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Archive for November, 2008

FYI - Unapproved drugs in Medicaid

by John Goodman

Almost $200 million over four years, and to read the media accounts you would think this is a bad thing. I suspect it is a good thing - for the patients and for the taxpayers. Aspirin was never approved by the FDA and many experts think that under today’s ridiculous rules it probably couldn’t pass.

Link: http://www.ncpa.org/sub/dpd/index.php?Article_ID=17297

It’s January 15, 2020: What Have We Learned About Healthcare in the Last Decade?

by Jim Carroll


It’s January 15, 2020: What Have We Learned About Healthcare in the Last Decade?

WHIT 4.0 promises to be an exciting conference that promises an unparalleled look into the future of health care. Rapid technological development and relentless innovation are the two key trends that will provide for a forthcoming massive transformation of our health care system in the future.

Even so, the challenge is: with so much knowledge and insight to be shared at WHIT, is it truly possible to understand where we are really going with the world of heath care?

It’s often difficult to do so. That’s why, for the last fifteen years, as I’ve been providing my guidance into future trends to a wide swathe of Fortune 1000 companies, associations, and other groups. I’ve learned that sometimes, it is easier to open up the minds of people to big trends by taking a look *back,* rather than by taking a look forward.

So let’s say it’s the year 2020. Now we all KNOW will have happened with health care in the last twelve years.

Futurist, trends & innovation expert Jim Carroll
Opening Keynote Remarks,
WHIT 14.0, January 15, 2020

I’m thrilled you invited me back.

After all, my comments as the closing keynote speaker at WHIT 4.0 in 2008 that the “folks in the audience need to wake the hell up, focus on opportunity, and seize the health care innovation agenda,” rubbed some traditionalists as being a little too aggressive!

It’s no wonder though! At the time, the economic malaise that was settling in had caused most innovators to shrink away, convinced their ideas for the future had no place and time for consideration. Fear, mediocrity and staid thinking ruled the health care agenda; everyone spoke of applying the same old band-aid solutions in a different way to the same problems, with no obvious results in sight.

But WHIT 4.0 saw a group of leading global health care thinkers come together, and imagine what “could be.” And I’m thrilled that in my own small way, my call to action encouraged and inspired these leaders to seize the future and provide the unique solutions which we so desperately needed at the time.

Looking back from 2020, it’s easy to spot the big changes that happened. Yet, they weren’t so clear at the conference of 2008, were they?

Here’s what we know now in the year 2020:

1. The system went upside down. We successfully transitioned the health care system from one which “fixed people after they were sick” to one of preventative, diagnostic medicine. This simple reality, though vastly complex from a scientific, methodology and implementation perspective, resulted in a dramatic shift in health care philosophies, a major transition in spending, and an overall improvement in the lives of ordinary citizens. This was the big transformative trend of the decade, and its impact was powerful and massive.

2. Bio-connectivity reinvented the concept of hospitals. Our medical system of the earlier part of the 21st century looks rather primitive at this point. Expensive hospital beds were stuffed full of non-critical care patients so that they could be closely monitored by medical personnel. A tremendous waste of spending and energy! Today, of course, we’ve transitioned to a virtual community oriented caregiving strategy, with a good proportion of both critical and non-critical care patients receiving health care at home, with a consequent cost reduction and refocus of critical health care spending. It was the rapid emergence of thousands of different bio-connected devices: home health care medical monitoring, diagnosis and treatment devices, that provided for an explosion in rethinking the essence of a good chunk of our health care system.

3. The #1 revenue source for Silicon Valley is now health care related. By 2008, most CEO’s of any type of technology company realized that the future lay far beyond social networking, Web 2.0 and other hyped social networking technologies. They came to know that the real opportunity lay in aiming the technology-innovation engine straight at the massive health care problems that were then so evident. Looking back, the results that they launched, whether with new products, business models, scientific discovery tools, continued invention of bio-informatics platforms that provided the foundation for diagnostic medicine : you name it, and the results were simply astounding.

4. High velocity change became “the new normal.”. It’s hard to believe that as recently as 2008, hospitals spoke of the need for insight into change management. The incessant debate over the benefits of the electronic health record dragged on ad-nasuem. Today, of course, change-adverse baby boomer doctors and other medical professionals have mostly retired. Today’s medical professional has their 239th generation iPhone at their side, they’re interacting with labs, medical libraries, their social-network-specialists peers and other knowledge-network peers : they continue to drive change at a furious pace. The EHR? It’s secure, bio-embedded, and has ripped inefficiency and cost wastage out of the system. We now know that the arrival of the first of the Gen-Connect generation of 2010 from medical colleges was the catalyst that drove massive, fast and furious rates of innovative change throughout the health care system.

