HR 3200

My conclusion regarding health reform was confirmed by the congressional budget office today. With the present plan there will be no savings. The plan as proposed does nothing to eliminate the parasitic bureaucratic insurance environment, nor the regulatory environment, In fact the plan would merely transfer these costs to the government. Unfortunately the AMA in an effort to boost it’s credibility came out today to support the House Bill. No surprise there….just when most sensible people rose up and told congress it’s too expensive.

Obama is creating a ‘health care crisis’ much as he did with the fiancial markets promising to pull it out with ‘stimulus funding’. Congress is begiing to say “enough is enough’.No one is going to be panicked into a hasty decision. Obama wants all or nothing at all.

It seems saner heads are prevailing, as well as the skeptical response of the public in general.

Unfortunately health care will have to wait further to see just how our economy will (if) recover. As evidenced by the state of affairs in California even those well established programs such as SCHIP are being curtailed or eliminated, and this in the largest and perhaps most affluent state in the country.

Nevertheless changes do need to be made, and sooner rather than later. The cry of ‘emergency’ and crisis are beginning to sound like crying ‘wolf’. That only goes so far….banks, equity firms, mortgage crisis, credit crisis, and financial scandals . Obviously all those responsible were not playing with their ‘own money’ This too would be an enormous problem with a universal, or public program.

The most imminent medical issue is that there are a lot of providers who are about to quit, retire, or find some other less stressful financial vehicle, even if it means living under a bridge.

The Death of the SGR

Way back in the early 90s the Sustainable Growth Rate was introduced to us by Congress and Medicare.  This would result in an annual reduction of physician's fees annually, unless congress took action to either eliminate that year's adjustment or postpone it until the next fiscal year.  After 4 years of 'deferrals' the amount  pending is 20%. In the midst of heated congressional examination and proposals for health reform, this 'adjustment' has not publicly been discussed.  It however is a major bone of contention amongst providers of medicare services.  It becomes more important in the face of other payors who base their reimbursements upon Medicare's fee schedule.

The SGR  includes the costs of drugs and other items billed by the      provider, and also the payments made to ambulatory surgery centers. These numbers are included in the calculation of provider expenses. Claims that provider payments have increased are largely due to these two amounts.  As we all know ambulatory surgery centers have literally exploded in volume, and pharmaceutical expenses have risen sharply as well.

In the past, not much has been made of this item.

HR Discussion Bill

I began reading the 850 page draft discussion bill for health care reform that the House of Representatives is now considering.

The bill is now in committee.

The contents of the proposal are frightening, and impacts not only reimbursements but also how, and what type and numbers of residency programs will be offered.  It usurps the role of established specialty boards and overides the goals of program directors. Every academic physician must read this document, and react immediately.  The content of the entire bill  goes beyond my limited time to discuss it's entirety here, but can be found at:

HR discussion Draft. Considerable length is given to the formation and administration of a "Health Care Exchange".  The extent of regulation and enforcement dwarfs the already present insurance company bureaucracy.  It is difficult to surmise how this will play out in terms of costs to the taxpayers of the United States.

del.icio.us Tags: health care bill discussion,health reform,health insurance exchange,HHS

Order your Edsel

 

The past two weeks seems to further elaborate on the issues creaging a  tightening of the Gordian Knot of Health care which

threatens to overwhelm and bring our healthcare system and even our economy to a grinding halt.

Physicians are rightly frustrated and outraged at the incursion of well meaning pundits, experts, health policy gurus and others, who have meddled with the patient doctor relationship. It may never be restored. 

The new wave of HIT and EMR adoption foists upon not only providers but misguieded taxpayers who are being sold a bill of goods akin to the "Edsel" of the 1960s.

Rick Weinhaus MD  writes in The Health Care Blog about the folly of today's unproven CCHIT certified EMRs. Here are some excerpts from his letter to David Blumenthal, ONCHT .

am writing to you on the need for user-friendly electronic health record (EHR) software programs. As a practicing physician with first-hand experience with hard-to-use CCHIT-certified EHR software, I would like to share with you a solution to this vital issue.

The CCHIT model for EHR software certification is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design.  This flawed CCHIT model takes valuable physician time and effort away from patient care and leads to increased potential for errors, omissions, and mistakes.

As a clinician, I have had first-hand experience with a top-tier CCHIT-certified EHR.  Despite being computer literate and being highly motivated, after a year and a half of concerted effort, I still cannot effectively use this CCHIT-certified program.  The poorly designed software constantly intrudes on my clinical thought process and interferes with my ability to focus on the needs of my patients.

