations' leaders to wrap their heads around.Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com1tag:blogger.com,1999:blog-3499517899392895430.post-88514274492191346772010-04-05T06:07:00.002-04:002010-08-29T06:14:07.627-04:00Editor's inbox: Reader questions breadth of sources in article on onsite clinics<span style="font-family: Arial,Helvetica,sans-serif;">BRIAN KLEPPER</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;"> </span><br />
<span style="font-family: Arial,Helvetica,sans-serif;">First published in <a href="http://ebn.benefitnews.com/news/reader-questions-breadth-of-sources-in-article-on-onsite-clinics-2683284-1.html">Employee Benefit News, April 5, 2010</a></span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">The article "</span><a href="http://ebn.benefitnews.com/news/reconfiguring-onsite-health-clinics-2682842-1.html" style="font-family: Arial,Helvetica,sans-serif;">Reconfiguring onsite health clinics</a><span style="font-family: Arial,Helvetica,sans-serif;">" (EBN February) presented a remarkably limited perspective on modern clinics, resulting in statements like this one: "'In a tough economy, an initial clinic approach should probably employ mid-level practitioners, such as a nurse practitioner or a physician assistant, because they are most cost-effective when rendering basic medical services,' explains Mercer's [Bruce] Hochstadt."</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">Hochstadt may be right in terms of cost alone, but he is most definitely incorrect in terms of creating a medical home, or long term financial impact and return on investment.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">What the article failed to appreciate or convey was that onsite clinics have evolved in several key ways over the last few years. Legacy clinic vendors tend to be heavy on bricks and mortar, and mostly run their clinics like old-fashioned doctors' offices, with few electronic health records and certainly no personal health records, analytics or clinical decision-support tools.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">Some have marginally effective call-center-based disease management and wellness programs, but often insist on copays to curb primary care utilization (as though that's where the money is).</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">As the Sprint/Nextel example described, these structures are expensive to build and run. But they provide little substantive medical management that either swaps higher health plan costs (for office visits, drugs and labs) for cheaper costs inside the clinic, or creates meaningful influence over excessive downstream costs. So they often do not provide savings or quality improvements.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">Newer onsite clinic vendors have developed more streamlined, easier-to-amortize physical plants. Rather than being just an occupational health or group health acute care clinic, they're fully realized, flexible medical management platforms.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">They are often physician-driven which, contrary to the article's thesis, results in significantly greater effectiveness and ROI, and operate best outside of fee-for-service reimbursement. </span><br />
<span style="font-family: Arial,Helvetica,sans-serif;">They induce employee/family participation through incentives like free office visits, free standard drugs and labs, which in turn lends them management control over a much larger portion of care.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">They are heavily invested in Web-based health IT tools, a magnitude less costly and more user-friendly than older technologies. In other words, these clinics are machines that provide targeted solutions to longstanding structural flaws in health care delivery.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">The failure to acknowledge these newer models suggests that no meaningful solutions are available in this sector. But some companies are consistently obtaining real group health savings of 15%-to-30% ROI in the first year, net of the clinic costs, while demonstrably improving quality.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">Though more difficult to quantify, there also are more significant savings in occupational health - workers' comp primary care, disability management, HR testing, retention/recruitment and lost work time.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;"></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;">Those interested in more contemporary, evolved clinics should look at WeCare TLC in Lake Mary, Fla. In addition, it appears that Marathon Health and HealthStat also are similarly focused on applying the best medical management lessons of the last 25 years, while serving as their employers' fiduciary. In each case, these vendors' employer-clients will vouch for the significant cost reductions they've experienced due to far more aggressive models than the article described.</span><br />
