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Archive for September, 2008

It’s About the Patient: Peter Neupert on Consumers, Standards, and what HealthVault Needs to Succeed

by Malorye Allison

Peter Neupert is Corporate Vice President, Health Solutions Group, at Microsoft, which is charging into the personal health record field with HealthVault.  After the recent spat of articles and editorials in Health Affairs debating health IT strategy, I was eager to hear Peter’s view on the “standards first?” controversy and how Microsoft sees the emerging consumer health world.

The company is betting that consumers will dive in and start demanding online records as a better and easier way to manage their health care.  “No single silver bullet will transform something as interconnected or complicated as health,” Neupert says.  “We believe consumers will be the primary actors of change because they are the voice that has been least heard.”

“Most incentives are around the needs of payers or providers,” he adds. “When people ask how they can impact things that are costing the most, such as chronic disease, the big gain is clearly around how we influence patients.  To do that, we need to change how we interact with consumers.”

Consumers themselves, he says “Want more information and better access, especially if they have to interact with the health care system frequently.”

But consumers won’t sit and type their health data into online forms themselves, nor will they chase down all their providers and ask them to do it.  For Health Vault to succeed, Microsoft itself needs to bring those providers along, and to add plenty of new layers of function to its offering as well.

“We need to reach the point where patients are saying ‘Aha, this makes my life easier,’” Neupert says.

It will take a lot more to fulfill the whole vision — that beautiful dream of a networked U.S. healthcare system, with networks all over the country seamlessly connecting to deliver optimal care to patients no matter where they have ended up seeking care.

I also asked Neupert where he stands on the recent “standards debate” that erupted in the latest issue of Health Affairs, and whether the U.S. health IT initiative is indeed constrained by an overreliance on technical standards.

He agreed there is too much focus on standards. He thinks we should put the highest priority on getting the content right, and once that’s achieved, standards will naturally follow.  In the meantime, “There is a ton of value we could be getting out of the data today.”

Peter sees today’s emphasis on standards as a straw man.  “The world of software is not like the physical world,” he says:  When building things like railroads, having standards from the start is crucial, or you end up with multiple small networks rather than a seamlessly interconnected whole.  “Software allows for translatable interoperability,” he says.  “If the data isn’t interoperable, it’s because people don’t want it to be.”

Exactly how will that one seamless mega-network arise if groups are working from different platforms at first? The answer, he says, lies in the metadata – the details that describe the data, and how it has been captured.

“Our focus is on metadata-driven translational interoperability – to get data moving better, faster,” Neupert says.

Of course, not everyone is thrilled to see a software giant like Microsoft striding into the personal health record field. Some bloggers are quite alarmed by the prospect, and have pondered what the company’s evil intentions must be or how keeping one’s health records on the web could horribly backfire.  I’m sure we’ll hear plenty more about that too.

In the end, either the whole field will quickly crest, making the early entrants really glad they got that quick start, or, it’s all a straw man and only a minor subset of us will ever be managing our health records online.

By the way, Neupert now has his own blog called “Neupert on Health.”
And you can read those Health Affairs articles here.

Massachusetts universal health insurance law: Changes in regs could prompt ERISA pre-emption challenge

by David Harlow

David Harlow is a Boston area health care lawyer and consultant who blogs regularly at HealthBlawg

Massachusetts has famously gotten many of the state’s uninsured covered thanks to the state mandate.  The “pay or play” approach taken has long seemed ripe for an ERISA pre-emption challenge (cf. the Wal-Mart case in Maryland).  The program now seems to be a victim of its own success, with enrollment in subsidized plans exceeding expectations, and the Commonwealth looking for additional revenues to fund the $130M shortfall.  One approach now proposed is to apply the “pay” part of the pay or play rule to a broader swath of employers — including many that have been “playing” by the rules to date.

