The Year of Reform

BRIAN KLEPPER

Originally published 12/23/10 on iPractice.

“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.”

William Osler, MD, 1849-1919

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.

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.

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.

Clinics As Health Care's Transformational Engines

BRIAN KLEPPER


Originally Published 12/1/10 in Medical Home News

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.

If Employers Walked Away From Health Coverage

BRIAN KLEPPER & DAVID C. KIBBE

Originally Published on 11/24/10 on Kaiser Health News

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?

It isn't so far-fetched. Enrollment by working age families in private health coveragedropped 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.

Keeping An Eye On The Health Care Prize

Published on Kaiser Health News, 9/20/10

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.

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 half or more of all expenditures wasted or unnecessary. But it was also a recipe for national disaster. Over the last decade, nearly all U.S. economic growth was absorbed by health care.

Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT

DAVID C. KIBBE and BRIAN KLEPPER


Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. 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.

An Open Letter (1) to the New National Coordinator for Health IT - Untying HITECH's Gordian Knot

DAVID C. KIBBE and BRIAN KLEPPER

First Published on THCB.

Congratulations to David Blumenthal on being named National Coordinator for Health Information Technology (ONCHIT). 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.

The job is fraught with difficulties, which Dr. Blumenthal has readily acknowledged. His recent New England Journal of Medicine (NEJM) Perspective, "Stimulating the Adoption of Health Information Technology," 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.

The country needs Dr. Blumenthal to succeed. The issues are complex and, with huge ideological and financial stakes involved, politically charged.

Clinical Groupware: Platforms, Not Software

DAVID C. KIBBE and BRIAN KLEPPER

First Published on THCB

Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools.

Since David first articulated Clinical Groupware's conceptual framework on this blog early last year -- see here and here -- 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.

A Self-Fulfilling Prophesy: The Continuity of Care Record Gains Ground As A Standard

BRIAN KLEPPER

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.

We could see this in a relatively quiet announcement this week at HIMSS 09. Microsoft unveiled this:

Editor's inbox: Reader questions breadth of sources in article on onsite clinics

BRIAN KLEPPER


First published in Employee Benefit News, April 5, 2010

The article "Reconfiguring onsite health clinics" (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."

Value Trumps Price In Onsite Clinics

BRIAN KLEPPER

First published in American City Business Journals (in Boston, Silicon Valley, Jacksonville, Nashville, San Jose and elsewhere.)

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:

13 Questions to Ask On-Site Clinic Vendors

BRIAN KLEPPER

First published in Workforce Management Online

Commentary: How can you evaluate which clinics are the best? Here, in the opinion of a health care analyst and clinic company advisor, are some questions and rationales to help identify the vendors that will be most likely to provide the best possible experience, quality improvement and savings.

Thinking about opening a primary care clinic at your business site? Many organizations are.
 
Work-site medical clinics are catching on as employers discover they can save significant dollars and improve the care for their employees and families. Clinic vendors’ medical management and business models vary dramatically, however, and, as a result, so do their impacts on cost and quality.

DAVID C. KIBBE and BRIAN KLEPPER

 

Right now, American health care information technology is undergoing two enormous leaps. First, it is moving onto Web-based and mobile platforms - which are less expensive and facilitate information exchange - and away from client-server enterprise-centric technologies, which are more expensive and have limited interoperability. In addition, more EHR development activity is headed into the cloud, driven by large consumer-based firms with the technological depth to take it there. Both these trends will facilitate greater openness, lower user cost, improved ease of use, and faster adoption of EHRs.

But they could also impact the shape of EHR technologies in another profoundly important way. What is often lost in our discussions about electronic health record technology in the US is the relationship these tools have to our health and health care problems...globally. We could be designing our health IT in ways that are good for the health of people both here and around the world, not simply to enhance care in the US.