Just this year the National Research Council report on health care IT came to a similar conclusion. The report found that currently implemented health care IT programs often

provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system.  Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks

It is astounding that physicians would be willing to accept inferior technical tools for administration and record keeping when we insist upon medical diagnostic and therapeutic equipment that must pass muster and require regulation by the FDA, and other healthcare regulatory organizations.

We absolutely need standards for data, data transmission, interoperability, and privacy. There is no need, however, to specify the internal workings of EHR software. To do so will stifle innovative software designs that could improve our health care system. If CCHIT is allowed to mandate the meaning of the term “certified-EHR,” the $17 billion allocated for EHR adoption and use will largely be wasted.

HL 7 guy explains our current conundrum:

There are real and tangible reasons why Information Technology as it exists is of very little help to many clinicians.

Gathering the information to feed into the systems is obtrusive and disruptive to the clinicians workflow.

For an hour of clinician and patient interaction there is approximately an hour of data input as most EMR applications are currently built. This is extremely inefficient.

Clinicians aren't secretaries or clerks that can be typing away all day. They have to cure and save the lives of their patients.

Frustrations imposed by improperly built software have created an apathetic attitude from most clinicians towards technology.

Until technologists understand this and start building solutions based on use cases and that fit seamlessly into the clinicians workflows, adoptions will be scarce and the failure rate will be high.

 

LiveJournal Tags: healthtrain express,gordion knot,ehr,cchit,blumenthal

The Final Frontier---where no man has gone before

 

For those of you in the know, this week is a critical time in health care reform. The Sentate’s Health, Education, Labor, and Pension committee, chaired by Senator Ted Kennedy is analyzing and weighing the various bills being proposed in Washington, this week. NPR is carrying a good portion of the proceedings. There is a lot at stake. Not only will proposed changes make immediate impacts, but in the future these changes will have unintended consequences. This happened with Medicare, the HMO act of 1971, Congressional budget regulations regarding sustainability (SGR) adjustments each year, and others. The federal government is slow to act, and slower to re-act. Legislation cut in stone is often in the end counterproductive.

Some of the proposals lead to well intended false hopes and promises. A major flaw regarding a public health program is that it would stimulate competition in the private market. That is highly doubtful, based on common sense. It’s like the 800 pound gorilla competing with a 150 pound chimpanzee. The federal government has many built in advantages, such as contracting, freedom to set rates arbitrarily, sheer overwhelming market presence, and force. Will government competition include predatory premiums way below market values? Will payments be locked in, and will it be prohibited by providers to charge less than the public health program? These are serious questions, considering how CMS has acted in the past. Are we going to see more credentialing restrictions for providers? Will this open a door to a ‘federalized medical license’? (maybe that is a good thing)

Even though this appears to be a critical year in terms of interest and action hasty actions can and will lead to unintended consequences and disaster.

These are the members of the committee:

COMMITTEE MEMBERS

Democrats by Rank

Edward Kennedy (MA)
Christopher Dodd (CT)
Tom Harkin (IA)
Barbara A. Mikulski (MD)
Jeff Bingaman (NM)
Patty Murray (WA)
Jack Reed (RI)
Bernard Sanders (I) (VT)
Sherrod Brown (OH)
Robert P. Casey, Jr. (PA)
Kay Hagan (NC)
Jeff Merkley (OR)

Republicans by Rank

Michael B. Enzi (WY)
Judd Gregg (NH)
Lamar Alexander (TN)
Richard Burr (NC)
Johnny Isakson (GA)
John McCain (AZ)
Orrin G. Hatch (UT)
Lisa Murkowski (AK)
Tom Coburn, M.D. (OK)
Pat Roberts (KS)

There is one MD on the committee, Dr Tom Coburn of Oklahoma. Of note are also several ‘powerful deal makers on the committee, including Ted Kennedy (Chairman) Chris Dodd, Barbara Mikulski, Orin Hatch. There are also several ‘young senators’.

Will the ‘old wise men’ make the right decisions for the younger generation of Americans?

Now is the time to put in your two cents. Despite the overwhelming feeling amongst physicians of futility and despondence it is vital you make your voice(s) heard NOW. Without physician input and support any systemic changes will be hampered and doomed just as they have in the past 25 years.

During these committee hearings, NPR points out that looking around the room behind the cameras are the 268 seats filled with special interest lobbyists.