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<span style="font-family: Arial,Helvetica,sans-serif;">Brian Klepper, Ph.D. Atlantic Beach, Fla.</span>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-42920030327872293652010-04-02T06:14:00.009-04:002010-08-29T06:20:04.678-04:00Value Trumps Price In Onsite Clinics<span style="font-family: Arial,Helvetica,sans-serif;">BRIAN KLEPPER</span><br style="font-family: Arial,Helvetica,sans-serif;" /><i><br style="font-family: Arial,Helvetica,sans-serif;" /><span style="font-family: Arial,Helvetica,sans-serif;">First published in </span><a href="http://www.bizjournals.com/jacksonville/stories/2010/04/05/editorial3.html?s=industry&b=1270440000%5E3134861&t=printable" style="font-family: Arial,Helvetica,sans-serif;">American City Business Journals </a><span style="font-family: Arial,Helvetica,sans-serif;">(in Boston, Silicon Valley, Jacksonville, Nashville, San Jose and elsewhere.)</span></i><br style="font-family: Arial,Helvetica,sans-serif;" /><br style="font-family: Arial,Helvetica,sans-serif;" /><span style="font-family: Arial,Helvetica,sans-serif;">Onsite health clinics are new territory for most employers. It can be difficult to sort through the different approaches used by different vendors. Worse, in difficult economic times it’s tempting to “get in” as cheaply as possible.But like many purchases, you may get what you pay for with clinics, especially if you scrimp. Here are three reasons to favor value over price when considering an onsite clinic vendor:</span><span style="font-family: Arial,Helvetica,sans-serif;"><br />
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<ul><li><span style="font-family: Arial,Helvetica,sans-serif;"><b>An investment.</b> Most employers believe their health plan expenditures are high enough already. For them, a clinic represents an additional expense, and only makes sense if it can provide a return on investment that lowers overall group health and occupational health costs. Ask vendors for data and testimonials that their clinics save money and improve the quality of care.</span><span style="font-family: Arial,Helvetica,sans-serif; font-size: small;"><span></span></span></li>
</ul><ul class="disc" style="font-family: Arial,Helvetica,sans-serif;"><li><span style="font-size: small;"><span><b>Many impacts</b>. Properly configured, clinics do far more than reduce costs for office visits, drugs and lab tests. They can positively impact the chronic diseases that consume two-thirds of a health plan’s costs. They can influence specialty and inpatient care, which the Dartmouth Atlas shows have the highest concentrations of waste. And they can affect the five major areas of occupational health — workers’ compensation primary care, disability management, human resources testing (pre-employment screens, drug screens, Department of Transportation exams), retention/recruitment and lost work time — that, together, cost two to three times as much as a group health premium.</span></span></li>
</ul><span style="font-family: Arial,Helvetica,sans-serif; font-size: small;"><span></span></span><ul class="disc" style="font-family: Arial,Helvetica,sans-serif;"><li><span style="font-size: small;"><span><b>Total effectiveness results from a clinic’s component medical management mechanisms</b>. Optimizing quality and cost within the complexity of health care requires assembling an array of tools and programs, each targeted to a specific health care problem. Each approach has dedicated costs, but most also produce savings that outweigh their expenses.</span></span></li>
</ul><div style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span></span><span>For example, incentives such as free office visits, laboratory tests and free standard drugs, mostly low-cost generics, induce employees to use the clinic and help the primary care staff gain more control over the care process. Physicians cost more than nurse practitioners, but are more likely to create a fully realized medical home and have a better chance of influencing downstream care.</span></span></div><div style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span><br />
Clinical analysis and decision support tools help identify patients with health risks or gaps in care that deserve attention. Onsite, face-to-face disease management programs have a far better chance of influencing chronic disease costs than call center programs.<br />
</span></span></div><div style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span>Modern clinics are a powerful innovation in an employer’s benefits arsenal. But they must be robust to be effective, integrating a variety of proven mechanisms. With those properly in place, the results can be quantifiable improvements in health care quality, cost and employee morale.<br />
</span></span></div><div style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span>In other words, a clinic’s cost may be important. But the value — the benefit you receive for the cost — should be the reason you implement a clinic. It will certainly be how you’ll judge your investment.</span></span></div>Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-87763001607578391582010-03-22T11:24:00.004-04:002010-08-27T11:40:37.242-04:00On Really Managing Care and CostBRIAN KLEPPER<br />
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One of my favorite health care stories is about <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/06/datadriven-health-care-an-interview-with-jerry-reeves-md.html">Jerry Reeves MD</a>, who in 2004 took the helm of a 300,000 life health plan in Las Vegas, including about 110,000 union members, and drove so much waste out of that system - without reducing benefits and while improving quality - that the union gave members a 60 cent/hour raise. There was no magic here. It was a straightforward and rigorously managed combination of proven approaches.<br />