2009: A Year of Surprises and Change for the EHR Technology Market

DAVID C. KIBBE and BRIAN KLEPPER

2009 began with a bang for legacy Electronic Health Record (EHR) vendors, promising strong sales and windfall profits on the heels of stimulus package incentive bonuses initially worth more than $19 billion to doctors and hospitals. But things changed dramatically along the way.

Here ten surprises and notable events that have impacted the EHR market:

The NHIN and the Health Internet: A Matter of Cost, Control and Timing

DAVID C. KIBBE and BRIAN KLEPPER 

There is growing tension within the Obama administration's health team over who will control health data exchange: everyone (including consumers and their doctors), or just large provider organizations. The public debate will be framed in terms of privacy, security, and the adequacy of current exchange standards. But what really matters is who gets to make decisions about where health data resides, how it can be accessed, how much exchange will cost, and how long it will take for exchange to become routine.

Will Business Force Reform Back To The Drawing Board

BRIAN KLEPPER and DAVID C. KIBBE

Until now, non-health care business has been noticeably absent from the health care reform proceedings , and quiet about the bills' impacts on their management of employee benefits, on cost, and on the larger issues of global competitiveness. Where have the voices been of the powerful business leaders who will pick up much of the tab?

They've finally surfaced, and now we'll see whether they have the will to bring reform back on track. They certainly have the strength. The question is whether this salvo by the business mainstream could force Democrats to reconsider and revise the content and structure of their proposals.

Saving Health Care. Saving America

BRIAN KLEPPER, DAVID C. KIBBE, ROBERT LASZEWSKI and ALAIN ENTHOVEN

So far, Congress' response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors' interests rather than to those of the American people. More than 3,330 health care lobbyists - six for every member of Congress - contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, "A person can reach no other conclusion than this is a quid pro quo [this for that] activity."

Why Standards Matter (2): Health IT Enters a New Era of Regulatory Control

DAVID C. KIBBE and BRIAN KLEPPER
 
The recent history of electronic medical records in ambulatory care, or what we now call EHR (electronic health record) technology, can be divided roughly into three phases. Phase I, which lasted approximately 20 years, from about 1980 to the early 2000's, was an era of exploration and early adaptation of computers to outpatient medicine. It coincided with the availability of PCs that were cheap enough to be owned by many doctors, and with the increased capacity of off-the-shelf software programs, mainly spreadsheet and database management systems such as Lotus, Excel, Access, and Microsoft's SQL, to lend themselves to computerized capture of health data and information.

Health 2.0 2009 - Key Health 2.0 Issues for Reform

Will Republicans Be Spoilers or Problem-Solvers on Health Care Reform

BRIAN KLEPPER and DAVID C. KIBBE

In theory Congress' return from recess next week could offer a new beginning to the health care reform process, giving everyone a chance to take a deep breath and recalibrate the components of change.

Nine months into the wrangling around a new Administration, the talk-show right has seemingly hijacked the discussion on health care, Democrats' signature issue, with the standard tools that demagogues have always used: leveraging popular prejudices with oversimplification, hyperbole, and distortion. The die-hard GOP faithful's leaders - Gingrich, Palin and others (see this off-the-deep-end speech by Rep. Mike Rogers (R-Mich)) - are of course playing spoilers, independent of the cost. They hope to goad centrist voters into abandoning the Democrats so they can retake power. Witness South Carolina Republican Jim DeMint's comment, "If we're able to defeat Obama on this, it will be his Waterloo. It will break him."

Health Care Reform's Deeper Problems

BRIAN KLEPPER and DAVID C. KIBBE

Congress' health care reform debate has highlighted how American governance is broken and the difficulty of addressing our national problems.

Take, for example, whether health care is in crisis at all. Conservative commentators argue that America's health system is fine, that our excellent care simply costs more than other countries' poorer quality, and that most uninsureds can afford coverage. 

They ask why we should revamp a great system for the two or three percent of Americans who get less.

This misrepresents reality, though.