5. Customer service became the #2 mission.. Number one, of course, remains ensuring that patients receive top-notch, first-rate health care as soon as they need it. But the revolution to health care service delivery came when retail, consumer and branding experts took over a good part of the health care delivery infrastructure. They quickly overhauled and rebuilt the entire philosophical underpinning of that infrastructure, so that it was customer focused, friendly, fast, subject to expectation metrics — service delivered with a smile! Suddenly, patients came to realize that their health care system was no longer stuck in an adversarial 19th century mode — the concept of “service” re-energized staff, provided for streamlined operations, and allowed for innovation to flourish in an unprecedented fashion.

6. The triumph of device intelligence. By 2020, most of us found that our “personal area network” included much more than our MP3’s, video players and other digital content: it included huge chunks of intelligence from our daily health interactions. My prescription bottle now came with an embedded RFID tag. At some point in the prior ten years, the role of packaging transitioned from being a passive protector of the product, and became an active component of the overall effectiveness of the particular medication. My pill bottle now linked to the Internet, providing me with an instant concise summary of the current status of this particular medical condition. Linkage of prescription efficacy to online databases also became a key method by which pharmaceutical companies tracked the ever more rapid development and release of new, effective drug products.

7. Computational analytics allowed us to rapidly refocus resources. By 2010, we came to realize that many of society’s deepest problems had a chance of being solved by processing complex analytical algorithms with massive computing horsepower. We aimed our innovation engine at energy, eco and health care, and the results were staggering. Looking back, it allowed us a significant shift in thinking. For example, while today we accept the health care location intelligence professional as an accepted part of the hospital team, back in 2010 they were but a rare anomaly. Back then, no one believed that it would be possible to link the massive amounts of information found in the global ‘data-cloud’ to the rapid emergence of particular medical conditions. Today, of course, most health care facilities use the insight of such professionals to regularly track, monitor, and devise proactive plans to deal with new emerging challenges.

8. We transitioned to a medical culture of “just-in-time-knowledge.” Given the constant doubling of medical knowledge in ever shorter time spans — from originally doubling every years in 2005, the pace picked up — we came to know that the system could no longer function based on an antiquated model of one-time knowledge delivery. Medical schools adapted, providing for the “velocity” of knowledge that was required by ever more rapid scientific advance. The relationship between medical colleges and students changed ; primarily, from a period of short term, concentrated knowledge delivery, to one of lifelong, ongoing replenishment and rejuvenation of knowledge. It is now estimated, in 2020, that the average doctor and nurse refreshes their entire knowledge base every 18 months.

9. We adapted to faster science through high-velocity structure We can now look back at the period of 2010-2020 as an era of profound change when it came to medical innovation. Given the fast pace of discovery of new medical knowledge, we witnessed a massive acceleration in the number of new medical procedures and treatments, pharmaceuticals and bio-materials, medical technologies and devices, diagnostics and methodologies. We came to realize that it was our ability to rapidly ingest new knowledge that became a key savior in our re-engineering of the concept of our health care; it was our speed of action that defined our success. We focused on velocity, and the results, looking back, were staggering.

10. We rose to the challenge with determination! . In 2008, we were morose; we had no belief in the future; wracked by economic self-doubt, we came to believe that the health care system would continue to crumble. And yet, we found inspiration! We heard the soaring phrases of challenge posed by President Obama at his inauguration. We realized that he caught the imagination of an entire generation ; who came to know that this decisive, broken and complex industry was now their new Peace Corps. Along came an awakening that they could turn their attention from sharing quick-knowledge hits on now-defunct networks like Facebook and Twitter, and instead, heed a greater call to action. They aimed their minds towards one of the deepest challenges of our time and turned on their innovation engines. And as we know now, that was a truly transformative moment.

Looking out to the folks here at WHIT 14, January 15, 2020, I do know what we’ve learned in the last decade. Innovators are heroes. They are the people who are willing and able to cut through the clutter of tiny trends and massive noise, able to see the long term transformative trends that provide for real change, real opportunity, real growth, and real solutions.

There were some of you in the room with us on that day, December 10, 2008.

You heard the need for innovation. You understood the opportunity for growth. You knew that we were on the edge of something big. And so you took a deep breath, and forgot about the challenges of today, and began to re-energize yourself on the opportunity of tomorrow.