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Dr. Reeves' work betrayed the lie that tremendous health care costs are inevitable. To a large degree, the nation's major health plans abetted this perception when they effectively <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/03/will-cigna-remake-the-health-plan-marketplace.html">stopped doing medical management in 1999</a>. (Most have recently begun managing again in earnest.) The result was an explosion in cost - 4 times general inflation and 3.5 times workers earnings between 1999 and 2009 - that has priced a growing percentage of individual and corporate purchasers out of the health coverage market, dangerously destabilizing the health care marketplace and the larger US economy. In 2008, PriceWaterhouse Coopers published <a href="http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml">a scathing analysis</a> suggesting that $1.2 trillion (55%) of the $2.2 trillion health care spend at that time was waste.<br />
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Barbara Barrett was trained as a paralegal. She is now General Manager of <a href="http://www.thelangdalecompany.com/tlc-benefit-solutions-inc/">TLC Benefit Solutions, Inc</a>., the benefits management arm of Valdosta, GA-based <a href="http://www.thelangdalecompany.com/">Langdale Industries, Inc</a>., a small conglomerate of 24 firms with 1,000 employees, engaged primarily in wood products for the building construction industry, but also in car dealerships, energy and other concerns.<br />
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Valdosta is rural, which puts health benefits programs at a disadvantage. Often there is only one hospital nearby and so little cost competition. Rural Georgians also may have lifestyles that make them prone to chronic diseases, which are expensive. And so on. You get the idea.<br />
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Here's the interesting part. Since 2000, when Barbara assumed responsibility for the management of Langdale's employee health benefits, per employee costs have risen from $5,400/year per employee to $6,072/year per employee in 2009. That's an average health plan cost growth of 1.31 percent per year.<br />
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As the chief sponsors for most Americans' health coverage, businesses have struggled to cope with health care cost while identifying value. Large American businesses, with tens or hundreds of thousands of employees, have recruited high profile benefits professionals - think of <a href="http://www.healthqualityalliance.org/member-center/members/jill-berger">Jill Berger</a> at Marriott, <a href="http://blogs.pitch.com/plog/2009/04/reporters_notebook_for_the_cur.php">Ned Holland</a> at Embarq, <a href="http://www.vbhealth.org/about/leadership/board/peter-hayes-m-d">Peter Hayes</a> at Hannaford Brothers or (the recently retired) <a href="http://microsoftjobsblog.com/blog/cecily-hall-meets-president-barack-obama/">Cecily Hall</a> at Microsoft, each with terrific reputations - who, with their staffs, orchestrate sophisticated campaigns focused on the health of their employees and their families, and on the cost-effectiveness of their programming. Even so, few large firms provide comprehensive, quality benefits at a cost that remains consistently below national averages, and <a href="http://www.workforce.com/section/00/article/24/60/59.php">for years now</a> America's CEOs have routinely reported that their top business concern, health care, is their most unpredictable, large cost.<br />
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For mid-sized business, though, - here I'm referring to firms with 200-5,000 employees - the task is significantly more difficult. Health benefits managers in these companies have far fewer resources, typically work alone without the benefit of staff, and are often overwhelmed by the complexity of their tasks. Held accountable for their organizations' health costs, they often default to whatever the brokers and health plans suggest.<br />
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But a few excel. For them, managing the many different issues - e.g., chronic disease, patient engagement, physician self-referrals, specialist and inpatient over-utilization, pharmacy management - is a discipline. A couple years ago, I was introduced to someone like this.<br />
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I compared Langdale’s health plan cost growth to the average commercial coverage inflation rate for an employer with 200+ employees provided in <a href="http://kff.org/insurance/7936/index.cfm">the Kaiser Family Foundation/Health Research and Educational Trust (KFF/HRET) 2009 Employer Health Benefit Survey</a>. The calculation showed that, in that nine years, Barbara's management allowed Langdale to provide its 1,000 employees and their families with comprehensive medical, dental and drug benefits for $29 million less than the average of other firms that size. That's a nine year savings of $29,000 per employee, or an average of $3,200 per employee per year lower than the national average. All without reducing benefits or transferring the cost burden to employees, and while quantitatively improving quality.<br />