As the Boston Globe reported last week

The current law requires most employers with more than 10 full-time employees to offer health coverage or to pay an annual “fair share” penalty of $295 per worker. It gives companies an option of paying at least 33 percent of full-time workers’ premiums within the first 90 days of employment or making sure that at least 25 percent of their full-time workers are covered by an employer plan.

But the proposed new regulations would require employers to meet both requirements, or pay the penalty. The rules, if adopted, would take effect Oct. 1 and raise about $45 million this fiscal year, according to state documents.

The Globe article notes that Matt Fishman, VP for community health at our local 800-pound gorilla, Partners Healthcare (the biggest health care system, and also the biggest employer, in the Commonwealth) argued against that change not because Partners would rather not comply, but because the change, he fears, would open the doors to a legal challenge. 

The commentariat and blogerati have been divided to date on whether the Massachusetts version of pay or play would survive an ERISA preemption challenge. (Examples here, here, here and here.)  Personally, I have taken the cynical-realist approach, expecting that so long as the penalty for not playing remained as artificially low as the $295 a head figure in the initial Massachusetts rules, and the definition of “playing” was as expansive as it has been, it would not be worthwhile to mount a challenge.  I agree with Matt that ratcheting up the stakes in the pay or play game make it more likely that someone will pull the trigger and initiate an ERISA pre-emption challenge. 

I won’t hold my breath waiting for an amendment of ERISA that would eliminate the possibility of such a lawsuit — Some have been waiting for such an amendment for years; some have been inveighing against it as leading to an unworkable morass of state-by-state mandates that would be difficult for large employers to comply with, which is what the ERISA provision was intended to avoid in the first place.  Of course, if this country is really ready for health care reform in a big way (a very big if), this will become a moot question.

David Harlow   

None of your Business, or is it?

by Jody Dzuranin

I recently attended a forum of workplace wellness managers and they voiced similar frustrations of employees who were pushing back against taking the health risk assessment.  The main reason cited is the fear that this personal health information will be used against them by their employer or their health insurance company. No matter how many incentives (or disincentives) were on the line, people do not want their employer dictating health behavior change.   It led me to ponder our current structure.  Why does it fall to the employers to try to convince their employees to lead a healthy lifestyle?   It is not a comfortable position for the employer or employee.  I really don’t think my boss needs to know what I weigh, but in small companies who are administering their own HRA, that is exactly what is happening. If I know my employer is going to see this information, I may not be honest in answering these personal questions.  (I expect that the weight question and number of drinks per week are the 2 questions that are answered dishonestly most often).  Something needs to shift in this model.  On one hand, I think it is very important that the consumer (patient) has access to as much of their personal health information as possible, to become a good “self leader” as Dee Edington, PhD calls them.  A good self leader will share their health information with their health professionals and take an active role in their own wellcare plan.  On the flipside, who has more motivation than the employer who pays the expensive health insurance premiums, to make this helpful health information available to the employee?   The right spot for it would be to come through the health professionals, but mostly people only see their doctor when they are ill.  Who is responsible for wellcare?   I think healthcare, health insurance and personal health information has become over-complicated to the point where the patient feels like an observer, rather than an active participant in the process.   If we can streamline and simplify, we can bring the consumer back into the center of this unbalanced equation.

This post seems to raise more questions, than provide answers.  Hopefully I will have more to share next week.  I will be blogging at the 4th Annual Consumer Healthcare & Wellness Congress in Washington DC, September 15-17, 2008.  I look forward to learning which corporate wellness, health prevention and promotion initiatives are gaining traction with employees and saving money.   I am sure there will be lots of “healthy” conversation on this topic and more.     I hope to see you there!

McCain’s Health Care Reform, Is it “Change” and Can it Work?

by Malorye Allison

It was the briefest mention possible, but at least John McCain did touch upon health care in his acceptance speech last night at the Republican National Convention.

McCain spent a bit more time bashing Obama’s approach then discussing his own: “My health care plan will make it easier for more Americans to find and keep good health care insurance. His plan will force small businesses to cut jobs, reduce wages, and force families into a government-run health care system where a bureaucrat stands between you and your doctor,” he said.