Thank you very much.


Jim Carroll is one of the world’s leading futurists, trends & innovation experts, with a client list that includes the Walt Disney Organization, Pearson PLC, CapitolOne, Readers Digest Food & Entertainment Group, Lincoln Financial, Toshiba, IBM, Motorola, Nestle, BBC, Deloitte, Caterpillar, and the Swiss Innovation Forum. He regularly challenges health care organizations and professionals to step beyond mediocrity, and seize the challenges of today with innovative thinking. Jim health care clients include Cardinal Health Care, Providence Health, Harvard Pilgrim Health Care, Pharmalink, the Association of Organ Procurement Organizations, the Health Care Industry Distributors Association, the American Society for Health Care Risk Management, Blue Cross Blue Shield and the Canadian Medical Association. Contact him at jcarroll@jimcarroll.com, or browse his site, www.jimcarroll.com

World Health Care Blog welcomes John Goodman, President, National Center for Policy Analysis

by World Health Care Blog

The World Health Care Blog is pleased to welcome posts from John Goodman, PhD, President of the National Center for Policy Analysis. Dr. Goodman maintains “The John Goodman Health Blog” on the NCPA Web site. Dr.Goodman will be a featured presenter at the 4th Annual World Healthcare Innovation and Technology Congress, Dec. 8-10 in Washington, D.C.

Is it Politically Correct Now to Focus on Healthcare Fraud? Part II

by Don Simborg

In my previous blog, I talked about physician resistance to building anti-fraud measures into electronic health record systems (EHRs). To be clear, I do not know any physicians who commit fraud nor condone it and based on the information available to our expert panels on healthcare fraud, only a very small percentage of physicians engage in fraudulent activity. Building fraud management into EHRs is aimed not solely at physicians who commit fraud, but others, including organized crime that will use legitimate EHR records to perpetrate fraudulent claims.

The recommendations made by our panel to DHHS for anti-fraud measures in EHRs involved the requirement to produce automatically to a secure and immutable file certain audit information during the production of encounter notes by physicians using an EHR. Such “metadata” is easy and of low cost to produce in a computer system whereas it would be near impossible to collect in the current paper system. It would include improved documentation of the identity of the author, time and location of entry, method of entry, and certain other aspects of the process of entry that when made available to computerized pattern detection software, would enable the flagging of suspicious transactions. Requiring such audit trails now for certification of EHRs would be much easier than attempting to retrofit such software at a future time after EHRs become widely adopted.

The concern of physicians is that such increased ability of surveillance by law enforcement and insurers would increase the likelihood of false accusations of fraud. I believe that the result will be just the opposite. The problem physicians have now is the difficulty of defending themselves against such accusations. The same “metadata” that can be used to detect fraudulent patterns is the best protection that physicians will have to demonstrate the legitimacy of their entrees into the record and their subsequent claims. Without such audit documentation, which is the rule rather than the exception in EHRs today, there is inadequate documentation and serious concern about the admissibility of their current electronic records as evidence in a court procedure.

What is needed for the physicians is to insure that the process of surveillance and the process of determining the threshold for investigation are done in a manner that minimizes the chance of false positives. The first step is to have a dialogue with the physician organizations on how best to achieve these needed protections. There are some gray areas where one person’s coding problem is another person’s fraud. But there is so much deliberate, organized and blatant fraud that surely we can set the threshold of suspicion to avoid a serious problem with false accusations.

A Gartner report has stated that any investment in anti-fraud software will bring a 5/1 return on investment. This is clearly the easiest and most immediate manner in which the Obama administration can begin to make good on its promise of saving $2500/family in healthcare costs. We need to make this investment before we succeed in achieving widespread adoption of EHRs. Without it, costs will go up, not down, with such adoption.

Donald W. Simborg, MD

World Health Care Blog welcomes Don Simborg, M.D.

by World Health Care Blog

The World Health Care Blog is pleased to welcome Don Simborg, M.D. as a contributing writer. A featured speaker at the World Health Care Congress Leadership Summit on the Road to Interoperability, Dr. Simborg is Co-founder and Board Member, Health Level 7 (HL7);Founding Member, American College of Medical Informatics; Chairman, Executive Team, Anti-Fraud Project, ONC; Board Member, Foundation on Research and Education, American Health Information Management Association (AHIMA). Please view his recent post on “Is it Politically Correct Now to Focus on Healthcare Fraud?”