LiveJournal Tags: health train express,ARRA,congressional hearing,health,labor,pension

A Political Message and Agenda

The final key to HIT adoption may lie with the beleagured physician (provider) as he attempts to deliver the best (healthcare), science based medicine to his patient (consumer).  The names and titles may change, but the challenges remain the same.

The simultaneous arrival of financial crisis, healthcare crisis, ARRA, and Health Information Technology adoption seems to be the 'perfect storm' for political meddling with medical care.

This statement appears at the introduction of the 'HIT Certification Course" sponsored by an unamed group using the term HIT Certification and a web site   'healthitcertification.com '

The web site does have a contact us link.  There appear to be many pundits or 'experts' on healthcare policy', a few physicians, and lots of titles listed as: faculty and advisors.

In it's opening statements, I quote:

"While some would have approached the current recession in a different manner, President Obama reflects upon the activities that helped spur growth after the Great Depression of the 1930s with spending for jobs that will modernize aging infrastructure and hopefully restore the middle class way of life in the U.S."

Accompanying this statement is the following illustration

I don't quite get the association between FDR and HIT. Is there a not so hidden agenda with this connection?  How can anyone cast negative aspersions on a program associated with FDR, the defeat of Nazi Germany, The Japanese Empire, The New Deal, Social Security, and all while sitting in a wheel chair and smoking cigarettes with a cigarette holder?? I am not certain however he would authorize his likeness in support of Obama's opportunism in regard to health care.  Create chaos and dysfunction and jump into unravel the mess.

I took some of my valuable patient time to read through some of the certification courses (offered free as a bait for the 'real course' which participants pay mightly to register.

It struck me as peculiar that a federal program would require 'consultants' physicians, and others to take a course which they must pay  for to obtain information regarding federal funding.  Why would the government even allow this, when they are funding billions of dollars to develop the training and infrastructure. (This is all nicely outlined in ARRA and HITECH)

So, all of you who have money to burn....go ahead, and throw some at me.

I'd rather be seeing patients. (especially without an EMR).But then again, I am rapidly becoming obsolete (and fossilized).

LiveJournal Tags: obama,hitech,hit,fdr,healthtrain express,political agenda,ARRA,health it certification

Is Help on The Way?

 

Readers may turn their attention to the Federal Register, outlining the plan as part of the ARRA stimulus package to develop Regional Extension Centers for assisting in developing Health Information Exchanges and assist in the build out of EMRs, and interoperability amongst providers. This 'small tome' of the register is largely unreadable and unintelligble.  The facts are in there somewhere if you are not prone to migraine and/or presbyopia.  The goals and mandates are in there, whether they will truly be funded, and/or  pursued is up to doubt.

Certainly the Obama Administration talks the talk, and may walk the walk.  It remains to be seen whether regional differences and serious reservations which remain will impede the flow chart.

Art----Computer----Science----Patient

Paul Ravetz: Can the art of medicine exist in the computer age?

In today's post on KevinMD,  Paul Ravetz recognizes what most of us already understand (where the rubber hits the road).  Tell it to the HIT group, salivating  over the ARRA.

 

"Does the “Art of Medicine” really exist, or perhaps more important, can it do so in the computer age?

 Aesclepius

Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.

Communication with your patient is the epitome of the Art of Medicine.

However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship - time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”

So, who will you communicate with? Will it be the patient, or your workstation?

LiveJournal Tags: computer,worksation,art of medicine,aesclepius,paul kravetz,kevinmd

Health Train Express----Shortening the Trains

 

In the past ten years we have experienced an Internet bubble, a Housing bubble, and Financial Markets Bubble.  What is the next bubble to burst.

Could it be a health care bubble?

George Lundberg in a recent post on The Health Care Blog enumerates on the development of bubbles in real estate, silicone valley, financial markets, and presents a scary prediction of what may very well occur in health care.  Some experts predict a sixty percent (60%) adjustment in overall health care expenditures as compared to the present portion healthcare consumes (or adds) to the GDP.

Trimming Health Care Costs

There is a movement afoot to nominate George Lundberg for Surgeon General. For those of you who wish to support this movement, you can go to  the Web Site to sign the petition.

While we are on the topic if influential people for the Obama administration and their ties to the administration, here are some interesting facts for your evening game of Trivial pursuit.

What highly placed official at the NIH (National Institutes of Health is related to a key player in the White House?

Answer:  Ezekiel Emmanuel, MD  is the brother of  Rahm Emanuel, Barak Obama's Chief of Staff.

Rahm Emanuel

Ezekiel Emanuel

Another key figure in Health Care Reform, and it's impact on the Federal budet is Peter Orzsag.