The “c” word was used liberally throughout his speech, such as when he declared that, “We need to change the way government does almost everything.”

At a glance, McCain’s health plan is indeed the more radical of the two, because he’s aiming to reform the tax code and his approach could impact the longstanding employer-based health insurance system. Currently, employers who pay for their workers’ health insurance can exclude every dollar of that from employee income and payroll taxes. This translates to a massive tax break for those workers.

MCain’s uniform tax credit system means everyone gets the same break – a $2,500 credit for individuals, and $5,000 per family.

So, the first question is, if McCain wins, can he possibly get support for this when the Democrats want something so very different? As, the ReformPlans Comparison Grid shows. the two candidates are at polar opposites on the specific steps to reform health care. Obama has shown some flexibility on how he approaches health care reform, but many of the Democratic lawmakers are still emphasizing the steady expansion of public programs. A significant number of those lawmakers would love to have a single-payer program.

Is compromise possible? Or under McCain, would we just see more of the same dreadful impasse?

Finally, neither McCain nor his rival has really explained how they are going to make health care more affordable for anyone – patients, employers, or the government.

Recently Aon Consulting Worldwide released data that health care costs will increase about 10.6 percent over the next 12 months. The good news was that this is the smallest increase in years. But the bad news is that there is rising evidence that we have squeezed most of the benefits out of all those little fixes – disease management, wellness, and generics drugs.
Meanwhile, growth in Medicaid costs is eating up state budgets.

Pretty soon, we need to address the root problems here. The U.S. health care system must be re-engineered so there is a real correlation between spending and value. Only someone brave enough to wrestle with that problem is going to have any effect.

Unfortunately, health care seems to be totally eclipsed by the economy and Iraq right now. We must hope that some of the rumblings from people like Senate Finance Committee Chairman Max Baucus and the Bipartisan Policy Center are signs of real determination to keep this issue alive.

What would life be without unintended consequences?

by Lola Butcher

Dr. Paul Ginsburg, president of the Center for Studying Health System Change, underscores the difficulty of turning passive patients into savvy shoppers:

I don’t think consumers are going to be very receptive to using price information until they have more confidence in understanding the quality of different providers… Consumers can actually act perversely in the sense of not having confidence in the quality information, and equating higher price with higher quality, and thus shifting to higher priced providers, even if they actually reduce their quality of care in the process.

At the World Congress on Consumer Healthcare and Wellness in mid-September, Dr. Ginsburg will participate in a panel that addresses something everyone in health care is wondering about: Will Consumers Be Effective Catalysts to Reform the U.S. Health System?

Here’s part of our conversation:

Butcher: You just released a study that says 56 percent of American adults - that’s more than 122 million people - sought information about a personal health concern from a source other than their doctor during 2007. Does this suggest that Americans are becoming more active participants in their healthcare decision making?

Ginsburg: Oh, yes, they certainly are. American’s interest in their health has increased a great deal, say, over the past decade. We just know how much more space newspapers and television is devoting to personal healthcare issues, and of course we have a lot of development on the internet as far as sites that people can go to seek this information.

Butcher: Many health plans have developed consumer support tools - speaking of the internet - such as online information about hospital and physician quality, and calculators that help plan members estimate the cost of care. Are consumers using these tools, and if so, how are they using them?

Ginsburg: Well, I’ve spoken to the plans, and the plans are all eagerly developing these tools. So when you ask them, Are consumers using them? They don’t know.

My sense is that this is clearly the direction long-term where plans will play an increasingly valuable role as an information intermediary. But I think we’re at the very early stages of it, and I doubt that there’s a lot of use. I doubt that consumers are depending on it.