If We Build the Medical Home, Will All Primary Care Docs Come?

by jsidorov

by Jaan Sidorov of the Disease Management Care Blog

Among its many good qualities, the patient centered medical home (PCMH) has been lauded as the means to primary care. Yet, assuming the PMCH has plenty of merit by itself, what does that have to do with rescuing primary care?

Simple question, but the answer is more complex. Most reasonable observers agree that primary care is hard work and undervalued. The demoralized physicians leaving primary care are not being replaced in sufficient numbers by medical school graduates, leading to shortages in many areas of the country. While the causes for this are myriad, supporters of the PCMH suggest it can reverse medical student disinterest and help the current cohort of primary care physicians to hang in there.

Will it? In this day of slavish devotion to evidence-based health care, just where is the evidence for this contention? There are no surveys of what rank and file community-based primary care physicians actually think about the patient centered medical home. In particular, we don’t know how well it will address the physicians’ lifestyle concerns or their income expectations.

There are plenty of studies on what they believe ails their profession. Physicians are unhappy about the loss of clinical autonomy, the number of hours they work and their inability to obtain services for their patients. Being responsible for any gatekeeping services is also a dissatisfier, as well as being under pressure to see a minimum number of patients per day. For younger physicians, income is a more distant consideration, compared to personal satisfaction and fulfillment outside of work.

And just what is it about the medical home that will fix these problems? Just because there is a medical home doesn’t mean high cost radiology services will not continue to come under preauthorization, that drug formularies will not put continue to put certain medications out of reach, that restrictive physician networks won’t be used or that managed care organizations won’t continue to bluntly prod physicians to achieve HEDIS benchmarks. Keeping patients away from the emergency room or the hospital requires a zealous amount of hustle that goes well beyond the 8-5 business day.

Much of the supplemental payment for the extra services of a medical home are calculated to cover the expense of those extra services such as health information technology, staff that manage care management services and the additional physician time necessary to oversee the primary care site team. It’s only after these costs are met that physicians are expected to be rewarded. We don’t know what their price point is.

The support for the medical home by rank and file primary care physicians may be overestimated. True, there are reports that the PCPCC and TransforMED pilots underway have been enthusiastically received, but this represents a small fraction of the docs out there who may not be representative of the usual mainstream doc. The point is we don’t know how they will react and, without more data, we cannot be sure that if we build the support for the medical home that they will come.

We also need to vigorously look for other solutions to what ails primary care outside of the unproven assumptions surrounding the PCMH.

Is it Politically Correct Now to Focus on Healthcare Fraud? Part I

by Don Simborg

At the World Congress Road to Interoperability Leadership Summit in Boston this past July, I brought up the topic of healthcare fraud as an example of one of the health IT related issues being neglected by the current DHHS administration. In the meantime, I have been one of the many volunteers working with the Barack Obama Health Policy Team and, of course, am pleased with the focus on healthcare as a key priority not only in the campaign, but in the upcoming administration. I was disappointed, however, in being unable to raise the fraud issue to any significant level of attention by the campaign. In retrospect, I should not have been surprised as this topic has surprising political sensitivity.

Healthcare fraud is estimated to cost $200B/year – a rate that is 30 times that of credit card fraud. In the past three years, there have been two expert panels commissioned by the Department of Health and Human Services (DHHS) to examine the issue of healthcare fraud as it relates to the emerging use of health information technology. I was the chairman of both of these expert panels. The report issued by our first panel in 2005 concluded that the enormous healthcare fraud problem would become worse in an electronic environment unless proactive anti-fraud measures were built into electronic health record systems and other health information technologies. As a result of that report, the second panel was commissioned to recommend specific anti-fraud measures that should be required of electronic health record systems. A second report was produced in 2007 which recommended 14 such measures. These measures were largely focused on improving the ability to audit the “who, what, when, where, and how” of producing electronic health records and the prevention of medical identity theft.

The recommendations in the second report were strongly opposed by physician groups including the American Medical Association, the American College of Physicians, and the American Academy of Family Practice. As a result, any mention of anti-fraud activities has been omitted in the current DHHS five year plan for health information technology. The physician groups correctly pointed out that implementation of any means to further monitor physicians for fraud would be threatening to all physicians who would fear the possibility of having to defend false accusations of fraud. The reputations of the Office of the Inspector General and the Department of Justice have been tarnished in this regard by highly publicized instances of such false accusations in the current environment leading to costly and traumatic defenses by some physicians. The physician groups argued that if adopting electronic health records meant increased surveillance against fraud, this would further deter the already slow adoption of such technologies. As one physician compliance officer told me, “physicians are not going to buy the gun that shoots them.” Since increasing adoption of technology has been the highest priority in the Bush DHHS administration regarding technology, the adoption goal has trumped any focus on fraud.