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<img src="http://brianklepper.info/page2/page85/files/langdale002b32210.jpg" /> <br />
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So how did Barbara approach the problem? Here are a few of her steps:<br />
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Under her leadership, Langdale set up TLC Benefit Solutions, a HIPAA-compliant firm that administers and processes Langdale's medical, dental and drug claims. This allowed Barbara to more directly track, manage and control claim overpayments, waste and abuse. <br />
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The claims also gave her immediate access to quality and cost data on doctors, hospitals and other vendors. She supplements these data with external information, like Medicare cost reports for hospitals in the region. This allows her to identify physicians and hospital services that provide low or high value. She then created incentives that steer patients to high value physicians and services and away from low value ones. When complex services necessary to treat certain conditions are not available or of inadequate quality or value locally, she shops the larger region, often sending patients as far away as Atlanta, three and a half hours away. <br />
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She analyzes the claims data to identify which patients have chronic disease and which patients are likely to have a major acute event over the next year. Chronic patients are directed into the company's opt-out disease management/wellness/prevention program. Acute patients are connected with a physician for immediate intervention. <br />
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She provides Langdale's employees and families with confidential health advocate services that explain and encourage use of the company's wellness, prevention and disease management programs. And she uses incentive programs to reward patients who enter these programs and meet targets. <br />
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Barbara has mounted many more initiatives in group health, but her responsibilities also extend to life, flex plan, supplemental benefits, retirement plan, workers’ compensation, liability and risk insurance. The results for Langdale in these areas include lower than average absenteeism, disability costs and turnover costs.<br />
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The point is that Ms. Barrett and Langdale have been pro-active, endlessly innovative, and aggressive about managing the process. That attitude and rigor has paid off through tremendous savings, yes, but it has also produced a desirable corporate environment that demonstrates that Langdale values its employees and the community. The employees and their families are healthier as a result, and are more productive at work. This has borne unexpected fruit. The industries Langdale is in have been hit particularly hard by the recession, and the benefits savings Barbara’s efforts generate have helped save jobs.<br />
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Barbara Barrett and many others like her on the front line are virtually unknown in health care. Most often, their achievements go unnoticed beyond the executive offices. But they manage the health and costs of populations in a way that all groups should and could be managed.Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-29775603883022680302010-03-20T11:41:00.009-04:002010-08-27T14:14:53.555-04:00Vote YesBRIAN KLEPPER and DAVID C. KIBBE <br />
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<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/_GxIbBXVl5Lk/THfdQlPuC6I/AAAAAAAAJFM/pByPgzdwfU0/s1600/reform.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="265" src="http://2.bp.blogspot.com/_GxIbBXVl5Lk/THfdQlPuC6I/AAAAAAAAJFM/pByPgzdwfU0/s400/reform.jpg" width="400" /></a></div><br />
One of us was at a local diner yesterday, when a good friend and health plan broker walked up to say hello. This guy delivers premium increases every day to employers, and understands how broken things are. "I hope Congress votes yes," he said flatly. "We've got to finally move beyond the status quo and try to change the system."<br />
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As conflicted as we are over it, we agree and we hope it passes. The die is now cast, so there is no point in <span style="color: #002be1;"><u><a href="http://www.thehealthcareblog.com/the_health_care_blog/2010/03/after-the-failure-of-reform.html">continuing to urge a different approach</a></u></span>. As terribly flawed as it is on cost controls, the bill represents two very important things that, in our opinion, the nation desperately needs.First, it will significantly open access, bringing America much closer to universal coverage and making personal financial distress a much less likely outcome of sickness or injury. As Nicholas Kristof <span style="color: #002be1;"><u><a href="http://www.nytimes.com/2010/03/18/opinion/18kristof.html">pointed out </a></u></span>Wednesday, that alone will dramatically improve the health of the nation. Widespread uninsurance and under-insurance have been a national disgrace for decades. Passing this bill would be a commitment to move beyond that shame.<br />