Mr. Orzsag holds a cabinet positon as Director of the Office of Management of the Budget (OMB).

Mr Orzsag is presented as the 'ultimate  nerd' combined with political savy.  He has a keen interest in health care economics, health care reform, and brings key analytical tools merged with knowledge of how to apply it to the political process.

His animating passions are far grander — health care, energy policy and Social Security overhaul, for starters.

Soon he will focus more closely on health care, his central policy obsession. In recent years, many say, he has helped popularize the idea that reducing health care costs is essential to the country’s economic future and the sustainability of the federal budget.

To address the problem, he wants to do no less than change the way medicine is practiced, eliminating unnecessary tests and unproven treatments in favor of what he calls a higher-value approach that he says will actually improve health. But no one quite knows how much money such measures would save, and Republicans already accuse him of trying to limit care

LiveJournal Tags: Rahm Emanuel,Ezekiel Emanuel,Peter Orzsag,OMB,George Lundberg,Health Train Express

The Ultimate Medical Home -The White House

 

Can the medical home reconcile the high cost of HIT? Was Marcus Welby MD the penultimate medical home?

Despite the "warm fuzzy" acronym of "Medical Home" readers should realize policy makers are not proposing a Marcus Welby MD for every patient.

Two of the best articles on this subject of HIT and medical homes are in todays" columns on The Health Care Blog.

Elsewhere,

Some of our congressional leaders still do not 'get it". Charles Schumer proposes that any government run program in health care reform follow the standards and regulations of private insurers. Many of our current problems relate to the manner in which private insurers operate. Mr Schumer is a powerful power player in the New York Financial Banking and Wall Street world.

Democrats in Congress hope to shift the debate from the question of whether to create a public health insurance plan to the question of how it would work.

George Lundberg MD contemplates a 60% reduction in health care expenditures with an 'implosion' imminent in the health care bubble.

The White House has held a 'briefing of stakeholders' this week. who promise a reduction of over 2 trillion dollars in health costs over the next ten years. The complete listing is at the above link.  My question is how can the AMA guarrantee these reductions?

The vast majority of the White House statement is 'politically correct, and couched in meaningless promises. 

LiveJournal Tags: white house,medical home,Schumer,private insurers,medicare,AMA,George Lundberg

The Myth of Health IT

In an opinion piece, former HHS Deputy Secretary Tevi Troy challenges common beliefs about health IT and questions whether the $20 billion included in the federal stimulus package for health IT will improve the country's health care system. Washington Post.

5 Myths on Health Care's Electronic Fix-It

In The Washington Post:

By Tevi Troy
Sunday, April 26, 2009

Are electronic health records the panacea for all our health-care ills? Congress seems to think so: With strong cheerleading from President Obama, it has approved $20 billion for EHRs as part of the stimulus package. Health information technology undeniably holds a lot of promise, but it's still in its infancy. Is it worth a stimulus now? A look at some health IT myths:

1. Electronic health records will cure our health system.

EHRs will potentially provide a lot of benefits, most notably by reducing medical errors -- e.g., doctors prescribing medications to patients with an allergy to them -- that kill as many as 98,000 Americans each year. A much-cited 2005 Rand Corp. study of EHRs found that they could save $77 billion annually and potentially eliminate 200,000 adverse drug reactions. Yet a more recent analysis, by Stephen Parente and Jeffrey McCullough in Health Affairs, found that "the evidence base is not yet sufficient" to show that EHRs would improve outcomes.

Implementing EHRs to improve billing -- which would be the simplest and least creative way to spend Congress's money -- is not enough. EHRs can improve our system and help achieve the assumed cost savings only if they bring about changes in the way we practice medicine. Doctors have extremely limited time with their patients. EHRs would help by giving them access to the patients' documents, including all previous tests and conditions, in advance, and by allowing patients to communicate with physicians via e-mail. With the right kind of EHRs, doctors could obtain real-time guidance on the best care for a specific patient from databases containing all the latest diagnostic and therapeutic guidelines.

But this technology is evolving rapidly, and implementing systems in the right way will require thoughtfulness and creativity. As pediatrician and health IT expert Kenneth Mandl, who co-wrote a skeptical analysis of subsidizing EHRs for the New England Journal of Medicine, told the New York Times, "If the government's money goes to cement the current technology in place, we will have a very hard time innovating in health care reform."