One of the chicken-and-the-egg problems is that I don’t think consumers are going to be very receptive to using price information until they have more confidence in understanding the quality of different providers… Consumers can actually act perversely in the sense of not having confidence in the quality information, and equating higher price with higher quality, and thus shifting to higher priced providers, even if they actually reduce their quality of care in the process.

Butcher: Is America’s healthcare system organized in a way that allows consumers to be effective shoppers for healthcare services? And does the healthcare marketplace respond to consumer behavior in the same way that the retail marketplace works?

Ginsburg: No, the healthcare system is very far from accommodating consumer desires, to the degree they have them, of being effective shoppers. For most cases, medical care isn’t standardized enough that you can just call up places and, knowing what you need, find out what the price is and the indicators of quality. Because so much of health care involves diagnosis, checking into what something is going to cost (and learning about) a provider (requires the patient) to invest a lot of time and money to make that call.

If you go to the dentist, if you need an inlay put in, a dentist won’t give you that over the phone because they’re going to say it all depends on the details of your condition. So, you’re going to have to invest the time and money of visiting a dentist to get an estimate.

So, I don’t think the healthcare consumer will ever be able to be as good a shopper as in other areas.

Is that patient who he claims to be?

by Lola Butcher

This is the kind of remark that gets my attention:

Throughout the country, I’m seeing more and more reports where you have people checking into hospitals, into clinics, and so forth, and they are posing as the individual who owns this particular social security number and/or insurance policy, and they’re either getting medical treatments under that person’s insurance, or they’re getting pharmaceuticals, prescription drugs, under that person’s medical insurance.

That’s from Robert Siciliano, chief executive officer of IDtheftsecurity.com, who spoke to me about medical identify theft.

Mr. Siciliano will speak at the upcoming World Healthcare Innovation and Technology Congress later this year. Here’s more of our conversation….

Butcher: Information technology is in the process of transforming healthcare delivery. Patients are telling physicians about their symptoms over e-mail and checking their lab tests on line, to give just a couple of examples. What security issues should hospitals and physicians be thinking about?

Siciliano: First, it does start with your information technology administrators. They are responsible to protect you from the outside–from criminal hackers– and from the inside, if you happen to have a bad seed working within your organization. So, it all starts with the IT administrators. The physicians themselves, and the employees at all levels, need to understand what their responsibilities are regarding safety or security and privacy policies, and those policies must be enforced at all times.

Butcher: If a patient’s personal healthcare information does end up being stolen from a hospital’s computer system, what happens? What is the hospital’s liability?

Siciliano: Over the past few years, there have been some major, major breaches of personal information at the government level, corporations, associations, healthcare, insurance companies - you name it. Just about every industry has been affected by a data breach at one level or another.

And as a result of this, state to state, they have passed data breach notification laws, which require corporations–entities whose information has been compromised–to disclose that breach and to make sure that they notify those who have been affected by that breach, so that those people can then go out and take the necessary steps in getting protection, in getting some type of insurance, or credit monitoring, whatever the case may be, so that their identity is not further damaged as a result of that breach.

Unfortunately, criminal hackers have changed the motivation significantly over the past few years, and they are really targeting everyone. I mean, nobody is immune.

Butcher: It seems to me that protecting against identity theft ultimately is the individual’s responsibility. Do you see this changing in the future, and if so, how?

Siciliano: Unfortunately, it is absolutely the individual’s responsibility. While the organization may be responsible for doing their part to keep that data safe and secure, ultimately, if it is compromised, it is in the personal identifying information, including name, address, and especially social security number, that individuals are ultimately responsible for self-protection.

Responsibilities do boil down to managing your own personal information, and ultimately making sure that, even if they do get that data, that there’s not a whole lot they can do with it.

Butcher: What should health care executives know about medical identify theft?

Siciliano: First, I think it’s very important that everybody understand the extent of the problem, that the issue of medical identity theft is becoming an ever bigger problem.

Identity thieves have been working at this for as much as 20 years now, and they’ve figured out just about every single way to compromise our information, and then turn that data into cash.