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Second, we believe the President is attempting to deal with many difficult problems thoughtfully and in good faith within an extremely toxic political environment. We want to see him succeed, because we think that his approach is good for America.<br />
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The bill is not what we hoped for. We're disappointed in the behaviors of both parties. But after a year of wrangling, it is what is possible now. There is no reason the bill's inadequacies can't be revisited.<br />
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We hope Congress votes Yes on this bill. Making care and coverage more accessible and more fair would be a momentous and long overdue achievement.Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-6866601611612478072010-03-14T11:45:00.002-04:002010-08-27T11:47:56.143-04:00The SurpriseBRIAN KLEPPER <br />
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Check out this March 3rd article - see the image - from the recent HIMSS conference, in which Dave Garets, President and CEO of <span style="color: #002be1;"><a href="http://www.himssanalytics.org/">HIMSS Analytics,</a></span> "gazes into the future and predicts major trends for the next 12 months." HIMSS Analytics is the research and consulting arm of the health IT vendors' association, and presumably on Health IT's leading edge.<br />
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From the article:<br />
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<i>"Q: What will constitute the surprise of 2010 - the one technology or policy or X-factor that no one saw coming."<a name='more'></a><br />
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"A: Clinical groupware in the ambulatory market that may be the disruptive innovation of ambulatory EMRs."</i>For the uninitiated, "Clinical Groupware" is a term that is rapidly gaining traction and that describes a new wave of inexpensive, ergonomic, useful Web-based care management tools. <span style="color: #002be1;"><a href="http://www.medpedia.com/users/68">David Kibbe</a></span> coined the phrase and articulated Clinical Groupware's conceptual framework on this blog early last year - see <span style="color: #002be1;"><a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/02/why-clinical-groupware-may-be-the-next-big-thing-in-health-it.html">here</a></span> and then <span style="color: #002be1;"><a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/06/clinical-groupware-when-notasgood-is-actually-better.html">here</a></span>. He noted that it:<br />
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<i>"...captures the basic notion that the primary purpose for using these IT systems is to improve clinical care through communications and coordination involving a team of people, the patient included. And in a manner that fosters accountability in terms of quality and cost."</i><br />
Dr. Kibbe formulated his ideas, not in isolation, but in continual discussions with innovators developing great new care management tools - e.g., <span style="color: #002be1;"><a href="http://www.docsite.com/">Docsite</a></span>, <span style="color: #002be1;"><a href="http://www.keas.com/">Keas</a></span>, <span style="color: #002be1;"><a href="http://www.relayhealth.com/">Relay Health</a></span>, <span style="color: #002be1;"><a href="http://www.visiontree.com/">VisionTree</a></span>, <span style="color: #002be1;"><a href="http://www.medicity.com/">Medicity/NOVO</a></span>, <span style="color: #002be1;"><a href="http://www.salesforce.com/">Salesforce</a></span>, <span style="color: #002be1;"><a href="http://www.practicefusion.com/">Practice Fusion</a></span> - that were realizations of the concept in one form or another. A group of these like-minded developers founded the <span style="color: #002be1;"><a href="http://clinicalgroupwarecollaborative.com/">Clinical Groupware Collaborative</a></span>, led now by Steve Adams, the founder of <span style="color: #002be1;"><a href="http://rmdnetworks.com/">RMD Networks</a></span>. If you're working in this or an aligned area, consider joining.<br />
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Which is all by way of saying that it is a stretch to say that "no one," especially HIMSS, saw this coming. From the moment that HIMSS became aware of Clinical Groupware - <span style="color: #002be1;"><a href="http://cchit.org/sites/all/files/EHRCertificationTownHallHIMSS20100305.pdf">it's newfound religion on Web-based and modular approaches notwithstanding</a></span> - influential members were concerned about the trend's disruptiveness. After all, if you're selling EHRs for $25,000 per physician and a new competitor comes along with complete systems or highly useful modular components for a fraction of that - or even <span style="color: #002be1;"><a href="http://practicefusion.com/">free</a></span>! - the pricing shift will wreak havoc on your revenue and market cap. It's enough to give even the most enthusiastic free marketeer the willies.<br />