2. Federal carrots and sticks are the only way to get doctors and hospitals to adopt EHRs.

It's true that far too few doctors and hospitals have electronic systems in place. The Congressional Budget Office has estimated that about 12 percent of physicians use them. According to a recent study in the NEJM, only 1.5 percent of U.S. hospitals have a comprehensive electronic records system available in all clinical units, and another 7.6 percent have a basic system available in at least one clinical unit. Seventeen percent of hospitals let doctors prescribe medicines electronically.

The stimulus package established 10-year EHR adoption goals of 70 percent for hospitals and about 90 percent for physicians. But even without the stimulus, the CBO estimates that 45 percent of hospitals and 65 percent of physicians will have EHRs by 2019. In other words, many doctors and hospitals are likely to adopt electronic systems even without the subsidies, which begin in 2011, and the potential penalties for failing to adopt, which are expected to begin in 2016.

3. Cost is the only reason the United States has such low adoption rates.

The initial capital investment in EHRs, estimated at between $15,000 and $50,000 for a practice and $10 million for a midsize hospital, is definitely a deterrent, but there are other reasons for delay. On the economic side, the financial incentives in medicine don't reward doctors for performance, so improving performance with EHRs is not a necessarily a priority. Cultural issues, especially among older doctors, are also a big obstacle. A 2008 study sponsored by the Department of Health and Human Services and the Robert Wood Johnson Foundation found that 29 percent of non-computerized hospitals cited doctor resistance as a major barrier to adopting health IT, and 42 percent claimed it as a minor barrier. David Blumenthal, the Obama administration's recently appointed health IT czar, wrote in the NEJM that beyond cost, the barriers to adoption of EHRs include "the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about the privacy and security of electronic health information."

4. Subsidizing EHRs will stimulate the economy or EHR adoption in the short term.

The stimulus package contains bonus payments of $44,000 to $64,000 to physicians who adopt and use EHRs effectively, beginning in 2011 and continuing through 2015, with the largest total spending taking place in 2014. After that point, doctors who do not use EHRs may be penalized. But even if the law called for the money to be spent earlier, the Department of Health and Human Services is not yet close to being ready with the payment rules, certification standards or definitions of key terms such as "meaningful use," which are called for by the end of 2009. Federal encouragement of EHRs could actually serve as an anti-stimulus, because IT companies could be reluctant to develop new products until the government sets the certification standards. Furthermore, doctors and hospitals, seeing the promise of federal dollars 20 months away, will be unlikely to buy new record systems until the government money starts to flow.

5. We know how much we're investing in this effort to promote health IT.

The media typically describes the investment in EHRs as $20 billion. But this doesn't count $12 billion in estimated savings for EHR adoption that may or may not happen, so the real number is closer to $32 billion. And the $32 billion is only an estimate, since the bulk of the stimulus dollars for health IT is in what is known as mandatory spending, meaning that the money is paid out as long as applying doctors and hospitals meet the appropriate requirements. So the actual number could go as high as $50 billion or even higher. This is unsurprising, since Obama called for an investment of $20 to $50 billion in health IT on the campaign trail. So we may not know the actual amount -- but in Washington, it's always a good idea to bet on the higher number.

ttroy@hudson.org

Tevi Troy, deputy secretary of the Department of Health and Human Services from 2007-2009, is a visiting fellow at the Hudson Institute.

Emergency on The Health Train Express???

The  H1N1 viral particle

Okay, what constitutes an emergency??  Our public health authorities now are linked to the Department of Homeland Security.  "Pandemic" is now being used to describe what is not even an epidemic in terms of numbers or morbidity or mortality.

Apparently our bureaucracy of federal and state administration requires the declaration of an 'emergency' to release funding for events such as this.  Let's be clear and scientific about all of this "political posturing' and bad science. We are not in the midst of, nor even approaching a 'pandemic' let alone an epidemic.

On a daily basis we are given figures as to how many deaths and/or reported cases of H1N1 Infuenza have been diagnosed. What we are not being told is how many non H1N1 cases are occuring concurrently.  How does this year's total for 'flu' compare with previous years. 

News travels now at the speed of light, whether true or false. 'Diseases such as flu now travel at the speed of flight.

Fear and panic should not replace caution and sensible behavior.

Public health officials need to inject some sanity into the equation, and media companies need to tone down their rhetoric about H1N1 (now more politically correct than Swine Flu)

Egypt slaughters 300,000 pigs. (Don't they have kosher dietary laws anyway?

Rob and Kevin on the Health Train Express

Kevin MD will be hosting Rob Lambert on a live Q&A at 10 PM EDT  Wednesday, April 29, 2009.  Join us.