The question is what the Obama administration will do regarding this problem. The last thing it wants to do is alienate physicians or undermine the adoption of health IT – one of the cornerstones of its plans to reduce healthcare costs. In part II, an approach to this issue will be discussed.

Donald W. Simborg, MD

Security Expert Robert Siciliano on Express Scripts Data Breach

by Malorye Allison

Based on what’s just happened at Express Scripts, consumers should indeed be wary of having their health information online. The company just announced it is being blackmailed with the threat of a massive data exposure. A letter demanding payment included personal data on 75 Express Scripts members.

“It’s not the first time data has been held for ransom, and it won’t be the last, “ says Robert L. Siciliano, chief executive officer, IDTheftSecurity.com and a speaker at the upcoming WHIT v.4.0 conference.

Express Scripts is one of the nation’s largest PMBs. It’s not clear that those threatening the company have access to more patient data than they have already shown. “If they had access to 75 records, chances are they have access to 75,000 or more,” Siciliano says. “But it could just be an inside job, where someone has pulled together the data from the 75 records to make it look like they have more.”

Siciliano finds it striking that the would-be extortionists actually tried blackmail the company. “They must be from overseas,” he says, “Not realizing that Americans just panic when these things happen and immediately call the authorities.”

Over the last few years, he says, hackers have switched from working for fun to doing it for profit. This has left many companies vulnerable. “It’s the wild wild Web out there,” Siciliano says “And data is the new currency.” He points out that it is not possible to make any data 100% secure, and that “the guys in the white hats” are constantly racing against the “bad guy” hackers in the black hats to stay ahead. Still, many companies are under protected because they have data that they simply forgot about or they are underestimating the threat.

The Wall Street Journal reports that in the past year, “compromises involving patient data have occurred at the National Institutes of Health, insurer WellPoint Inc. and New York-Presbyterian Hospital/Weill Cornell Medical Center, among others.”

In the end, Siciliano says “It will cost Express Scripts hundreds of thousands when it is all over.”

e-Prescribing: Something that Works

by Malorye Allison

As the pundits compare Senator Barack Obama and John McCains’ plans ad nauseum, it’s getting a bit depressing seeing the list of things that are broken in our health care system, and how difficult it is going to be to fix them. So, I’m going to focus on something that works — e-prescribing.

Yes, going paperless is painful, and yes it can be expensive too, but just don’t say that the upside has been way overblown. The eRx Collaborative in Massachusetts has hopefully put that fear to rest. This bold effort was launched in 2003 to “jumpstart” e-prescribing in the state, and it’s raking in some impressive numbers. In late August, the group announced that Collaborative prescribers transmitted 15.6 million prescriptions over the last 4.5 years. Approximately 50,000 of those prescriptions, or 2.3% were changed due to drug safety alerts, a key feature of the system.

That probably doesn’t translate to 50,000 lives saved, or anything nearly that dramatic, but given the number of medication misshaps that harm Americans each year (IOM estimates that at about 1.5 million) it’s clearly a good thing.
More than 5,600 doctors are already ePrescribing thanks to eRx Collaborative, and the group is on track to bring 200 new prescribers onto the system this year. Last week Blue Cross Blue Shield of Massachusetts (BCBSMA), one of the Collaborative’s founding members, announced it is upping the ante: As of January 1, 2011, docs must be using e-prescribing to qualify for any of its physician incentive programs.

The e-Rx program helped Massachusetts garner the safest prescriber of all title at the Safe-Rx annual awards this summer. But what I like best about this initiative is the whole idea of “getting out ahead” of health care reform, and setting up information systems that supported the goals of the state’s then looming new health care law.

Clearly, e-prescribing works. It saves lives, it’s doable, and in this case, it came about through the efforts of actual stakeholders—BCBSMA, Tufts Health Plan and Neighborhood Health Plan, who tagged some useful applications (Zix Corp.’s PocketScript and DrFirst’ Rcopia) to get the ball rolling.

They could still be sitting there, debating how to do this, instead, they are watching the prescriptions roll in while saving money and lives.

Now the Centers for Medicare and Medicaid Services has announced that doctors who use e-prescribing can get a 2% bonus starting in 2009. Doctors fees are going up 1.1%, and they can also earn up to 2% extra for reporting quality measures. Add the e-prescribing bonus and that’s a total of 5.1% raise.

Could this be a trend?