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That concern found expression through HIMSS influence over <span style="color: #002be1;"><a href="http://www.cchit.org/">CCHIT</a></span>'s - the Certification Commission for Health Information Technology - certification process. CCHIT's criteria were initially spun to favor HIMSS members' products, mostly old-fashioned client-server tools that are complex and not interoperable, and to <span style="color: #002be1;"><a href="http://www.healthleadersmedia.com/content/235965/topic/WS_HLM2_TEC/HIT-Panelist-Bashes-CCHIT-as-Legacy-Vendors-Puppet.html">stifle support of newer, more streamlined solutions like Clinical Groupware</a></span>. Remember that, early on, everyone thought CCHIT certification would be the criterion for receiving ARRA HITECH stimulus funding, so the criteria could be used to steer the money, conflicts of interest notwithstanding. Fortunately, cooler heads prevailed on the HHS Policy Committee and that heist was averted, or at least it seems so at this point.<br />
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The good news is that Dave is right. Clinical Groupware is evolving rapidly and will seamlessly link tools, care teams and patients. It does look disruptive and undoubtedly is the future. If they're watching, this should give serious pause to all those investors <span style="color: #002be1;"><a href="http://www.thehealthcareblog.com/the_health_care_blog/2010/03/glen-tullman-allscripts.html">driving up Allscripts stock price</a></span>.<br />
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Because, in the end, many old-guard EHRs - the ones Clinical Groupware will replace - produce dreadful customer experiences like <span style="color: #002be1;"><a href="http://www.thehealthcareblog.com/the_health_care_blog/2010/03/its-not-about-meaningful-use-.html">the one described recently by John Moore</a></span>. His article described a market begging for innovation, where the old guard is locked into its past market domination and excessive pricing, and the users are increasingly frustrated.<br />
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Of course the irony here is that Clinical Groupware will most surprise and disrupt HIMSS' member organizations, the core of Mr. Garet's constituency, who thought the matter was settled a year ago.Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0tag:blogger.com,1999:blog-3499517899392895430.post-36059427113244720792010-03-08T11:48:00.002-05:002010-08-27T11:55:30.932-04:00Why Rush Vendor Certification of EHR TechnologiesDAVID C. KIBBE and BRIAN KLEPPER<br />
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A surprise move by ONC/HHS indicates the wheels may be falling off health IT reform at about the same rate they've fallen off Democrats' broader health reforms.<br />
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David Blumenthal and his staff have unveiled two separate plans to test and certify EHR technology products and services. We don't think this is a good idea. We've supported the purpose and spirit of the ARRA/HITECH incentive programs, and believe ONC's/HHS' re-definition of EHR technology puts it on a trajectory to improve the quality and efficiency of health care in the U.S. But this recently-announced two-stage EHR technology certification plan bears all the marks of a hastily drawn up blueprint that, if rushed into production, could easily collapse of its own bureaucratic weight.<br />
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The new Proposed Rule puts vendors through the wringer, twice. As defined by ONC, vendors with "complete EHRs" and those with "EHR modules" will have to find an "ONC-approved testing and certification body" (ONC-ATCB) that will take them through a "temporary certification program" from now until end of 2011. Then in 2012, under a "permanent certification program," they'll have to switch over to a National Voluntary Laboratory Accreditation Program (NVLAP)-accredited testing body for testing, after which they must seek an "ONC-approved certification body" (ONC-ACB, not to be confused with ONC-ATCB) that can provide certification. The ONC-ATCB will be accredited by ONC, but the ONC-ACBs will be accredited by an "ONC-approved accreditor" (ONC-AA).<br />
Confused? This is just the start. We can't imagine many federal agency Notices of Proposed Rule Making (NPRM) that have created, in a single document, more new acronyms. And the prose in the document can challenge even the most focused minds. For example, the drafters of the NPRM recognize that things could get a little complicated, saying:<br />
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"Should CMS finalize its proposed staggered approach for meaningful use stages, we recognize that some confusion within the HIT industry may arise during 2013 and 2014 because of this apparent inconsistency and the divergent use of the term “meaningful use.”<br />
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But, then they go on to clarify:<br />
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"We would anticipate, therefore, that ONC-ACBs would clearly indicate the certification criteria used when certifying Complete EHRs and/or EHR Modules, and identify certifications according to the calendar year and month rather than the meaningful use stage to reflect the currency of the certification criteria against which the Complete EHRs and/or EHR Modules have been certified. Consequently, if an eligible professional or eligible hospital were seeking to obtain a certified Complete EHR or certified EHR Module in 2014, for instance, that eligible professional or eligible hospital would look for Complete EHRs and EHR Modules certified in accordance with certification criteria current in 2014, rather than Complete EHRs and EHR Modules certified as meeting certification criteria intended to support meaningful use Stage 1, Stage 2, or Stage 3. We request comments on ways to ensure greater clarity in the certification of Complete EHRs and EHR Modules."<br />
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Got that? Glad they're requesting comments, though we're not sure where to start. The use of the word "staggered" to describe ONC's programs is apt: this new NPRM is going to leave a lot of people staggering, as in punch drunk.<br />
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We would like to see ONC and HHS abandon temporary certification in favor of a single, permanent certification process, even if it means delaying testing and certification until mid- or late 2011. The hurry appears to be related to the need to have at least some EHR technology tested and certified by the end of 2010, so at least some physicians and hospitals can meet the meaningful use criteria. That would require them to use "certified EHR technology" by the official start year for the incentive programs, 2011.<br />
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But we don't think this timetable makes sense any longer, and the rush may jeopardize the whole program. Between meaningful use, accreditation, testing, and certification, there are simply too many moving parts to implement and coordinate in too short a time.<br />
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Delays seem inevitable. For example, we know that the release of the meaningful use final rule will be postponed until early summer and perhaps longer due to the large number of comments received and their implications. A consortium of physician membership groups will soon recommend that the meaningful use criteria be simplified. It also predicts that many small and medium sized medical practices will sit on the sidelines during 2011 and 2012, rather than rush into risky attempts to meet the meaningful use requirements. In addition, CMS has said it won't be ready to accept EHR technology product and service data until 2012, at the earliest. That timeline could be ambitious by about a year.<br />
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The ONC/HHS interim final rule (IFR) may have inadvertently caused another kind of delay. It set initial standards and implementation specifications for EHR technology - we applauded this - endorsing a modular EHR technology approach that opens the door to industry innovation. But it will take time for market entrants to bring modules and components to their customers, and perhaps longer to integrate different EHR vendors' modules in plug-and-play fashion. In other words, by opening up the market, ONC/HHS created circumstances that will almost certainly delay the goals it seeks.<br />
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So what if, to get the certification process right, ONC were to postpone payments by one year? It would be worth it.<br />
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The "permanent certification" plan in this new NPRM is very reasonable. Under it, NIST would be involved in setting up the testing of EHR technology software under the auspices of the National Voluntary Laboratory Accreditation Program. A single accrediting body would be chosen by ONC/HHS to oversee, supervise, and accredit the certification entities, following established international standards, including the International Organization for Standardization's (ISO) standards 17011 and Guide 65, that have guided conformity assessment in numerous industries, and ISO 17025 that is used for assuring quality of testing and calibration laboratories.<br />
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So each vendor would follow an orderly progression: first, ensuring that the product meets the technical testing criteria and then, having passed those technical tests, moving on to certification. The stability of this process has much to commend it.<br />
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We're not alone in thinking that delaying the EHR incentives start date is a good idea. At a HIMSS session on Monday, March 1, Congressman Tom Price (R-Ga.), an orthopedic surgeon, said that ONC's delay in issuing guidance on the certification process has prompted him to organize Congressional members. They'll send a letter to federal officials asking to postpone the start date for for demonstrating meaningful use to qualify for incentive payments. Price said members of Congress are currently collecting signatures for the letter and could send it to HHS within a week.<br />
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David Blumenthal is smart, dedicated, and is hiring many talented, experienced people into ONC. But rushing ARRA/HITECH's policy and statute beyond what is humanly possible could ultimately be at cross-purposes with the very goals they're trying to achieve.Anonymoushttp://www.blogger.com/profile/04601782822996620271noreply@blogger.com0